THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES w rtH?0k THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. VOL. I. THE <£^£6^>/^ INTERNATIONAL ENCYCLOPEDIA **** SUBGEKY A SYSTEMATIC TREATISE ON THE THEORY AND PRACTICE OF SURGERY BY AUTHORS OF VARIOUS NATIONS EDITED BY JOHN ASHHURST, Jr., M.D. PROFESSOR OF CLINICAL SURGERY IB THE UNIVERSITY OF PENNSYLVANIA LLUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IN SIX VOLUMES YOL. I. NEW YORK WILLIAM WOOD & COMPANY 18S1 Copyright : WILLIAM WOOD & COMPANY, 1881. < OLLIHB, FBI PREFACE. v.) The object of this work is to furnish, in a comprehensive and yet not unduly extended form, a Systematic and Practical Treatise upon all those subjects which are properly considered to pertain to the Science and Art of Surgery, the various topics discussed in the several volumes having been intrusted to distinguished writers of various countries, who are believed to be specially qualified to give authoritative instruction, each upon the particular subject which he has undertaken. The general plan of the work is as follows : — In the First Volume are embraced such subjects as may be looked upon as belonging to General Surgery, including Inflammation, regarded both from the position of the Pathological Histologist, and from that of the Clinical Observer and Practical Surgeon ; Erysipelas and Pyaemia ; Hydrophobia and Glanders ; Scrofula and Tubercle ; Rachitis, and Scurvy. Articles follow upon the Reciprocal Effects of Constitutional Conditions and Injuries ; upon the General Principles of Surgical Diagnosis ; upon Operative Surgery in General ; upon Plastic and upon Minor Surgery ; upon the use of Anaesthetics ; upon Shock; upon Traumatic Delirium and Delirium Tremens; and upon Amputations. In the Second Volume will be begun the study of Special Surgery, those affections being first considered which, though local in themselves, may yet be met with in any part of the body. The Volume will also contain articles upon the several varieties of Venereal Disease, and will begin the discussion of Injuries and Diseases of the Various Tissues of the body. (v) yj PREFACE. The Third and Fourth Volumes will conclude the Surgery of the Tissues, and the latter will also begin the consideration of Injuries and Diseases of Special Regions. Regional Surgery will be continued through the Fifth and Sixth Volumes, and the last will contain, in addition, a History of Surgery, which (his health permitting) has been promised by Professor Gross. An Appendix will embrace papers on Hospital Construction, and similar important topics of collateral interest to Surgical Science ; and a full Analytical Index will, in connection with the Table of Con- tents and Subject Index in each Volume, serve to facilitate reference to every part of the work. For the plan of the Encyclopaedia, the arrangement of the material, and the general supervision of the whole, the Editor is responsible, as he is also for those Articles which bear his own name (in the present volume, the Article on Amputations), and for a few notes, chiefly in regard to practical matters, which may be distinguished by their being included within brackets [thus]. But for the facts and opinions in the various Articles, with the exceptions named, the entire responsibility rests with the individual authors. In a work of this character, some repetition is unavoidable, inasmuch as the subjects of the several Arti- cles necessarily overlap each other in many instances; but this very circumstance is rather of advantage than otherwise, as enabling' the render to compare the independent views, upon questions of importance, entertained by different writers of equal eminence. In regard to the illustrations which accompany the work, it has been flic aim of both the Editor and Publishers to supply whatever might he really serviceable in rendering the text more clear, while at the same time introducing none which were not truly illustrative. For some subjects, a large number are required, while for others, the use of any illustrations would be of at least doubtful value. In accordance with tin' Publishers' preference, the plates and almost all of the wood-cuts - |)t. some of instruments, etc.) are original, and have been executed PREFACE. Vll expressly for this work, either from photographs or from drawings, many of which are from the skilful pencil of the Editor's friend and former pupil, Dr. J. Madison Taylor. The Editor desires to offer his sincere thanks to the many distin- guished surgeons and physicians, who — in several instances, at the cost of great personal inconvenience — have given him their aid as collabora- tors, and without whose valued assistance the production of the Ency- clopaedia would have been impossible. His thanks are also due for important help of various kinds, rendered by Dr. W. M. Carpenter, of New York, and by Dr. H. R. Wharton and Dr. F. C. Sheppard, of Philadelphia. JOHX ASHHURST, Jr. Philadelphia, 2000 West Delancey Place, November, 1881. ALPHABETICAL LIST OF AUTHORS. (VOL. I.) D. HAYES AGNEW, JOHN ASHHURST, Jr., JOHN H. BRINTON, HENRY TRENTHAM BUTLIN, FRANCIS DELAFIELD, WILLIAM S. FORBES, WILLIAM HUNT, CHARLES T. HUNTER, CHRISTOPHER JOHNSTON, HENRY M. LYMAN, C. W. MANSELL-MOULLIN, J. LEWIS SMITH, ALFRED STILLE, S. STRICKER, WILLIAM H. VAN BUREN, A. VERNEUIL, PHILIP S. WALES. (viii) THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. ARTICLES CONTAINED IN THE FIRST VOLUME. Disturbances of Nutrition; the Pathology of Inflammation. By S. Stricker, M.D., Professor of Experimental and General Pathology in the University of Vienna. Pa^e 1. Inflammation. By William H. Van Buren, M.D., LL.D., Professor of the Principles and Practice of Surgery in the Bellevue Hospital Medical College, New York. Page 65. Erysipelas. By Alfred Stille, M.D., LL.D., Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania, Philadelphia. Pa^e 161. Pyemia and Allied Conditions. By Francis Del afield, M.D., Adjunct Professor of Pathology and Practical Medicine in the College of Physi- cians and Surgeons, Medical Department of Columbia College, New York. Page 203. Hydrophobia and Rabies. Glanders. Malignant Pustule. By W". S. Forbes, M.D., Demonstrator of Anatomy in the Jefterson Medical College, Senior Surgeon to the Episcopal Hospital, Philadelphia. Page 215. Scrofula and Tubercle. By Henry Trentham Butlin, F.R.C.S., Assistant Surgeon to, and Demonstrator of Surgery at, St. Bartholomew's Hospital, London. Page 231. Rachitis. By J. Lewis Smith, M.D., Clinical Professor of Diseases of Chil- dren in the Bellevue Hospital Medical College, New York. Pao-e 251. Scurvy. By Philip S. Wales, M.D., Surgeon-General of the United States ^ av y- . Page 277. (ix) X THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. The Eeciprocal Effects of Constitutional Conditions and Injuries. By A. Verneuil, M.D., Professor of Clinical Surgery in the Faculty of Medicine, Paris. Page 307. General Principles of Surgical Diagnosis. By D. Hayes Agnew, M.D., LL.D., Barton Professor of Surgery in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, Philadelphia. Page 337. Shock. By C. W. Mansell-Moullin, M.A., M.D. Oxon., F.R.C.S., Fellow of Pembroke College, Oxford; Late Travelling Fellow, Univ. Oxon.; Surgical Registrar to the London Hospital, London. Page 357. Traumatic Delirium and Delirium Tremens. By William Hunt, M.D., Senior Surgeon to the Pennsylvania Hospital, Philadelphia. Page 379. Anjesthetics and Anesthesia. By Henry M. Lyman, A.M., M.D., Professor of Physiology and of Diseases of the Nervous System in the Rush Medi- cal College, Chicago. Page 403. Operative Surgery in General. By John H. Brinton, M.D., Lecturer on Operative Surgery in the Jefferson Medical College and Surgeon to the Jefferson Medical College Hospital, Surgeon to the Philadelphia Hospi- tal, and to St. Joseph's Hospital, Philadelphia. Page 435. Minor Surgery. By Charles T. Hunter, M.D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Episcopal Hospital, Philadelphia. Page 479. Plastic Surgery. By Christopher Johnston, M.D., Emeritus Professor of Surgery in the University of Maryland, Baltimore. Page 531. Amputations. By John Ashiiurst, Jr., M.D., Professor of Clinical Surgery in the University of Pennsylvania, Philadelphia. Page 551. CONTENTS Preface ..... Alphabetical List of Authors in Vol. I. List of Articles in Vol. I. . List of Illustrations PAGE V viii ix xxxvi DISTURBANCES OF NUTRITION ; THE PATHOLOGY OF INFLAMMATION. By S. STRICKER, M.D., professor of experimental and general pathology in the UNIVERSITY OF VIENNA. the contractility of the cells of (Translated by ALFRED MEYER, M.D., of New York.) Hyperemia . . ' . Active hyperemia Passive hyperemia Anosmia and ischemia . Causes of hyperemia and ischemia Contractile elements of bloodvessels Contractility of the capillaries Contractility of the capillaries compared to glands .... The vaso-motor nerves Hyperemia of irritation and paralysis . The mechanical hyperemias Consequences of hyperemia ; oedema and hemorrhage Cardinal symptoms of inflammation General remarks concerning the inflammatory changes of tissues Historical remarks concerning the theory of inflammation Virchow's suppuration-theory Cohnheim's migration-theory Doctrine of the tissue-metamorphosis Suppurative keratitis .... Paths for nutrition and spaces for collection of oedema Apparent migration of cells in the midst of tissue and vital processes in the basis-substance ........ (xi) 1 2 3 3 4 4 5 9 11 18 19 20 23 24 25 25 25 27 28 33 34 Xll CONTEXTS. Suppurative inflammation in tendon, cutis, bone, cartilage, and other connective substances Tendon Cutis Bone Cartilage . Theory of fibrillar and of connective substance . On the cell-nucleus ..... Comparison between the supposed fibrillar substances and the other connective substances The transversely striped muscular fibres ; continuation of the discussion on the nature of the fibrillae The smooth muscular fibres and the central nervous system ; continuation of the discussion, etc. .... Smooth muscular fibres "White and gray matter of the central nervous system Suppuration of the spinal cord New observations on the supposed fixed cells. Conclusion of the discussion on the nature of the fibrillar Epithelium and endothelium Endothelium .... Epithelium .... Healing by first intention and healing by granulation Transplantation of cutis Regeneration ..... Non-inflammatory new formations Degeneration of the tissues Fatty degeneration Amyloid degeneration Calcareous degeneration Colloid defeneration 37 37 38 38 38 41 42 43 44 47 47 47 48 51 55 55 56 57 58 59 60 61 61 62 62 62 INFLAMMATION. By WILLIAM II. VAN BITREN, M.D., LL.D., pi:'. I ESBSOB or THE PRINCIPLES A.M. IUACTICE OF SURGERY IN THE BELLEVUE HOSPITAL iMKUICAL COLLEGE, NEW YORK. '" neral considerations regarding inflammation. Definitions of inflammation Irritation and injury ( llassification of causes Predisposing can i I >efect in quality of blood l'i esence of poison in blood 65 68 68 68 70 70 71 CONTENTS. Xlll Causes of inflammation — Defective or deranged nervous supply- Period of life . Habit of body, etc. Habitual functional hyperemia Climate, etc. . Exciting causes Cold and sudden chilling Incised wounds Punctured wounds Presence of foreign material in woun Mechanical violence, wrenching, straining, etc Contusion Presence of a clot of blood Persistent mechanical action . Action of chemical irritants . Heat .... Poisonous action of minerals . Poisonous action of plants Poisonous secretions of animals Venom of serpents Parasites ... Microscopic fungi Putrid substances Modes in which poisons are absorbed Symptoms of inflammation Redness .... Heat .... Swelling .... Pain .... Impairment or abolition of function Traumatic or inflammatory fever Phenomena of traumatic fever Nature of fever Causes of surgical fever Infective and non-infective inflammation and fever Blood-poisoning, septicaemia, and pyaemia , Inflammatory exudations Passive and active exudation ; oedema Exudation of plastic lymph Croupous exudation Plastic or coagulable lymph Union by first intention Healing under a scab Destructive inflammation. Pus formation Suppuration and granulation Union by secondary adhesion . Physical qualities of pus . 71 72 73 73 73 74 74 75 7G 76 78 78 79 80 80 80 81 82 82 84 85 85 90 92 95 96 97 97 98 99 99 100 102 103 105 106 106 107 108 109 110 111 111 112 112 114 114 XIV CONTENTS. Destructive inflammation — Anatomical characteristics of pus . Liquid portion of pus . Sources of pug ...... Abscess ...... Formation of pus on serous and mucous membranes . 115 116 116 117 119 Phenomena attending pus formation Ulceration ....... Gangrene ....... Significance of suppuration . Significance of odors from pus 119 120 121 122 122 Poisonous qualities of pus .... Pus involves waste of tissue 123 124 Uses of pus ..... Varieties of pus ..... Substances mistaken for pus .... 124 125 126 Injurious consequences of suppuration . Purulent infiltration with connective-tissue necrosis 126 127 Hectic fever ...... 129 Chronic inflammation ..... 130 Induration ..... 131 Hyperplasia and hypertrophy Catarrhal inflammation ...... 131 132 Inflammation in the scrofulous .... 133 Inflammation in the syphilitic .... Terminations of inflammation .... 134 135 Resolution ...... . 136 Tissue production ..... Gangrene ...... . 136 . 137 Treatment of inflammation .... . 138 Prevention ..... . 138 Detection and removal of causes . 139 Insurance of favorable conditions Mitigation and control of manifestations . 139 . 140 Prevention ...... . 140 Rest and immobility .... 142 Position ...... . 144 Cold . . 144 [rrigation . . 145 Beal ;mi' t and Dursing Diet . ligation of main artery . 154 154 . 154 CONTEXTS. XV Treatment of inflammation — Stimulus ........ 155 Nursing .... 155 Medicines employed in treating inflammation 155 Anodynes .... . 156 Quinine .... 156 Mercury .... 156 Astringents .... 157 Laxatives and cathartics 157 Depressants .... 158 Antiseptics ..... 159 ERYSIPELAS. By ALFRED STILLfi, M.D., LLD., PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA. Synonyms and derivation of name History of erysipelas Causes of erysipelas Sex and age . Cold Cachectic conditions Sewer gas, etc. Contagion . Specific cause of erysipelas Causes of erysipelas as illustrated by the history of epidemi disease ..... Cases illustrating unity of various types Connection of epidemic erysipelas with puerperal fever Morbid anatomy of erysipelas . Symptoms of erysipelas Wandering erysipelas . Temperature in erysipelas Phlegmonous erysipelas CEdematous erysipelas Gangrenous erysipelas Erysipelas of face and scalp Bilious erysipelas . Metastatic erysipelas Erysipelas of new-born infants Erysipelatous peritonitis Diagnosis of erysipelas . Prognosis of erysipelas . outbreaks of the 161 161 162 162 163 163 164 105 167 168 170 173 176 177 178 179 182 183 183 184 186 186 186 187 188 188 Xvi CONTENTS PAGE Prophylaxis of erysipelas ..... 190 Treatment of erysipelas 191 Views of the ancients . 191 Trousseau's view 192 Blood-letting . 193 Cold .... 194 Astringents and stimulants 194 Nitrate of silver, iodine, etc. . 195 Surgical treatment 195 Punctures and incisions 196 Carbolic acid . 197 Internal treatment 197 Purgatives and emetics 197 Alcoholic stimulants, etc. 198 Quinia 198 Tincture of chloride of iron . 199 Treatment in infants and old persons 201 Treatment of erysipelas of air-passages 201 Treatment of epidemic erysipelas . 201 PYEMIA AND ALLIED CONDITIONS. By FRANCIS DELAFIELD, M.D., ADJUNCT PROFESSOR OF PATHOLOGY AND PRACTICAL MEDICINE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL DEPARTMENT OF COLUMBIA COLLEGE, NEW YORK. Nomenclature of pyremia ....... 203 Nature of pyaemia ........ 204 Theory of pus absorption . . . . . . .204 Chemical theory ........ 204 Germ theory . . . . . . . . 205 Examination of blood and tissues ..... 205 Experiments on animals ...... 206 Symptoms and lesions of pyasmia ...... 207 Mechanical and infectious emboli . . . . .211 Treatment of pyaemia . . . . . . . .211 Prolonged suppuration ........ 213 Spontaneous pyaemia . - . . . .214 CONTEXTS. XV11 HYDROPHOBIA AND RABIES; GLANDERS; MALIGNANT PUSTULE. By WILLIAM S. FORBES, M.D., DEMONSTRATOR OF ANATOMY IN THE JEFFERSON MEDICAL COLLEGE ; SENIOR SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. Hydrophobia and rabies Cause of hydrophobia Rabies in the dog . Incubation of hydrophobia Symptoms of hydrophobia Symptoms of first stage Symptoms of second stage Symptoms of third stage Morbid anatomy of hydrophobia Diagnosis of hydrophobia Prognosis of hydrophobia Treatment of hydrophobia Preventive treatment Curative treatment Glanders Symptoms of glanders Symptoms in the horse Symptoms in man Diagnosis of glanders Prognosis of glanders Treatment of glanders Malignant pustule Symptoms of malignant pustule Pathology of malignant pustule Treatment of malignant pustule PAGE 215 215 21G 217 218 218 218 219 219 220 221 222 222 223 225 225 225 226 227 227 227 228 228 229 229 SCROFULA AND TUBERCLE. By HENRY TRENTHAM BUTLIN, F.R.C.S., ASSISTANT SURGEON TO, AND DEMONSTRATOR OF SURGERY AT, ST. BARTHOLOMEW'S HOSPITAL, LONDON. Tubercle ......... 231 Illustrative cases . . . . . . . .231 Analysis of the above cases ...... 23-4 Morbid anatomy of tubercle ...... 234 VOL. I. — B XVI 11 CONTENTS. Origin and natural history of tubercle Infection of tubercle Nature of tubercle . Pathology of tubercle Treatment of tubercle Scrofula Illustrative cases . Nature of scrofula . Morbid anatomy of scrofula Diagnosis of scrofula Tissues and organs affected by scrofula Relation of scrofula to tubercle Modifications produced by scrofula in other Gonorrhoea and epididymitis Syphilis Gout . Causes and course of scrofula Prognosis of scrofula Treatment of scrofula Constitutional treatment Local treatment diseases PAGE 235 236 237 238 238 240 240 241 242 242 243 244 245 245 245 246 246 246 247 247 248 RACHITIS. By J. LEWIS SMITH, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. Frequency of rachitis . * . . . . . . . 251 Age at which rachitis occurs 252 Foetal rachitis . 253 Causes of rachitis . 254 Inheritance . 254 Food . 254 Artificial production of rachitis . 255 I bitzmann's observations . 256 Anatomical characters of rachitis 257 Stage of proliferation and altered nutrition 257 Cartilaginous changes . 257 Osseous changes , 258 Pathology of rachitis 259 Stage of deformity . 260 Changes in cranial bones 260 Cranjotabes 261 Symptoms of craniotabes . 262 Connection with 1 aryngismus stri< lulus 263 CONTENTS. XIX Changes in vertebra . Changes in maxillae Changes in ribs Changes in bones of upper extremity Changes in bones of pelvis Changes in bones of lower extremity Effect of rachitis on dentition . Changes in soft tissues Stage of reconstruction Symptoms of rachitis Complications and sequela? of rachitis . Diagnosis of rachitis Prognosis of rachitis Treatment of rachitis Diet Medicines . PAGE 2G4 264 265 266 267 267 268 269 270 270 271 272 273 274 274 275 SCURVY. By PHILIP S. WALES, M.D., SURGEON-GENERAL OF THE UNITED STATES NAVY. Synonyms 277 History of scurvy 277 Etiology of scurvy 285 Geographical limitation 285 Age 285 Sex 286 Low temperature . 286 Depressing emotions 286 Foul air 287 Impure water 287 Individual peculiarities 287 Food supply 288 Use of salted meats 288 Deficiency in quantity and quality of food 289 Deficiency in variety of food 289 Morbid anatomy of scurvy 290 Rigor mortis 290 Skin and connective tissue 290 Periosteum 291 Joints 291 Serous membranes 291 Mouth, gums, etc. . 291 Nervous system 291 XX CONTEXTS PAGE Heart ......... 291 Lungs .... 292 Stomach and bowels 292 Liver, spleen, and pancreas 292 Kidneys 292 Pathology of scurvy 293 Symptoms of scurvy 295 Scorbutic cachexia 295 Impairment of mental powers 296 Pains in limbs 296 Changes in gums . . 296 Extravasations of blood and cedems L 297 Hemorrhages . 298 Serous effusions 298 Cerebral symptoms . 299 Embolism, etc. . 299 Urinary symptoms . 299 Splenic and hepatic symptoms 300 Ophthalmic and aural symptoms 300 Fever . 300 Diagnosis of scurvy 301 Prognosis of scurvy . 301 Treatment of scurvy 302 Prophylaxis 302 Curative treatment . 304 THE RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. By A. VERNEUIL, M.D., PROFESSOR OF CLINICAL SURGERY IN THE FACULTY OF MEDICINE, PARIS. Classification of constitutional conditions 307 Reciprocal influence of constitutional conditions and injuries 308 Period of dyscrasia .... 309 Period of peripheral lesions . 309 Period of visceral lesions . 309 Time of operation . 310 Mode of operation 310 Choice of dressing 310 Constitutional treatment 311 Arthritism 311 Rheumatism 311 Gout . 312 Herpetism . 313 CONTENTS • XXI PAGE Cancer .... 313 Scrofula 315 Tuberculosis 316 Scurvy . 317 Leucocythremia 318 Haemophilia 318 Syphilis 319 Malaria . 321 Alcoholism 322 Delirium tremens 323 Morphinism 324 Saturnism or lead-poisoning 324 Hepatism ; nephrism ; cardism . . 325 Hepatism .... . 326 Nephrism .... . 327 Cardism .... . 329 Aneurism of aorta 329 Arterial atheroma . 329 Locomotor ataxia and various neuroses . . 329 Hysteria and epilepsy . 330 Insanity .... . 330 Diabetes mellitus . 330 Alcohol diabetes . 331 Phosphaturia, azoturia, polyuria, etc. . 331 Pregnancy .... . 332 Rules for operations during pregnancy . 334 Infancy ..... . 334 Old age . 335 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. By D. HAYES AGNEW, M.D., LL.D., BARTON PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. Analytical and synthetical modes of investigation Difficulties in surgical diagnosis General examination of a patient Age Sex Occupation Habits Antecedent history Personal history Mental and moral states 337 338 339 339 339 340 340 341 341 342 XX11 CONTENTS. Social condition Residence . Duration of disease Special examination ; personal investigation Posture or attitude External expressions of parts Information derived from touch Weight Mobility . Temperature Color Translucency Mensuration Sound Movements Smell Interrogation of internal organs Circulation Thermometry Respiration Nervous system Significance of pain Mobility . Digestive apparatus Genito-urinary system PAGE 342 343 343 343 343 343 345 345 345 345 345 345 346 346 346 347 347 347 348 349 350 351 351 352 354 SHOCK. By C. W. MA^SELL-MOTTLLIN, M.A., M.D. Oxon., F.R.C.S FELLOW OF PEMBROKE COLLEGE, OXFORD; LATE RADCLIFFE'S TRAVELLING FELLOW, UNIV. OXON. ; SURGICAL REGISTRAR TO THE LONDON HOSPITAL, LONDON. Causes of shock . . 357 Mental emotion . 358 Sex and age . 359 Pain .... . 359 Mental pre-occupation and expectation Cases attended by shock Symptoms of shock Prostration with excitement . 359 . 359 . 362 . 363 Pathology of shock . 365 Goltz's experiments . 366 Tappeiner's and Muller's experiments Lewisson's experiments . 367 . 369 uosis of shock — reaction . 369 CONTENTS • XXlll PAGB Treatment of shock . . . . . . . .371 Prevention of shock 371 External heat . 371 Stimulants .... . 372 Opium .... 372 Artificial respiration and transfusion 372 Venesection 373 Ammonia .... 373 Strychnia, belladonna, and digitalis 373 Use of anaesthetics 374 Fatty embolism .... 374 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. By WILLIAM HUNT, M.D., SENIOR SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. Traumatic delirium Meaning of term delirium . Connection of delirium with insanity Anatomy of delirium Causes of traumatic delirium Hemorrhage Shock .... Embolism and thrombosis Lesions of nerves of special sense Bites of serpents Bites and stings of insects, etc. Hydrophobia, tetanus, and chorea Surgical operations Surgical or traumatic fever Compound and simple fractures Lacerated wounds Burns and scalds Erysipelas Epilepsy and catalepsy Hectic fever . Pyaemia, phlebitis, etc. Diagnosis of traumatic delirium Treatment of traumatic delirium Delirium tremens Causes of delirium tremens Delirium tremens and mania a potu Symptoms of delirium tremens Diagnosis of delirium tremens Treatment of delirium tremens 379 379 379 380 381 381 382 382 383 384 385 385 385 385 387 387 389 391 392 392 393 393 394 394 395 397 397 399 401 XXIV CONTENTS. ANESTHETICS AND ANAESTHESIA. By HENRY M. LYMAN, A.M., M.D., PROFESSOR OF PHYSIOLOGY AND OF DISEASES OF THE N ERVOUS SYSTEM IN THE RUSH MEDICAL COLLEGE, CHICAGO. PAGE Meaning of term anaesthesia ....... 403 History of anaesthesia 403 Early history 403 Nitrous oxide gas . 404 Ether .... 404 Chloroform 405 Phenomena of anaesthesia 406 Effect of inhalation on air-passages 406 Effect on eyes 406 Effect on general sensibility 406 Effect on brain 407 Effect on power of volition 407 Effect on power of muscular movements 407 Effect on reflex action 408 Effect on respiration . 408 Effect on action of heart 408 Effect on temperature 408 Effect on secretions 408 Physiology of anaesthesia . 409 Mode of administering anaesthetics 412 Accidents of anaesthesia 412 Syncope ..... 412 Asphyxia .... 412 Toxic effect on nervous centres 414 Influence of rate of inhalation 414 Influence of age, sex, temperament, etc. 414 Influence of cerebral and spinal diseases . 414 Influence of intra-thoracic diseases 415 Influence of excitement or terror . 415 Treatment of accidents of anaesthesia 415 Employment of anaesthetics 416 Anaesthesia in surgery 416 Anaesthesia in obstetrics 416 Anaesthesia in dentistry 417 Local anaesthesia 418 Other modes of producing anaesthesia 419 Electricity .... 419 Rapid respiration . 419 Intravenous injections 419 CONTENTS. XXV PAGE Anaesthetic mixtures ....... 420 Hypnotism ...... > 421 Compression ..... 422 Mortality consequent upon artificial anaesthesia . 422 Mortality from chloroform .... 422 Mortality from ether .... 423 Mortality from nitrous oxide 423 Post-mortem appearances after death from artificial anaesthesia 423 Anaesthetic substances ..... 424 Hydrocarbons and their derivatives 424 Methane ..... 424 Ethane . 424 Tetrane 424 Pentane . 425 Octane . 425 Ethylene 425 Amylene . 425 Turpentine . 425 Benzene 425 Methylic chloride 426 Methylene bichloride . . 426 Chloroform 426 Carbonic tetrachloride 426 Methylic iodide 427 Iodoform 427 Hydrochloric ether 427 Dichlorethane 427 Trichlorethane . 428 Aran's ether . 428 Bromide of ethyl . 428 Hydriodic ether 429 Monochlorotetrane 429 Chloride of amyl 429 Iodide of amyl 429 Nitrite of amyl 429 Pyrrol . 429 Alcohols 430 Wood spirit 430 Alcohol 430 Carbolic acid . 430 Chloral hydrate 430 Butylchloral hydrate 430 Ethers 431 Methylic ether 431 Ether . 431 Methylal 431 Ethereal salts 431 Nitric ether . 431 XXVI . cc IM'EMc PAGE Formic ether ........ 432 Acetic ether . 432 Aldehydes . 432 Ketones 432 Inorganic substances 432 Nitrogen 432 Nitrous oxide . 432 Carbonic oxide 433 Carbonic acid 433 Bisulphide of carbon 433 Supplementary note as to deaths from chloroform . 433 OPERATIVE SURGERY IN GENERAL. By JOHN H. BRINTON, M.D., LECTURER ON OPERATIVE SURGERY IN THE JEFFERSON MEDICAL COLLEGE, AND SURGEON TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL, SURGEON TO THE PHILADELPHIA HOSPITAL, AND TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA. Qualifications of a surgeon Personal qualifications Knowledge of anatomy Demeanor .... Selection of cases, etc. Diagnostic power . Preparation for an operation Operations of necessity and expediency Time for operation Preparation of patient Rest .... Preliminary treatment Anaesthesia .... Comparison of ether with chloroform First insensibility from ether Administration of ether After-treatment of ether anaesthesia Administration of chloroform Local anaesthesia . Otlur means of producing anaesthesia Mode of conducting an operation i-tants .... Posture of patient . Immediate dangers Instruments 1 fee of blunt knives . 435 435 436 437 437 438 438 439 439 440 440 441 441 442 443 443 445 446 447 448 448 449 449 449 4,50 451 CONTEXTS XXVll PAGE Drainage ......... 451 After-dressing .... 451 Treatment of patients after operation . 452 Diet ..... 453 Care of bladder and bowels 454 Hygienic surroundings 454 Traumatic or surgical fever 455 Conditions determining results of operations 456 General condition of patient 457 Obesity .... 457 Plethora .... 458 Leanness .... 458 Habits of patient .... 458 Drunkenness .... 458 Gluttony .... 459 Influence of nervous system 459 Age and sex 459 Age ..... , 459 Sex .... 4G0 Race and temperament 461 Seasons and weather 461 Locality .... 463 Visceral affections . 463 Heart and arteries 463 Lungs 464 Urinary organs 465 Liver .... 467 Bowel affections 467 Cachexia? .... 468 Conditions connected with operation itself 469 Hemorrhage . 469 Shock 469 Local condition . 470 Hemorrhagic diathesis 470 Condition of patient after operation 470 Hospital hygiene . 471 Causes of death after operations 472 Hemorrhage . 472 Shock .... . 473 Delirium .... . 475 Thrombosis and embolism . 475 Air in veins 476 Gangrene and sloughing 476 Tetanus .... 476 Erysipelas .... 477 Pyaemia and septicaemia 477 XXY111 CONTENTS. MINOR SURGERY. By CHARLES T. HUNTER, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA ; SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. Surgical dressings Lint Charpie Tow Oakum Cotton Paper-lint . Jute . . Compresses Pledget Tent Meche Pellets and bullets . Retractors . Oiled silk . Gutta perclia or rubber tissue Waxed paper Water-proof paper The protective Mackintosh Use of bandages Roller bandages General rules for bandagin< Special bandages . Circular bandage Oblique bandage Spiral bandage Spiral reversed bandage Spiral bandages Spiral reversed of upper extremity Spiral of finger Spiral of hand or dcmi-gauntlet Spiral reversed of lower extremity Spiral of chest Spiral of penis Spica bandages Spica of thumb Spica of shoulder Spica of groin PAGE 479 479 479 479 480 480 480 480 480 481 481 481 481 481 482 482 482 482 482 483 483 483 484 485 485 485 485 485 486 486 486 486 487 488 488 488 489 489 489 CONTEXTS. XXIX Spica of both groins . Spica of foot . Figure-of-eight bandages . Figure-of-eight of elbow Anterior figure-of-eight of chest Posterior figure-of-eight of chest Suspensory and compressor of breast Suspensory and compressor of both breasts Yelpeau's bandage Bandages for the head Figure-of-eight bandage of head and jaw Crossed or oblique bandage of angle of jaw Recurrent bandage of head V-bandage of head Other roller bandages Recurrent bandages for stumps Single T-bandage Double T-bandage Sling or four-tailed bandage . Many-tailed bandage of Scultetus Handkerchief bandages Fixed dressings or hardening bandages Plaster-of-Paris bandage Starch bandage Gum and chalk bandage Silicate of potassium bandage Paraffin bandage Glue and oxide of zinc bandage Revulsion and counter-irritation Rubefacients Vesicants . Acupuncture Issues Moxa . Seton Actual cautery Paquelin's cautery Bloodletting Scarification Puncturation Cupping Dry-cupping Wet or bloody-cupping Leeching . Artificial or mechanical leech Venesection Bleeding from external jugular Bleeding from internal saphena PAGE 490 490 491 491 491 492 492 493 493 493 493 494 494 495 495 495 496 496 496 497 497 498 498 500 500 500 500 500 500 501 501 502 502 503 503 504 505 505 505 505 505 505 506 507 508 508 509 509 XXX CONTENTS. Arteriotomy Transfusion of blood Direct transfusion . Aveling's method Roussel's method Indirect transfusion Hewitt's method Allen's method Other methods Arterial transfusion Auto-transfusion Intra- venous injection of milk, etc Artificial respiration Mouth to mouth inflation . Richardson's bellows Howard's direct method ' . Sylvester's method . Marshall Hall's ready method Vaccination Revaccination Hypodermic injections . Aspiration Surgical uses of electricity Electrolysis Galvano-cautery Galvanization and faradization Massage Stroking or effleurage Kneading or petrissage Percussion or tapotement . Passive and active motion . Muscle-beating Use of the thermometer in surgery Clinical thermometer Surface thermometer Use of the sphygmograph PAGE 509 509 510 510 511 511 511 512 513 513 513 513 514 514 515 515 515 516 516 517 518 519 521 522 523 525 525 525 525 526 526 526 527 527 528 529 PLASTIC SURGERY. By CHRISTOPHER JOHNSTON, M.D., EMERITUS PROFE880R <>1 SURGERY IN THE UNIVERSITY OF MARYLAND, BALTIMORE. Synon History of plastic Burgery Lesions remediable by plastic surgery 531 532 533 CONTEXTS. XXXI General principles of plastic operations Classification of plastic operations General rules for plastic operations Skin grafting Hamilton's observation Reverdin's observations Poncet's observations Bryant's observations Coste's observations Ollier's observations Pollock's observations Bert's observations Martin's observations Hodgen's observations Donnelly's observations PAGE 535 536 537 538 539 539 543 543 543 544 544 546 546 547 549 AMPUTATIONS. Br JOHN ASHHURST, Jr., M.D., PROFESSOR OF CLINICAL SURGERY IX THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA General remarks upon amputation History of amputation . Among the Greeks and Romans Among the Arabians During the middle ages Invention of the ligature . Invention of the tourniquet History of circular operation History of flap operation . Conditions calling for amputation Avulsion of a limb Compound fractures and luxations Lacerated and contused wounds Gunshot injuries Lesions of arteries Effects of heat and cold Mortification Dry gangrene . Hospital gangrene Diseases of bones and joints Morbid growths Tetanus Deformities 551 552 552 553 553 554 555 556 558 559 559 560 560 561 562 5G2 562 563 563 564 564 564 564 XXX11 CONTENTS. Instruments required for amputation Tourniquet Esmarch's apparatus Amputating knives Saws Cutting pliers or bone-nippers Bone forceps Artery forceps and tenacula Ligatures . Retractor . Sutures Needles Dissecting forceps • Scissors Operative methods employed in amputatior Circular operation . Modified circular operation Elliptical operation Oval operation Method of Scoutetten Method of Malgaigne Single flap operation Double flap operation Ravaton's method Vermale's method Sedillot's method Langenbeck's method Teale's method Lister's method Relative advantages of different modes of amputating Simultaneous or synchronous amputations Table of cases of synchronous amputation Dressing the stump Cold-water dressing Air dressing Pneumatic occlusion and pneumatic aspiratior Perchloride of iron dressing Open method Antiseptic dressing Wadding dressing . Bordeaux and earth dressings Simple dressing After-treatment of stump Structure and diseases of stumps Structure of stumps 1 diseases of stumps . Sloughing Erysipelas and difFuse cellulitis PAGE 565 5G5 569 570 571 573 573 574 575 577 577 578 578 579 579 579 582 583 584 584 584 584 585 585 585 586 587 587 588 589 590 592 593 593 594 595 596 597 597 598 598 599 600 601 601 G01 602 602 CONTENTS. XXX111 Hospital gangrene .Spasm of muscles Retraction of muscles Contraction of tendons Hemorrhage . Aneurism, etc. Neuromata Periostitis, osteitis, and osteomyelitis Necrosis Caries Hypertrophy of hone . Adventitious bursa? Prothetic apparatus and adaptation of artificial limb Prothetic apparatus for upper extremity Prothetic apparatus for lower extremity Mortality and causes of death after amputations Table of one hundred cases of amputation Analysis of causes of death in above cases Effect of age Effect of constitutional condition Effect of sex Effect of hygienic surroundings Erysipelas, pysemia, etc. Effect of nature of lesion . Effect of period of amputation Effect of part involved Special amputations of the upper extremity Amputations of fingers . Through phalanx . Through interphalangeal joint Entire finger Two adjoining fingers All four fingers Amputations of hand Thumb through metacarpal Thumb with metacarpal Through one or more metacarpals Fifth metacarpal Other metacarpals . Whole metacarpus . Amputation at the wrist Circular method Elliptical method . Flap methods Amputation of the forearm Circular method Flap methods Mixed methods VOL. I. — C PAGE 602 602 602 603 603 604 cm 604 605 605 606 606 cor, (',07 608 610 612 (317 618 622 622 023 624 625 627 629 631 631 631 631 632 631 63 i 63 1 631 631 635 636 636 636 637 637 638 G38 639 639 639 610 XXXIV CONTENTS. Amputation at the elbow Elliptical method . Circular method Flap methods Amputation of the arm . Circular method Oval method Flap methods Amputation at the shoulder Oval method (Larrey) External nap method (Dupuytren) Antero-posterior flap method (Lisfranc) Amputation above the shoulder Special amputations of the lower extremity Amputations of toes Through phalanges At interphalangeal joint . At metatarsophalangeal joint All toes simultaneously Amputations of the foot Fifth toe with metatarsal . Great toe with metatarsal . Two or more metatarsals . Through continuity of metatarsus . Entire metatarsus . Hey's amputation Lisfranc's amputation . At medio-tarsal joint (Chopart) Sub-astragaloid amputation Hancock's amputation Tripier's amputation Other amputations . Amputations at the ankle Syme'a amputation Roux's amputation . l'irogoff's amputation Ferf circularly-arranged, smooth, muscular fibres, by the contraction of which the lumen must be narrowed. The larger the artery, the more does tin.-; coat of smooth muscular fibres become mixed with elastic elements, and the more is the contractility of the entire tube impaired. The capability of contraction is accordingly much more marked in the smaller arteries than in the large ones, the smallest arteries having indeed the power of contracting until their lumen has disappeared. When the contraction of the circular muscles subsides, the arteries must widen again and refill, in consequence of thf pressure which the blood (really the heart) exerts upon them. Thus contraction of the circular muscular fibres causes a narrowing of the vessels, while relaxation of the circular muscular fibres produces a widening of the same. If is generally supposed that the elastic tissue also takes part in the narrowing of arteries, for it is thought that the elastic fibres are distended by the impulse which the blood receives during systole, and assume their former dimensions during diastole. It is, indeed, true that the arterial wall is 1 Studien aus dein Instit. f. experim. Path., 18G9. CONTRACTILITY OF THE CAPILLARIES. 5 distended in consequence of every systole ; but it is not proved that the so-called elastic substances of the arterial wall are involved in this distension. In general, we do not know whether the elastic substances of the organism possess any elasticity worth mentioning. We must not be deceived by the name "elastic;" the iibres have been called elastic, because the filaments of a torn end curve inward like elastic springs; but Ave do not know if these fibres are distensible like caoutchouc ; I do not even consider it at all likely. The researches of Spina 1 show that the elastic fibres are cells which have become old and resistant; cells (or processes of cells) which, in inflammation, again become as soft, as mobile, and as capable of proliferation, as young cells of the embryo. There is no reason for considering the cells which have become resistant to be more distensible than the other tissues. I regard it as more likely that the artery, as a whole, possesses a certain degree of elasticity, and that it in toto possesses the power to contract after a certain distension, as soon as the pressure or tension relaxes. The walls of veins likewise have smooth muscular fibres, but not circularly arranged, as in arteries. And yet the veins are contractile in a marked degree. If we irritate mechanically the exposed jugular vein of a rabbit, it contracts until its lumen almost disappears. The contraction of veins is the more striking because they are also very distensible. As soon as the blood- current is obstructed in the jugular vein, the vessel swells, although the blood flows in it under a very low pressure. AVe know very little about the mechanism of this contraction; it is not clear how muscular fibres which run lengthwise can produce a narrowing of the lumen. The bloodvessels, however, have other arrangements besides the muscular fibres, by means of which their lumen can be contracted. These arrangements are presented by the Intima. The intima of the bloodvessels lines the entire vascular system. In the heart, it is represented by the endocardium. The endocardium leads directly to the intima of the arteries, which is continued in the capillaries, and beyond the capillaries again becomes the intima of the veins. In the capillaries the intima lies in immediate contact with the surrounding tissue, or is only accompanied by the rudiment of an adventitia. In other words, the wall of the capillaries consists of nothing, or almost nothing, but the intima. Now the capillaries possess a certain degree of contractility; they can actively contract and dilate, although they have no muscular fibres. In this state of affairs we might even suspect that the veins w r ere capable of contraction and dilatation, in consequence of the contractility of their intima. But the contractility of the capillaries has not the same character as muscular con- tractility. The doctrine of the contractilit}' of the capillaries is not at all generally accepted, and only a portion of those who accept it have actually observed the phenomenon. Therefore we must not blindly admit this doctrine, and build up theories upon it. We must first familiarize ourselves more closely with it, and, as it is a subject of very great importance in pathology, and especially in respect to the theory of inflammation, I shall devote a separate section to its consideration. The Contractility of the Capillaries. — In the year 1865, 1 for the first time advanced the assertion that the walls of the capillaries were not. as was at that time supposed, mere lifeless, structureless, 2 elastic membranes, but that they consisted of a contractile substance. I had observed that the capillaries of the fresh lj'-prepared membrana nict'dans of the frog, when 1 Mediz. Jahrbfieher, 1873 und 1875. 2 Nuclei had indeed been ascribed to thern, but with this single exception they were considered structureless. 6 PATHOLOGY OF INFLAMMATION. examined in the aqueous humor, changed their lumens; that in certain places the}' alternately narrowed and widened. These observations, however, were merely accidental In some of these membranes I saw the change ; in many others I did not succeed in observing it. But, as it was already known at that time that the cells of embryos were distinguished by their contractility, I chose the tadpole for a further examination of the subject. For the tadpole is the embryo of the frog, and has this advantage, that the bloodvessels can be examined in its transparent tail in vivo — that is, as long as the circulation continues ; and I found, indeed, that the capillaries of the tail 1 contracted under the influence of powerful irritation, as, for example, under the influence of strong induction currents. But I was not sure of the matter; at times I obtained a favorable result, at others not. I could, therefore, give no positive answer regarding this property of the capillaries. A number of additional circumstances, however, gave me an insight into certain other properties. I discovered on this occasion that the walls of the vessel were pierced by red blood-corpuscles 2 — a discovery on which Cohnheim subsequently based a new theory of suppuration (migration theory). I found, furthermore, that the walls of capillaries were not structureless; that here and there they were granulated, like protoplasm; that their outlines were irregular; that here and there the}' had points and nodules. Then I noticed that the walls of the capillaries had processes ; 3 that various phases of growth of these processes were recognizable up to a junction with the processes of neighboring capilla- ries. It appeared that these processes became hollowed out, commencing at the root (at the inner wall of the older capillary), and were thus transformed into new capillaries. Walls of vessels, I argued, which resemble protoplasm, which send out processes, are living walls. The capillaries are protoplasm in the shape of tubes. Just as protoplasm is permeable for foreign bodies, so, too, are the walls of capillaries. My statement concerning the penetration of the vascular wall was soon generally accepted, but its contractility, and even its permea- bility (my view of it), were contested. The blood-corpuscles, it was said (in < >i '] m >sition to my assertions), passed through openings (stomata) of the vascular walls. At the same time, Eberth, Aeby, and Auerbach, discovered (but each one independently of the other) that by the injection of a solution of nitrate of silver 4 into the vascular system, a series of brown lines Flg- 2 ' (Fig. 2) could be produced in the capillaries, and in the intima of arteries and veins; lines similar to those ob- tained on the surface of serous membrane by staining with silver. The lines on the serous membranes are regarded as the outlines of cells, and it was accordingly said that the brown lines of the capillaries were also outlines of cells ; and the more so, because nuclei were recognizable in the fields that were bounded by the lines. (See Fig. 2.) Well, then, the capillaries were composed of flat cells — cells of the same kind as those which cover the serous membranes. They were the continuation of the intima (endothelium) of the arteries; the capillaries them- selves were endothelial tubes. At the borders of the cells 1 All bloodvessels, whether large or small, whether afferent or efferent, are here capillaries as regards Btructure. They all consi.it merely of an intima. There is not yet a muscular coat or an ad ventitia present. ■ Studies fiber Bau and Lebeu der capill. Blutgcfiisse. Wiener Sit/.nngsberiehte, 1866. '' 'lie- mere fact thai tl apillaries had processes was known previously. * The method Ltself bad already bees made known hy Recklinghausen. CONTRACTILITY OF THE CAPILLARIES. 7 there were stomata through which the blood-corpuscles passed. Remak, and subsequently His, had already asserted that the bloodvessels were formed by a juxtaposition of cells, and now it was said this assertion was proved. The brown lines, it was said, showed us the places of junction of the cells which formed the vessel. It seems to me, however, that the supposition of the existence of stomata in the wall of the vessel is now generally abandoned. There is no longer any doubt that the blood-globule can pass through any point of a capillary. The supposition, too, that the bloodvessels are built up by the synthesis of cells (like a chimney) is, as far as I know, no longer supported by anybody. However, I must attribute great value to the discovery of the silver-lines. For this discovery has led me to a theory which I must now regard as fully proved; to a theory which is alike of importance for the doctrine of inflam- mation and for that of histogenesis. Since I was compelled to accept the existence of these brown lines, and yet, on the other hand, was convinced of the formation of capillaries by the hollowing out of a formerly solid material, I indulged in the following reflection: The capillaries really are formed by the hollowing out of masses of protoplasm. Subsequently, the outlines of single territories in the walls are differentiated (metamorphosed), and these territories appear to us like cells, on account of their nuclei. Originally, this interpretation was based on speculation onl} T , but now, after I have worked in this direction for nearly fifteen years, after I have examined tissues of all types with regard to their normal and pathological genesis, this interpretation has become a fundamental theory. This theory is as follows: When the egg undergoes segmentation, it is not divided into parts which fall asunder. 1 This falling apart of the subdivisions occurs at certain places only. The blood-corpuscles and the lymph-corpuscles separate completely after their division. On the other hand, cells which form a tissue remain connected at least in groups. The partition here is only apparent. A cell grows and then transforms a portion of its body (Zell-leib) 2 into a dividing line between two halves. If this process is repeated, a large number of cells, connected by such boundary lines, must finally be produced. If the cells grow without the development of boundary lines, we have very large cells produced, the so-called "giant-cells." These boundary lines are living matter, just as the cells themselves, though still differing from them in some respects ; they have been formed by a chemical alteration of a portion of the body of the cell. The staining with silver assists us in recognizing their chemical differentiation; they are more deeply stained than the cells. In other words, they absorb more silver, and therefore assiime a deeper brown color under the influence of light. Such boundary lines occur between endothelium and epithelium; they occur between the cells of the cornea, of cartilage, of bone, of tendons, and of other tissues. Between the endothelium and epithelium, however, they remain relatively small borders for life, whether the cells grow or not. In the cornea, in cartilage, in bone, in tendon and in other tissues, the intermediate substances (Zwischen«ubstanzen) increase in extent with advancing age, and this increase takes place at the expense of the cells. The cells diminish in circumference, or entire cells perish ; that is to say, they are entirely converted into basis substance. I repeat it once more, they are transformed, but they remain alive; they can be metamorphosed again into the form of cells, and this is, in fact, what occurs when the tissues 1 There are some exceptions to this rule. The first vitelline spheres of the rahhit's egg, for example, look as though they would fall apart if the vitelline membrane were not there. But that does not hold for the subsequent segmentation which concerns us most here. 2 A. Brticke has introduced the term "Zell-leib" into literature, and it has been generally accepted. [Note of the Translator.] 8 PATHOLOGY OF INFLAMMATION. suppurate. This basis-substance assumes a fixed character which varies according to the nature of the tissue; it becomes different in bone', different in tendon, and different in cartilage. And these peculiarities of the basis- substance invest the tissue with its peculiar type. The metamorphoses of tissue sketched here will be spoken of again further on. For the present this reference will suffice to make clear the structure of* the capillaries. We know now that the presence of the brown lines after staining with silver by no means allows us to conclude that the nucleated fields were once isolated and have here been connected. And we have no cause for ignoring the experience that in the tail of the tadpole the vessels develop from solid sprouts. A very excellent confirmation of this doctrine of the development of vessels is found in the researches of E. Klein 1 on the embryo chick. The first bloodvessels in the embryo can evidently not be produced as sprouts of already existing vessels. The first bloodvessels, as shown by Klein, are formed by single cells. The cells grow ; the peripheral part of the enlarged body of the cell becomes bloodvessel ; the central part becomes isolated from the peripheral by the formation of slits between them, so that the central part then lies in a cavity. By the subdivision of this central portion blood-corpuscles are formed.* 2 We, accordingly, have to deal with an encapsulated closed bloodvessel, with blood-corpuscles in the interior. The individual capsules send out solid processes ; the processes become hollowed out, they coalesce with the processes of other capsules, and thus there is formed a system of communicating canals. In principle, then, this development of a vessel is analogous to the one already delineated. In the one case, as in the other, there are masses which are at first solid, and subsequently become hollowed out. A similar mode of formation of blood- vessels also occurs in neoplasms, and Kokitansky was the first who described them as cystic formations — as cysts containing blood-corpuscles. After all that I have already said, there can no longer be any doubt that in their embryonic state the capillaries consist of contractile protoplasm. But why do they not react invariably in the tail of the tadpole ? 3 A living muscle invariably contracts under the influence of sufficiently powerful irrita- tion, why not the capillaries? As the result of a comparison of" the capillaries of a mammalian embryo with those of the tail of a tadpole, I have been led to suspect that the capillaries of the latter animal acquire, at an earlier period than those of the former, that rigidity which is peculiar, even in a more marked degree, to the vessels of the adult animal. The tadpole, though it is an embryo as regards its stage of development, still lives independently in the water, and uses its tail as a means of propulsion, even before the blood circulates in it. And it is therefore readily understood why the tissue here acquires, at an early period, the rigidity which corresponds to its developed function. Accordingly, in my experiments, I made use of the youngest tadpoles possible (1.5 centimetre long), and directed my attention principally to the vessels lying nearest the edge, because I believed that their growth began at the margin of the tail. And, true enough, I learned 4 that under these circumstances the capillaries regularly narrowed their lumens after every somewhat powerful irritation, and again dilated the same after the removal of the stimulus. But, when I lay stress upon the fact that the capillaries react promptly only in an early embryonic state, I do not mean to say that the capillaries of older animals do not contract at all. If we consider certain phenomena in living ' Wiener Sitzungsberichte, Bd. 63. 2 This description is schematic. The occurrences in the interior of such a cell are exceedingly variable. Whal I have described, however, is in principle l>,-isr 5 - tions of these cells in my Manual of Histology. 5 These cells are at times so large that they nearly fill up the lumen of the acinus, and at others, again, so small that (as in Fig. 4) they merely form an epithelial lining for the relatively large lumen. But now Spina and I have discovered 6 that these glandular cells become so much enlarged under certain stimuli as to till up the lumen of the acinus (as in Fig. •">), and that they become smaller again after the stimulus has ceased to ad upon them. Since this observation is of general importance, I shall here briefly de- scribe how it may be made. You must cut out the membrana nictitans of a living frog and spread it out in the aqueous humor on the stage of a micro- scope arranged for conducting electric stimuli. 7 Now cut off with scissors 1 MUller'a Archiv, 1852, Bd. I. 2 Rynek, Untersuchungen aus dem Inst, fur Physiologie in Graz. Leipzig, 1870, S. 104. 8 Vulpian, L^-ons sur l'appareil vaso-moteur, t. i. Quatrieme lecon. * Wiener mediz. Jahrb. 1880. 6 American edition, pages 40 and 41. 6 Mediz. Jahrbucher, 1. c. " See Manual of Histology, American edition, page 15. THE VASOMOTOR NERVES. 11 the thick edges, especially the muscular layer which lies upon the lower third of the membrane, where it is inserted into the cutis. Now cover the speci- men with thin covering-glass, and look, with a high power, for one of the many easily-discoverable glands, but one with as large a lumen as possible. If you allow a few currents from the induction coil 1 to pass through the speci- men, the cells immediately swell up and soon fill the interior. If the current be too strong, the cells ' do not return again to their former position ; the gland dies in this condition, with large cells occluding its lumen. But if the current be not too powerful, the cells soon again diminish in size (retract) ; the lumen of the acinus again becomes visible. As a rule, the lumen does not again become quite as large as it was before the stimulation, in the case of the excised membrane. But no matter, the stimulus can be reapplied and the enlargement of the cells again observed. As a general thing, the cells do not react any more after the second or third stimulation. If, however, the stimulus be indirectly applied, that is, transmitted through the nerves, we can repeat the experiment very often and always observe a complete retraction of the cells. For this purpose you must place the web of a living frog under the microscope and irritate the ischiatic nerve. 2 When cells enlarge they must absorb fluid, since an increase of volume without an increase of mass is impossible. By a reduction in size, on the other hand, fluid must be forced out again. Now we have advanced the hypothesis that by this absorption and expression of fluid, secretion is brought about. But here this is of minor importance. Here we are only concerned with the fact that cells have been observed which actively enlarge in order to narrow a lumen, and actively retract again in order to enlarge the lumen. For this discovery proves that an active contraction as well as an active dila- tation of a vessel which possesses no muscular fibres, is not without analogy. The Vaso-motor Nerves. — The contraction as well as the dilatation of bloodvessels is regulated by the spinal cord, by means of special nerves which are called vaso-motor. It is true that, microscopically, the special relation between nerves and vessels is not yet sufficiently clear. "We know that nerves pass between and along the vessels, but we do not yet know the termina- tions of nerves in the vascular walls. On the other hand, the fact of the inner- vation of vessels has been placed on a secure basis by experiment. The doctrine of the vaso-motor nerves, founded on vivisection experiments, may be placed by the side of descriptive anatomy, as regards the certainty of its fundamental laws. This doctrine, too, forms a natural supplement to anatomy ; for in the corpse we cannot see the final terminations of the nerves, and, up to the pre- sent date at least, we have not been able, with the microscope, to distinguish the nerves in regard to their function. The microscope gives us no clue as to whether a nerve is sensory or motor, whether it obe} r s the will, or whether it supplies the vessels or the glandular cells. To all of these questions, vivi- section experiments give us positive answers. Experimental angeioneurology, then, in view of its great importance as regards the circulation, may, from this standpoint, be regarded as one of the most important doctrines in medi- cine. I would even advance the opinion that no physiologist, no pathologist, no therapeutist, can follow his profession in a precise manner without being familiar with this field of inquiry. 3 What I introduce here is, indeed, only 1 The strength of the current necessary, every one will readily find out by commencing with a very weak one and then increasing the strength until it has effect. 2 This irritation requires special precautionary measures. See, on this point, Strieker and Spina, in the article already quoted (Mecliz. Jahrhiicher, S. 368). 3 I have added this remark in order to combat the view that even this little is superfluous for the practical interests of surgery. 12 PATHOLOGY OF INFLAMMATION. an incomplete portion. Remembering the practical tendencies of the physi- cian, I shall not in those pages give more than is necessary for the compre- hension of the influence of the nervous system on hyperemia and ischsemia. The vaso-motor nerves come from the spinal cord, as was first recognized by Waller and by Budge. 1 They pass out with the roots of the spinal nerves, and then reach their peripheral terminal expansions by various routes. We can arrange these routes into two main groups : — A. First Main Group. — A large majority of the vaso-motor nerves leave the spinal nerves with the rami communicantes, and with the latter enter the great sympathetic. They run a short distance upward or downward in the great sympathetic, and then leave it in two ways: (1) As independent branches of the great sympathetic, as they are represented, for example, by the splanchnic nerves, which, I may remark, contain the principal mass of the vaso-motor nerves for the abdominal organs. (2) After they have ascended or descended a distance in the great sympathetic, they return again by means of rami communicantes to the spinal nerves, and together with these reach the parts which they supply. This arrangement holds good for the skin, the muscles, and the bones. Thus, for instance, the vaso-motor nerves of the foot leave the spinal cord with a series of roots of the dorsal and lum- bar nerves, descend in the great sympathetic, leave it deep in the pelvis, and reach and enter the sciatic nerve by means of a small communicating filament. B. Second Main Grovp. — A considerable number of vaso-motor nerves do not enter the sympathetic at all, but go directly into the corresponding spinal nerves, and reach their terminal expansions with them. Thus, the hind-paw of the dog receives both the previously mentioned nerves, which enter the sympathetic, and, on the other hand, the last-mentioned nerves, which come directly from the spinal cord with the roots of the sciatic, and reach the paw with the branches of that nerve. It will be convenient for the further dis- cussion of this subject to designate the last-mentioned class as the direct, and the first-mentioned as the indirect supply. The circumstance that a peripheral region of the body receives its vaso- motor nerves from many spinal roots, plays a part (as I shall show imme- diately) in the recovery from hyperemia. In order to illustrate my meaning for the present by a comparison, we need only consider the case of a man who draws his income from many sources; such a man need not suffer hunger though one or several sources be exhausted. To support this comparison by another (imaginary) case from practice, let us suppose that the lumbar por- tion of the spinal cord lias been completely separated from the dorsal portion by a projectile, but that the projectile has remained in the spinal canal, and has done no further damage, the great sympathetic being accordingly unin- jured. The lower extremities will now be completely paralyzed and insensi- tive, because all the nerves which give them sensation and voluntary motion have been divided. This condition is incurable. After the injury, moreover, the lower extremities are warm (hypersemic), since a considerable number of nerves have been divided, which formerly gave a certain tone to the blood- vessels. But these divided vaso-motor nerves were not the only ones which maintained the vascular tone in the limbs, for I have said that the sympa- thetic was uninjured. Now, as before, vaso-motor nerves from this penetrate the sciatic vaso-motor nerves which have not been at all injured by the pro- jectile. In fact, the hypersemia of the lower extremities passes away; they 1 1S53. Quoted from Vulpian's Leeons sur I'appareil vaso-moteur, t. i. p. 23. THE VASOMOTOR NERVES. 13 again become cool ; they must, accordingly, have again acquired a vascular tone in spite of the paralysis and loss of sensation. I consider this case only hypothetically in man, because I have only experimented on dogs. But I know that persons whose spinal cords have sustained complete lesions of con- tinuity in the lower dorsal region, have cold lower extremities during the course of the disease. Whether that which has been proved with regard to the hind-paw of the dog holds good for all other regions of skin and muscle, has not yet been ascertained; but, for reasons which I cannot explain here, it is probable that elsewhere this condition is also present. With reference to man, I hope that clinical observations will clear up this question. The vaso-motor nerves are divided according to their function into two groups : those, irritation of which contracts the vessels, and those, irritation of which dilates them. The former, called vaso-con stridors, normally produce a certain tone of the bloodvessels, and hence exert a continual influence on the distribution of the blood and on the fulness of the bloodvessels. In the supposed case of injury of the spinal cord and subsequent curable hyperemia, I, of course, had in mind only the vaso-constrictors. Their antagonists, the vaso-dilators, do not, as far as at present known, exert a continual influence; they act under certain conditions only, when they receive a special stimulus. The vaso-constrictors are dominated over by ganglionic cells (centres) of the spinal cord, and especially of the medulla oblongata, which plays so important a part in this function, that it for a long time was supposed to contain all the centres of the vaso-motor nerves, on which it was believed, on the other hand, that the spinal cord had no influence at all ; but this supposition has not been verified. I, in particular, have shown 1 that on the boundary line between the cervical and dorsal portions of the cord there are also located important centres for the vaso-constrictors. The nerve-centres which dominate the constrictors also control the blood pressure. This fundamental law of physiology we owe to Carl Ludwig and his pupil Thiry. 2 When the nerve-centres send out powerful impulses, and the vessels consequently become very narrow, the blood cannot flow out of the aorta readily. But since the heart pumps fresh quantities of blood into the aorta, the tension of the walls (i. e., the blood pressure in the aorta) must rise. When, however, the nerve-centres do not send any impulses, or only weak ones, then the bloodvessels dilate, the blood flows out of the aorta readily, and its tension must decrease. Exactly the same thing occurs here as in every system of pipes or rivers. When the channels of discharge are obstructed, the pressure on the lateral walls above the seat of the obstruction rises. A second fundamental law, the enunciation of which we likewise owe to C. Ludwig 3 and his pupils, tells us that the bloodvessels of the abdominal viscera are the principal regulators of the blood-pressure. The bloodvessels of the abdominal viscera, that is to say, have so great a capacity, and by dilatation and contraction can increase or diminish their contents to such an extent, that they act like a mighty reservoir. If this reservoir is wide open, it can contain so large a portion of the total amount of blood that the rest of the organism becomes anaemic. An animal with complete paralysis of the vaso-motor nerves of the abdominal viscera, therefore, bleeds to death, as it were, into its own abdominal bloodvessels. The nerves which influence these vessels lie principally, as already remarked, 1 Wiener mediz. Jahrb. 1878. Still earlier, one of my pupils (Schlesinger), and at the same period Vulpian, had shown that it could not be the medulla oblongata alone which controlled the vaso-constrictors. The full proof, however, of the existence of such centres in the spinal cord was brought forward in my paper just quoted. 2 Wiener Sitzungsberichte, 18(54, Bd. 49. 8 Arbeiten aus. d. physiolog. Anstalt zu Leipzig, 1867 u. ff. 14 PATHOLOGY OF INFLAMMATION. in the splanchnic nerves. Therefore, when the splanchnics are divided, an intense hyperemia of the abdominal viscera is produced, accompanied by a fall of the blood-pressure and an isehaemia of the remaining organs. The splanch- nics, as I have likewise already remarked, are branches of the great sympathetic, and before entering the sympathetic leave the spinal cord with the roots of the upper dorsal nerves. If we divide the spinal cord low down, at about the border of the dorsal and lumbar portions, the points of origin of the splanchnics scarcely suffer at all. An animal thus injured is paralyzed and insensitive in its hind-legs, but otherwise may feel well, as far as the condition of the wound permits. Indeed such an animal, as a rale, becomes perfectly well and lively again, and differs externally from a healthy animal only in dragging its hind-legs. It is quite different if the division be made higher up, about the region of the second or third dorsal vertebra. In consequence of such a wound, all the vaso-motor nerves of the abdominal viscera become separated from their central ganglia ; from those on the border between the cervical and dorsal portions of the qord, as well as from those in the medulla oblongata (see page 13). In consequence of this there ensues such an intense hypere- mia of the abdominal viscera, and such a considerable fall in the blood-pres- sure, that an ischemia of the other organs arises which may prove fatal. It is not, however, without importance for the physician to learn that, even after such a division of the spinal cord, the abnormal distribution of the blood is not always fatal; since the vaso-motor nerves of the abdominal viscera still remain connected with some centres which are located farther down in the dorsal portion of the spinal cord, and certainly reach as far as the region of the lower dorsal vertebrae. I have ascertained this by the following series of experiments : — If in a dog we divide the cervical portion of the cord just below the medulla oblon- gata, the animal soon ceases to breathe, because the nervous centres of respiration in the medulla oblongata (with which Legallois and subsequently Flourens have made us acquainted) are separated from the peripheral nerves of respiration. But if we employ artificial respiration, as is generally the practice in vivisection experiments, we can keep up the circulation and heart-beats respectively for hours. True, the blood-pressure is low, 1 because important vaso-motor centres of the medulla oblongata are disconnected from their peripheral nerves ; but the important vaso-motor centres at the lower border of the cervical portion still perform their function, for, as already observed, the incision is made high up in the neighborhood of the atlas. Now I have completely extirpated the cervical portion of the cord, from the medulla oblongata down to the fifth cervical vertebra. Such an operation causes some hemorrhage, in spite of all precautions ; the animal sutlers from this hemorrhage ; but the influence on the blood-pressure is trifling. But if I continue this extirpation down to the first dorsal vertebra, the blood-pressure sinks suddenly to an extremely low level (about 20 mm. mercury). But the circulation still continues. Yet, as soon as I proceed with the extirpation beyond the first dorsal ver- tebra, the blood-pressure falls to nearly zero, and soon the heart-beats cease. Thai it is really the accumulation of the blood in the abdominal viscera which causes death, can be demonstrated by an experiment which we also owe to C. Ludwig, and which, it scorns to me, is of the greatest practical importance. If we knead the abdomen vigorously at the time when the heart-beats are about to cense, these immediately become more energetic. For by this kneading a portion of the blood which has accumulated in the abdominal veins is forced (by the pressure of the hands) into the heart, and the ;i<-ii of w< '11 -developed frogs, during the first days of October, seventy-two hours suf- ficed. 2 I say presumably. In a subsequent section (page 52) I shall show that this assertion also is not quite true. SUPPURATIVE INFLAMMATION IN TENDON, CUTIS, BONE, ETC. 07 of cells at the expense of the basis-substance. The cells do not consume the basis-substance, but the basis-substance is converted into cell-body; is trans- formed again into protoplasm. By this time I was finally compelled to drop the assumption of fissures between the cells and basis-substance of the cornea. I was forced to assume that the parenchyma of the cornea was a coherent, living mass, which was traversed by neither crevices nor fissures. In the living cornea no cells migrate ; the migration is only apparent. The inflamed cornea of the frog is capable of assuming, at any part, the appearance and peculiarities of the amoeboid cell. Such a metamorphosed spot, however, is not yet a migrating cell. It does not become a migrating cell before it separates from its matrix, and such a separation takes place in mass, only in actual suppuration. But this does not exclude the possibility of certain pieces being separated under other favorable conditions, and of their appearing as migrating cells on the surface of the cornea or in some pathological cavity. I shall return to these new observations on the phenomena observed in the basis-substance, on a subsequent page (p. 52). For the present, what I have said will suffice to make the subject of suppuration of the cornea fully comprehensible. Suppurative Inflammation in Tendon, Cutis, Bone, Cartilage, and other connective substances. In the tendon, the cells have other forms, and a different arrangement from that which exists in the cornea. In the latter, the cells are flat and their broad sides lie parallel to the surface. Hence we see them most advantageously in entire cornea?, or in lamella? of entire cornea?, if spread out on the slide ; for then the cells present their broad surfaces to the observer. But in tendinous tissue, the cells are composed of little rods, which run parallel with the fasciculi of the tendon, and with its long axis. The processes of these cells arc ribbon-like ; they pass out from the rod-like cells just as flags do from flag- poles. In place of the flat cells of the cornea, with thread-like processes, we have, accordingly, in the tendon, rod-like cells (flag-poles), to which on the same level numerous (three or four) flags are attached. These flags however do not wave free, but become attached to the columns of basis-substance (" fibrillar fasciculi," these columns are called here), and as it were envelop them. In my lectures, I demonstrate this relation by placing a white Avax- candle, as representative of the fibrillar fasciculus or column of basis-sub- stance, side by side with a red wax-candle, as representative of a cell. On the free vertical border of the red candle (flagstaff), I attach, at each level, several flags cut out of red paper (Fig. 7), and wrap them about the white candle so as to inclose it as if in a sheath. In cross-sections, these rod-like cells with pendant processes resemble flat cells with thread-like processes; in short, resemble cornea corpsucles. In the cross-section of a tendon stained with gold, we therefore see a picture analogous to that of the lamella? of the cornea. In cross-sections of young ten- don, the cells are large, and the "basis- substance (in this instance the trans- C, cells. F. flags. F' is called Boll's Streifen. and is nothing else than a longitudinal section of a flag. 38 PATHOLOGY OF INFLAMMATION. verse sections of fibrillar fasciculi), on the contrary, sparse. The older the tendon becomes, the smaller are the cells and the thinner their processes, the more extensive on the other hand the basis-substance, i. e. the fibrillar fasci- culi. These cells and their processes are converted into elastic tissue, as has been shown by Spina. The older the tendon becomes, the more do the cells assume the character of elastic tissue. Hence the great power of resistance in the tendons of old persons and old animals. The structure of the cutis is similar to that of the tendon. 1 Only the bundles of fibrilke, or, in other words, the columns of basis-substance, do not run parallel with one another as in the tendon, but are interwoven. Waldeyer was the first to show 2 that the basis-substance in bone was formed from cells (called osteoblasts). It has furthermore been shown by Steudener 3 and I. Wolff, 4 that, with the increased age of bone, the cells (bone-corpuscles) become smaller, and the basis-substance between them greater. In addition, Heitzmann was the first to prove fully that the bone-cells had processes which traversed the basis-substance, sent out numerous branches there, and anasto- mosed with the processes of neighboring cells. The cavities in which the bone-cells lie, as well as the anastomosing network of finest canalculi in which the cell-processes lie, were already known ; and it was especially on a knowl- edge of these facts, as has been previously remarked (page 33 et seq.), that Virchow based his theory of nutrition of the tissues. Inasmuch as, adhering to Schwann's views, cells were regarded as vesicles, the small cavities in bone could also be considered as cells. Accordingly we were supposed to know of anastomoses of cells in bone, and herewith to have a substratum for the nutrient current. But inasmuch as the ideas of histologists on the nature of the cell changed in 1861 — inasmuch as since that time we have not ventured to recognize the presence of a cell except upon seeing a protoplasmic body with a nucleus — it has become clear that the cavities in the bone and the canaliculi are the residences of the cells, and not the cells themselves. In fact, the cells in bone have only been described at a later period by Krause, 5 and the protoplasmic processes by Heitzmann, as already mentioned. Thus we see a complete analogy between bone and the cornea stained with gold. Here, as well as there, the cells and their processes form a network the meshes of which are filled up with basis-substance ; here, as well as there, the basis-substance is produced from the peripheral zones of the bodies of the cells. But bone is distinguished from the other analogous tissues in that lime-salts are deposited in the basis-substance. More difficult than in the case of bone has been the inquiry into the rela- tion of things in cartilage. And yet cartilage is the very tissue which has the greatest interest for us. This interest is in the first place historical, because the earliest observations on inflammatory metamorphoses of tissues were made on cartilage by G-oodsir and Redfern. Virchow 's theory, that disturbance of the nutrition and function of the cells was the main criterion of inflammation, likewise found considerable support from an observation of cartilage. This tissue interests us, furthermore, because in certain portions, iit least, it lacks bloodvessels and nerves. How are the cartilage-cells nourished? How, moreover, is the inflammatory process propagated in cartilage if vessels and nerves are wanting — if the cells besides (each com- pletely isolated) are deposited in firm capsules of basis-substance? Virchow 1 Tin's lias been proved under my supervision by Dr. Ravogli of Rome. See Mediz. Jahr- bticher, 1879. 2 Arcln'v f. mikr. Anatomie, Bd. I. 3 Beitrage znr Lehre von der Knochenbildung. Halle, ls7. r >. * [Jnters. liber d. Entw. d. Knochengewebes. Leipzig, 1875. B Anatomie, 2 Auil. I. SUPPURATIVE INFLAMMATION IN TENDON, BONE, CARTILAGE, ETC. 39 said that the process was propagated from cell to cell. I opposed this view in 1869. The union of the cells amongst themselves I was not yet familiar with at that time, and I could not therefore conceive how the process pro- ceeded from cell to cell. An insight into the method of nutrition of cartilage was nevertheless granted to me even then. One of my pupils 1 had found that by staining hyaline cartilage with osmic acid he could make canals appear, by means of which the spaces in which the cells lay communicated with one another. Another of my pupils 2 had found that pigment-granules could penetrate the basis-substance of living cartilage. In order to see this, he pointed out, you need only inject the coloring matter into the blood, and then apply an inflam- matory stimulus to the cartilage. I availed myself of these discoveries to show that there must needs be a nutritive current in cartilage. In conse- quence of the stimulus of inflammation, I said, this nutritive current becomes increased. The current must come from the blood. The nutritive current carries pigment-granules along with it. The pigment-granules penetrate the cartilage, and remain lying there ; they serve as signs of the current which has passed, just as the stones which are swept along by the torrent and carried off, remain lying somewhere, and serve as signs of the flood which has passed away. Closely connected with this view of the case, and based on the researches of one of my pupils, 3 was the further assertion that the cartilage-cells like- wise underwent inflammatory changes, as stated by Goodsir and Redfern, and as maintained, too, by Virchow and his followers. But my position was hostile to the theory of emigration, and hence the supporters of that doctrine denied the capability of cartilage to participate in inflammation. In like manner, my assertion of the penetration of coloring matter into cartilage was disputed. More recently, however, the penetration of coloring matter into cartilage has repeatedly been seen, and is now quite generally admitted. But Spina 4 has shown even more, namely, that the pigment- granules advance through the processes of the cartilage-cells. The fact that there was cartilage the cells of which were united by processes, was known long ago. But that such was the structure of hyaline cartilage, that the apparently structureless, intermediate substance between the cartilage-cells was traversed by a system of the flnest processes, was not known. Heitz- mann 5 was the first to report the existence of such ramifications in the basis- substance of hyaline cartilage. He asserted, as early as 1872, that he could see these processes in the fresh condition. In addition, he has made a very fine network appear in the immediate neighborhood of the cells by staining with gold. But I was not inclined to regard these specimens as conclusive. Mean- while Spina has advanced new proofs of the existence of such processes ; they become visible when a thin section of hyaline cartilage is treated with alco- hol. Spina 6 has shown, furthermore, how the cells of cartilage become con- verted into basis-substance. I shall not enter further into a discussion of this matter, but shall only remark that wo have become familiar with a condition of things analogous to that in bone. On the other hand, Kassowitz, 7 after examining cartilage in various pathological conditions, has made the assertion that new cells develop in the basis-substance of cartilage, and that it is itself living matter. Accordingly we now see an analogy between cornea, tendon, cutis, cartilage, and bone. 1 Bubnoff, Wiener Sitzungsberichte, 1868. 2 Reitz, Wiener Sitzungsberjcbte, Bd. 55. 3 Hutob, Wiener med. Jahrbiicber, 1871. 4 Wiener acad. Sitzungsber. 1879. 6 Studien am Knorpel und Knochen. Wiener mediz. Jabrb. 1872. 6 Wiener acad. Sitzungsber. 1879. 7 Wiener mediz. Jahrbucber, 1S79-1880. 4:0 PATHOLOGY OF INFLAMMATION. True, there are differences between these kinds of tissue. The basis-sub- stances of cornea and cartilage appear homogeneous throughout under the microscope, with this difference, that we can see the cells of normal cartilage in a quite fresh condition, whilst we cannot see those of the cornea until alter the application of reagents. In these two kinds of tissue there are no blood- vessels, no interstices with nutrient fluid; they cannot become ©edematous. Tendon and cutis are not as homogeneous as cornea and cartilage. In tendon a loose interstitial tissue, in which the bloodvessels run, extends along the more or less dense bundles of tissue ; this interstitial tissue can become cede- matous. Accordingly only these more or less dense bundles of tissue furnish us with an analogy to the cornea as regards homogeneousness. "We have a similar condition in the cutis. But here, as already remarked, the bundles of tissue do not run parallel with each other, as in tendon, but are interwoven, whereby the transverse section in the cutis acquires a very complicated ap- pearance. Bone is likewise traversed by vessels, and encircling these we have, now abundantly, now more sparsely, a tissue (medullary tissue), which differs from the real compact substance of the bone. With respect to homogeneous- ness, only the compact substance of the bone is analogous to cartilage. 1 In fact it has now been indisputably proved 2 that compact cartilage customarily passes directly over into compact bone. If cartilage is transformed into bone, canals must be formed in the cartilage, and in these canals bloodvessels must be produced. The formation of canals in cartilage results from a so-called melting or liquefaction (Einschmelzung) of the substance of the cartilage. This liquefaction may be regarded as the physiological type of suppuration. It is exactly the same process as that which, in pathological conditions, we designate as the formation of an abscess. The basis-substance disappears, the cells enlarge and divide. In pathological conditions, we call the cavity which is formed an abscess-cavity, and the products of division, pus-cells. In normal liquefaction (Einschmelzung) the products of division are called medullary cells, and the cavities, medullary spaces. Similar conditions, moreover, prevail in developed bone. The compact substance may liquefy (einschmelzen) in the course of normal development as well as in patho- logical conditions. In the former instance we speak of medullary spaces and medullary cells ; in the latter instance of abscess-cavities and pus-cells. By the formation of medullary spaces, or of abscess-cavities, cartilage a3 well as bone becomes porous or spongy. The spongy bone can undergo com- plete suppuration if the liquefaction makes headway, if the spaces enlarge. On account of the physiological peculiarity of their basis-substance, bone and cartilage form a tissue sui generis. Their relationship with the cornea, ten- don, and cutis, has until now only been demonstrated with regard to the relation of cell to basis-substance. In the cutis, as I have said, the bundles of tissue do not run parallel as in the tendon, but are interwoven. In the cutis, however, the network forms compact masses, which do not offer space for the collection of oedema, as far as microscopical examination enables us to judge of the same. 3 Now, there i- a scries oftissu.es which consist of bundles analogous to those in the cutis, but in which the interlacement is so loose that fluid can very easily permeate them. To this class subcutaneous and submucous tissues belong. The loosest 1 I do not rcfrr here at all to the complicated relations in bone, since I cannot enter into a sufficiently detailed account, and I do not know, moreover, how much of the known structure is to t»' Been in the living Bubject. 2 Lieberkuhn, Stretzoff, Kassnwitz. 8 Within the cutis itself, however, such collections are probably possible around the vessels. THEORY OF FIBRILLuE AND OF CONNECTIVE SUBSTANCE. 41 arrangement of this kind is represented by the subarachnoid tissue. This consists only of single bundles which float in the space tilled with fluid. All of these tissues provided with interstitial meshes, were still called cellular tissue during the first ten or twenty years of our century. "Cellular" does not signify that cells are present, in the acceptation of the term as intro- duced into modern histology by Schwann, but that cell-like, honeycomb-like spaces are present. Job. Muller has introduced the expression "connective tissue" for this tissue. If we neglect the varying width of the meshes, and even the very existence of the meshes, we in fact see a columnar (strangfor- mige) formation prevailing in tendon, the tendinous membranes, the cutis, the mucous membranes, and subcutaneous and submucous tissues ; in the mesen- tery and in other serous membranes. This columnar formation is peculiar, therefore, to connective tissue, even where it does not produce a cellular tissue. In place of columnar formation, I shall henceforth employ the more usual term of connective-tissue bundle. Accordingly, connective tissue consists of bundles that are united in various ways. But every bundle consists of cells and basis- substance. Every bundle, whether large or small, therefore, forms a compact mass similar to cornea and cartilage. Every such bundle can suppurate, and that, too, in the same manner as described for the cornea. Theory of Fibrilla and of Connective Substance. Every bundle such as can be made to appear in tendon, cutis, subcutaneous tissue, subarachnoid tissue, and others, may also be designated fibrillar bundle. Uow the question of the occurrence and genesis of the fibrilla?, constitutes one of the most important chapters of normal and pathological histology. I might almost say it constitutes one of the most important chapters of all pathology. For that frightful host of diseases which are designated as cicatrizations, con- tractions, scleroses, and (in order to make special mention of only a single series), those severe forms of disease of the central nervous system known as tabes dorsalis, lateral sclerosis, and multiple sclerosis, which, though probably only chronic inflammations yet lead to the destruction of life in spite of all remedies, all consist essentially in the formation of such fibrilla?, or, still better, of a transformation of the nerve tissue into fibrillar tissue. Histologists had recognized the fibrillar by the examination of tissues that were dried or altered (contracted) by reagents. If we soften in water a dried cornea or a dried tendon, and tease it, we will see under the microscope very fine fibrilla?, which are arranged at times in large bundles, at others in small ones, or which traverse the field of view singly and in an irregular manner ; in short we receive the impression that the entire tissue consists of such fibrilla?, but that they have been thrown into confusion by the teasing. On the ground of these observations, it was said : Cornea, tendon, and cutis consist of fibrillar tissue. On similar grounds we can go further, and say in general: The connective tissue cords consist of fibrilla?, they are bundles of fibrilla?. More recently the basis-substance of macerated cartilage and bone lias also been recognized to be fibrillar. And thus we see another analogy between connective tissue, on the one hand, and bone, cartilage, and cornea, on the other. They all consist of cells and basis-substance; in the dried or mace- rated state they all disclose a fibrillar structure. In the year 1845, Eeichert classified all these tissues, and a series of others which I will mention hereafter, under the common name of connective sub- stance. Reichert in effect denied the existence of fibrilla? in a series of tissues. It was not the fibrilla?, but a peculiar substance, which was characteristic of all these tissues. Thus the term connective substance indicates, as it were, a 42 PATHOLOGY OF INFLAMMATION. histological theory. The entire armament of the older microscopic methods was brought to bear on this assertion of Reichert. In the first place it was Alex. Rollett, who, under Briicke's direction, demonstrated the existence of these fibrillse in spite of Reichert's assertion. The fibrillse, he said, are united by an albuminoid cement. If we preserve the cutis in lime-water, or in baryta-water, the cement is dissolved, and the fibrillse fall apart. These results agreed with the tendencies of the microscopists of that time, and a large majority of histologists take this standpoint even at the present day. The doctrine of the fibrillar structure of connective tissue appeared, and still appears, to stand on a solid foundation. The disclosure of fibrillse in bone by Ebner, 1 followed entirely in the spirit of the method by which Rollet had demonstrated the existence of fibrillse in the cornea. It was the old method of examining macerated tissues. "We are very much indebted to these methods. By their aid histology acquired its first solid foundations. The examination of contracted and macerated specimens is indispensable even to-day, and will remain so, perhaps, for all time. But the results must be checked by the examination of living tissues ; by the examination of tissues at various ages of their growth ; and finally by the examination of the tissues in pathological conditions. Neither the cornea, nor the tendon, nor the cartilage, permits of the recognition of fibrillse in the fresh state. 2 The basis-substance appears homogeneous in all. Now the objection may be raised that this proves nothing. The basis-sub- stances appear homogeneous, because the fibrillse are united by a cement ; because fibrillse and cement possess the same optical properties. If I deny the existence of fibrillse on account of the homogeneous .appearance of the basis-substance, I must likewise deny the existence of the cornea-corpuscles, it may be said. For the fresh cornea shows no structure at all ; it is of a glassy brightness. Must we not admit nevertheless that the network of cells does exist, but that we do not see it because it possesses the same optical properties as the basis-substance? Now this is a very weighty objection, but it is open to discussion, and in order to elucidate this question I shall next introduce a few remarks on the cell-nucleus. On the Cell-Nucleus. If we examine an amoeboid white blood-corpuscle of the frog, we will at times see nuclei, and at times not. A more accurate examination teaches us 3 that the nuclei come and go; that new nuclei also are formed, now in this, now in that part of the cell. It happens furthermore that on one side a nu- cleus gradually acquires the character of the cell-body, while on the other side a new addition is made to the nucleus from out of the cell-body. But as soon as we add acetic acid, nuclei immediately arise in definite shapes, in shapes that were previously not present. This configuration is now a lasting one, since cell and nucleus have become lifeless. The nuclei as they appear in reaction with acetic acid have been known long since. If anybody had asserted twenty years ago that such nuclei did not exist in the living while blood-corpuscles, the assertion would certainly have been regarded as entirely unjustifiable. Now matters are different. The assumption of the appearance and disappearance of nuclei in certain varieties of cells, is almost 1 The (llir ilia; of bone were known before this ; Waldeyer Lad described them in Max Schultze's Archiv, Bd. i. 2 Examined in aqueous humor immediately after excision. 3 First observed by Arndt, and then by myself (Wiener mediz. Jahrhucher, 1878). But the reader must refer to my article, since there are several varieties of colorless blood-corpuscles. FIBRILLAR AND OTHER CONNECTIVE SUBSTANCES. 43 universally admitted. The zoologists even say that my observation is not at all a new one ; that they were familiar with this phenomenon long ago, in the case of the lowest animal forms. Thus, in spite of the majority of cells (for example, young epithelial cells) having recognizable nuclei in the living specimen ; in spite of the nucleus being still regarded as an attribute of the cell, it is nevertheless admitted that there are cells in which the nucleus is not a constant factor — in which, at times, there is no nucleus at all present.} Furthermore, a majority surely of all pathologists admit that, during the' process of inflammation, nuclei appear in such large numbers as to exclude every doubt of their new formation. Now one might say that this is just the condition of things in the case of the network of cells in the cornea. It is true that cartilage and some other tissues enable us to recognize cells in the living specimen; it is true, like- wise, that we can regularly make cells appear in the cornea by the use of reagents; it is true that we can also see them in the inflamed cornea in a fresh state. But from the instances already cited, we cannot conclude with cer- tainty that they exist in the normal cornea. However, I have made new observations on this matter, and when, on a subsecment page, these observations are mentioned, I shall revert to the matter in hand. But before doino; so I must consider a series of other tissues. Comparison between the supposed Fibrillar Substances and the other Connective Substances. A series of tissues, the structure of which is essentially different from that of those already mentioned, is likewise included in the list of connective sub- stances; I mean the so-called framework of the brain and spinal cord (neu- roglia, Virchow), and the so-called adenoid tissue in the lymphatic glands. This tissue consists of cells and their processes, the latter being branched and forming an extensive network. The network is really the characteristic part of the tissue. The cells (points of junction of the network) are entirely ab- sent in certain parts, as, for example, in the sinus of lymphatic glands. Since fibrillar were regarded as characteristic of the connective substance, one was inclined to suppose that this mesh work took the place of the fibrillar But the meshwork of the adenoid substance, as well as that of the neuroglia, is on the other hand analogous to the network of cells in the cornea, in bone, in tendon, etc. ; while the fibrillae into which the latter tissues appear split (after maceration) traverse the basis-substance like the threads of woven cloth. Hence the network of the adenoid substances and of the central nervous system cannot be regarded as analogous to the fibrillae of the connective substances. The analogy between these tissues must be sought for in other points. In the lymphatic glands, the meshes of the network are filled with a fluid in which the lymph-corpuscles float, whence the whole tissue is so soft and spongy. In the gray matter of the brain and spinal cord, the network is filled with a mass which we do not thoroughly understand ; with a mass which gives to the gray matter its peculiar consistence. In the white matter of the brain and spinal cord, the meshes of the network are adapted to the nerve-> fibres; in other words the nerve-fibres are stuck into a net of connective sub- stance. It is probable, furthermore, that in the cornea, in bone, in cartilage, in tendon, etc., the meshes are filled with something that gives to each of these tissues a characteristic physical state. In bone, for example, it is the lime-salts mixed perhaps with other substances. We see accordingly that, in a lifeless condition, each of these tissues belonging to the connective substances 44 PATHOLOGY OF INFLAMMATION. shows cells under the microscope, besides a network of processes and an intercellular substance. If the cornea, or the cord of the tendon, has fallen apart into fibrillar the cleavage extends through the entire basis-substance, as was first recognized by Heitzmann ; it implicates the network as well as the intercellular substance. Only the cell-bodies themselves (the points of junction of the network) withstand the cleavage here and there. Hence also, histolo- tists of former times taught that connective tissue consisted of bundles of brils and of connective-tissue corpuscles. The Transversely Striped Muscular Fibres ; Continuation of the Discussion on the Nature of the Fibrill^e. The property of being resolved into fibrillre belongs not only to the con- nective substances, but also to other varieties of tissue. It has been made known (by Briicke if I mistake not) that transversely striped muscles which have been preserved in alcohol, are very easily separated into very fine fibrilla?. This method of preparation presents us with really splendid pictures of bundles of fibrillre. Each fibril shows the rudiments of the transverse stria- tion, and accordingly looks like a string of beads. On this account, too, we call the transversely striped muscular fibres, bundles of primitive fibrils. All the strings of beads together make up the bundle, the muscular fibre, this lying in a closed sac (the sarcolemma) which is everywhere closely adherent. Formerly, every such fibril was thought to consist of a series of little rods (sareous elements), that were united by a kind of cement, an intermediate sub- stance. As long as the fibrils cohere, it was said, they present the appearance of transverse striation, because a number of sareous elements with intermediate substance are arranged in juxtaposition, and run in a transverse direction. But it was supposed that the muscular fibre could be divided into disks, as well as into fibrils. Muscles of the hydrophilus, preserved in dilute muriatic acid, present such an appearance. 1 Every such transverse disk, consisting only of sareous elements, was called a Bowman's disk. Following Briicke and Rollett, Bowman's disks also received the name of chief substance (Hauptsub- stanz) and the cement between them that of intermediate sidstance. During the last fifteen years, however, the theory of the structure of muscles has materially changed. During this period, so many new and contradictory views on this subject have been published, that I am scarcely able to form a clear idea of the state of literature on the question. Therefore I cannot give a general survey of it, and I have no inclination to do so. I believe that the histologists who are at the present day quarrelling about the presumably very complicated structure of muscles, are on a wrong path. I have conclusive proof that muscle (as far as its perceptible, microscopic structure is concerned) is very simply formed. But I should like to support the description I intend to give by first drawing the following picture. In the transversely striped muscle, the appearance of things is at times somewhat the same as in a dance. The couples change, and the grouping varies. Whoever does not observe the changes, will, it is true, always sec dancing couples. Nevertheless they are not always I he same couples. And it may happen that at one time only single pairs are dancing; at another time two pairs are grouped together; then again several pairs. The dancers may resolve themselves into rows walking in single file (fibrillar), or may form a broad front and march in columns. Finally, they may break up the dance and move about without regular order, or may remain quiet after breaking up. 1 But as a rule several disks adhere together in the specimens. TRANSVERSELY STRIPED MUSCULAR EIERES. 45 If we look at the freshly excised (living) muscle from the extremity of a Hydrophilus piceus, we can observe transformations which correspond to the picture just drawn. The muscle of the aforesaid insect still makes very active movements under the covering glass of a slide. The mass of the muscle undulates to and fro, as it were, and the details therefore cannot be readily perceived. When it has become somewhat quieter, we can see so-called con- tractile waves proceed along single fibres; a knot, a protuberance, apparently passes along the muscular fibre. If the muscular fibres have remained any length of time on the slide, very peculiar phenomena make their appearance, which are probably pathological, because they are the forerunners of death. Some of the muscular fibres suddenly become converted into bundles of fibril- lar, suddenly the fibrillar structure disappears, and the broad ribbon-like character returns in its stead. Then, again, we see variations in the breadth of the ribbons, and in their distances from each other. In addition, the in- ternal structure of the broad bands changes. At times, such a band is bright in the middle and dark at the lateral zones; at times the condition is re- versed. The dark zones appear granular and irregularly bordered at one time, and at another homogeneous. Suddenly the transverse striation disap- pears in a fibre, and it assumes a fibrillar structure. Then the fibrillar are suddenly lost to sight, and the muscular fibre looks like a homogeneous mass provided with granules. A renewed undulation and we have again the ribbon-like appearance. As long ago as the year 18 70, 1 1 gave a similar description in my Manual of Histology. The more modern histological school, however, has scarcely taken any notice of this description. A number of distinguished histologists, then as well as since, have described certain of the variable phenomena as the structure of the muscle, and in this state of affairs it is comprehensible that very different views should prevail. One of my pupils (Heppner) has ac- counted for some of the variable phenomena on the ground of optical illusions. But I must now acknowledge that I myself was deceived in this respect. There are no optical illusions in question here. What Hensen, Krause, En- gelman, Merkl, and other histologists have described in the muscle, is really based on fact, but the fact itself is not constant. The muscles of the trunk of the frog, and also those of mammalia, are not as changeable as the muscles of insects. In the former instance the condition is really one of stability as long as the tissue is normal; but as soon as the muscle of the frog has an inflammatory stimulus applied to it, the stability ceases. True, no such movements arise as in the Hydrophilus muscle. There is a slow displace- ment — a displacement such as I have called internal flowing motion in the case of the white blood-corpuscle. Moreover, when a muscle is about to suppurate, the internal changes become more striking. The muscle loses its transverse striation, the nuclei increase in number, and finally the transversely striped muscular fibre is converted into a mass of young cells or pus-corpuscles. Such changes, and others which are analogous, have been repeatedly seen since the time of Bardeleben (1842), in inflammatory and non-inflammatory new formations in muscle. Otto Weber, Waldeyer, Tchanisky, and C. Weil (the two latter under my direction), and many other authors, have given ac- counts of such processes. More recently, the inflammatory processes have been again very accurately studied by Spina, who has found that not only pus-corpuscles, but also blood-corpuscles, can be developed from the trans- versely striped muscular fibre. 2 1 Strieker's Manual, American edition, pages 1086, 1087. * A similar discovery in the case of carcinomatous degeneration of the muscles of the tongue dad previously been made by C. Weil. 46 PATHOLOGY OF INFLAMMATION. These observations, now, force me to hold the following view: The mus- cular tibre is a contractile mass surrounded by a tube (sarcoli mma), a contrac- tile mass which, at the time of a normal discharge of function, has the peculiar appearance of transverse striation, or more correctly, of possessing transverse bands. But it is only a certain arrangement of the contractile substance which gives it this appearance; an arrangement consisting, perhaps, only of a varying density 1 of the mass. This arrangement can vary according to the order to which the animal belongs, and according to the function of the muscle. It can lead to all the changing appearances which have been de- scribed by histologists. In the fresh (living) specimen, the muscle can resolve itself into fibrilla?, and it is probable that the fibrilla? which are to be seen in specimens preserved in alcohol, made their appearance just previous to death. The best proof of the fibrillar change of the living muscles is offered by pathological processes, especially by inflammation, as has been shown in a most exhaustive way by Friedreich. 2 The fibrillar change in disease can^also be regarded as a fibrillar degeneration, as a destruction of the muscle. Be- sides, we know still another form of destruction of the muscular structure. The muscle may lose its peculiar, transversely-striated appearance, and become a homogeneous, granular mass. Such an appearance of the muscles has in- duced those pathologists who always examine only lifeless tissues, to believe that the homogeneous appearance is a sign of the death of the fibre. But the muscular fibre can continue to live as a homogeneous mass. Its nuclei can multiply; it can suppurate ; it can become converted into blood-corpuscles ; it can produce fat-granules. Various circumstances even seem to indicate that it may regain its normal state after a loss of the transverse striation. After this explanation, I return once more to the question of the nature of the fibrilla?. Is the living muscle fibrillar ? Does the muscular fibre consist of a bundle of fibrilla? ? We can now scarcely answer this question affirma- tively. And yet we must admit that there must be something contained in the muscle to permit of its changing into fibrilla? under the influence of certain stimuli. If we stain the living muscular fibre with chloride of gold, we recognize a fibrillar structure in the specimen ; indeed, here the fibrilla? or little bundles of fibrilla? seem united by an intermediate substance of a deep violet color. This arrangement has been the subject of numerous dis- cussions. Gerlach 3 has asserted that these deep violet tracings between the fibrilla? are the continuations of the nerves. But Gerlach 's assertion has been denied in various quarters. I must confirm the fact that there is a continuity between the threads of the terminal nervous apparatus (which are likewise stained a deep violet color) and the afore-mentioned violet intermediate sub- stance. But that we have here really to deal with the continuations of the nerve, I do not dare to assert. There is a stage in the course of the inflam- matory process in which the entire mass of the muscle has already changed its ap] learance. The transverse stripes have already disappeared ; the approach to suppuration is already declared; nothing more is to be seen of the violet tracings, but the terminal nervous expansion of Kiihne 4 is still to be seen distinctly, and almost unchanged. Considering this, I must now admit that in the muscular fibre, alongside of the main mass (the contractile substance), there is distributed still another substance which stains of a deep violet color — a substance which perhaps favors the separation into fibrilla?. The question 1 The beautiful color phenomena seen with polarized light (Briicke) are well calculated to support this view. 2 Qeber progressive MuBkelatrophie. Berlin, 1873. 3 Max Schultze's Archiv, Band xiii. 4 This is the terminal nervous expansion situated between sarcolemma and the contractile substance, and was discovered by Kiihne. [Note of the Translator.] SMOOTH MUSCULAR FIBRES AND THE CENTRAL NERVOUS SYSTEM. 47 of the nature of this substance is undecided, as is also the question of how this substance is distributed in the living muscular fibre. As regards the fibrillar, we have not yet reached a decision. For the present, let us remember that the fibrillar may appear and disappear again in the living muscle, and, furthermore, that in disease the muscular fibre can be definitively transformed into fibrillar bundles, not, however, losing thereby its functional power. And, relying upon these and other experiences, we will soon obtain a definitive answer. The Smooth Muscular Fibres and the Central Xeryous System. Continuation of the Discussion on the Fibrill^e. A more searching criticism of the hypothesis of the pre-existence of the fibrillar, is furnished us by those tissues which normally never appear fibrillar, whether examined in a fresh or in a macerated state, though it is true that they may become fibrillar when subjected to pathological changes. To this class belong : — (1) The Smooth ITuscidar Fibres. — In the normal state we recognize the smooth muscular fibres as spindle cells with oblong nuclei. In case of sup- puration, the smooth muscular fibres may subdivide and form pus-corpuscks. But there is a regular series of chronic processes in which they are changed into fibrillar The close relationship between fibroma and myoma is based on these transitions. In such neoplasms, we find undivided (non-fibrillated) smooth muscular fibres next to bundles of fibril he. Hence we may be in doubt as to whether we have to deal with a fibroma or a myoma, according as one or the other tissue is more abundant. (2) The White and Gray Matter of the Central Nervous System. — I have already stated that the medullated fibres of the white matter are stuck into a filamentous network of connective substance. ■ This network is directly continuous with that fine network which constitutes the neuroglia of the gray matter. 1 In the gray matter, however, the network is filled up with a mass which, in the living specimen perhaps, is homogeneous, but which appears finely granulated in hardened preparations. This fine network, plus the mass in its meshes, constitutes the basis-substance of the brain and spinal cord. In this basis-substance the ganglion cells and their processes are situated. These processes are of two kinds, as was first shown b}- Deiters. 2 In the first place, we have axis-cylinder processes, such processes as penetrate the white matter and become the axis-cylinders of the medullated fibres. In the second place, the ganglion-cells send out processes which form connections with the network of the neuroglia. These processes were called by Deiters protoplasma processes. Besides the ganglion-cells, we meet with other cells in the gray matter, concerning the nature of which we are not quite clear, and the processes of which are likewise continuous with the network. Many of these cells are called connective-tissue corpuscles. As I cannot here enter into the discussions on the minute structure of the gray matter, 3 I rest satisfied with this description, and recapitulate as follows : In the gray matter there are ganglion-cells and other cells, the pro- cesses of which form a fine network. The network, plus the mass in its meshes, constitutes the basis-substance. But there are also processes which originate in the ganglion-cells, pass directly into the white matter, and con- 1 This network is identical with the substance called " neuroglia" by Virchow. It was first accurately described by Bidder and Kupffer. See the history in my Lectures, p. 561 et seq. 2 Untersuch. iiber Gehirn und Ruckeninark. Braunschweig, 1865- 8 See my Lectures ; Lect. xxxii. p. 5til et seq. 48 PATHOLOGY OF INFLAMMATION. stittite the axis-cylinders of the medullated fibres. In addition, tlie network of neuroglia in the gray matter is continuous with the network of neuroglia in the white matter. In the white matter, however, the network is not filled up with a granular mass, but the meshes of the network adapt themselves to the nerve-fibres. The cells in the neuroglia of the white matter are sparse and very small. Besides the network of neuroglia, another network is found in the white matter, namely in the medullary layer of the nerves. This network was dis- covered by Kiihue and Ewald. 1 The medullated fibre consists of the axis- cylinder, of the medullary layer, and of a structureless sheath (Schwann's sheath) 2 which limits the medullary layer externally. Now it is the medul- lary layer which contains the aforementioned net. The meshes of this network are here filled with the peculiar substance that we call medullary substance. This is a substance rich in fat, which lends to the entire nerve its opacity. If we wish to see the network, we must extract the fat with alcohol and ether, or with alcohol and turpentine. Having deprived a peripheral nerve (for example, the sciatic nerve of the frog) of its fat, we recognize with a magni- fying power of 300 diameters, or better still, with a higher power, that the space between the axis-cylinder and Schwann's sheath is traversed by a knotted network ; by a network whose meshes now (after the extraction of the fat) are light and transparent, thus making the trabecular of the network very plainly visible. This network is inserted on one side into the axis-cylinder, on the other side into Schwann's sheath. Similar networks, though not as sharply defined, are also contained in the medullary layers of central nerves, and in the white matter of the brain and spinal cord. But not all the nerve-fibres of the white matter are medullated. We have, in this respect, the most varied gradations, from nerves with a very thick medullary layer down to nerves with a very thin one, and even axis-cylinders which do not show the presence of a medullary layer at all. Transverse sections of the spinal cord of man, or of the dog, which have been hardened in a two per cent, solution of chromic acid, and then in alcohol, show these relations very plainly, especially if they have been washed well and stained in carmine. For the network of connective tissue as well as the axis-cylinders are stained red by carmine, whilst the me- dullary layers remain almost colorless. If we cause inflammation and suppuration in the spinal cord of a dog, by means of injury, and then prepare it in the manner described, we learn as follows : In the immediate neighborhood of the suppurating spots, the axis-cylinders are thickened. This thickening is very unequal. We find axis-cylinders which are about as thick as a connective-tissue cord of the cutis, and all gradations down to the thinnest axis-cylinders of the normal spinal cord. The markedly thickened axis-cylinders have no longer a medullary layer. The medullary layer is destroyed by the thickening of the axis. Here the relation is exactly the same as it is between cell and basis-substance in the c< >rnea, in cartilage, and in other tissues. The axis-cylinder of the nerve takes the place of the cell ; the medullary layer represents the basis-substance. The medullary layer as basis-substance is distinguished from all other basis-sub- stances in that the meshes of the network in the medullary layer are filled with medullary substance, rich in fat ; it is distinguished, furthermore, in that the network of the medullary layer is easily demonstrable in fresh nerves; and finally in that this network is as firm and resistant as elastic tissues, as has b( m 'ii shown by Kiihne and Ewald. But this network is firm and resistant, only in a normal condition. In the course of the inflammatory process, it 1 Verhanrtl. d. naturhist. mediz. Veroino, Heidelbenr, 1S77. 2 Equivalent 1" tubular membrane. [Note of the Translator.] THE CENTRAL NERVOUS SYSTEM. 49 again becomes similar to the embryonic protoplasm. During this trans- formation the medullary layer disappears. Axis-cylinders and network now coalesce, and form one mass, which looks in transverse section like a large axis-cylinder. But in longitudinal sections we see that the swellings are very unequal; that marked intumescences alternate with spots of almost normal dimensions. Hence the swollen axis-cylinder is wont to look like a knotted club. In these swellings new nuclei arise (as was tirst recognized by Dr. Hamilton). 1 Hence a multinucleated protoplasmic mass takes the place of the medullated nerve. These large nucleated masses soon subdivide into smaller cells which resemble pus-corpuscles. This process, however, does not represent the ordinary form of suppuration of the spinal cord. When the spinal cord suppurates, large numbers of cells containing fat granules are formed. Now with regard to these fat cells in the inflamed spinal cord, a student, Ernst Baumler, has under my supervision quite recently obtained very remarkable results ; results which throw a re- markable light on the theory of suppuration as well as on general histology. The cells with fat granules which occur in the spinal cord are essentially dif- ferent from such fat cells as the colostrum corpuscles, and the fat cells found in the liver and in other glandular organs. The fat cells of the spinal cord are characterized in the first place by their very great variation in size, and by a peculiar appearance of the fat globules. But this is a minor considera- tion. Of much greater importance are the things which are to be seen in the interior of these fat cells after the extraction of the fat. Many of these cells still bear distinct traces of their genesis. Their body consists of a network of exactly the same kind as is observed in the still connected portions of the spinal cord in the neighborhood of the suppurative focus. Whilst on one side of the specimen (that is, towards the cavity of the abscess), these peculiar reticulated cells are found isolated, in the immediate neighborhood they are still connected together, though the lines of partition are already indicated ; and somewhat further off even these partition lines are wanting, though ex- actly the same network is present as in the cells. There can no longer be any doubt that the entire mass of white and gray matter has become sub- divided, in exactly the same manner as has been demonstrated in the case of the cornea by staining with silver. In the case of the cornea, however, a flaw, though only a slight one, still remained in the argument. Are the cells in the already completed abscess- cavity (/. e., the cells after the destruction of the tissue) realty the same as the cells indicated by brown lines in the silver-stained specimens of tissue not yet broken down by suppuration? This is, in a high degree, probable; but the pus-corpuscles of the cornea contain no direct signs of their genesis. In the other case, however, the subdivisions still bear signs of their origin. In the network there remain probably the debris of the very tatty medullary >ul>- stance (really intermediate substance). It is presumable, moreover, that the tissue also produces new fat. For the production of fat is one of the specific peculiarities belonging to Various tissues, and, among others, to the white nerve matter. However, let the fat come whence it may; the essence of the affair is not changed thereby. Not rarely we see also a nucleus in the network of some cells, on one of the trabecule. We also find cells in which the system of trabecule is only partly preserved, the remainder already having formed a homogeneous mass. This phenomenon is entirely comprehensible. I have proved by direct observa- tion 2 that cells which expel their fat-globules afterwards resemble ordinary 1 Quarterly Journal of Microsc. Science, vol. xv., new series. 2 Wiener Sitzungsberichte, Bd. 53 ; 2te Abth. VOL. I. — 4 50 PATHOLOGY OF INFLAMMATION. solid amoeboid cells. On the other hand, we know that in every amoeboid cell vacuoles can appear and disappear. From researches which have been made under my direction on the genesis of nerve-tissue, 1 we know moreover that embryonal cells, while building up the nerve-tissue, while being trans- formed into tissue of the central nervous system, produce numerous small vacuoles within their body, and thus are directly converted into a network. Only subsequently is the medullary substance produced within the network. Accordingly, the entire tissue is subdivided during the process of suppuration into components analogous to those from which it was constructed. Suppuration of the spinal cord is one of the rarest occurrences, unless as the result of injury. The chronic forms of inflammation, however, are less rare. Chronic inflammation of the spinal cord is characterized in most in- stances by the growth of the network of connective substance. The growth represents itself as an increase in mass of the various trabecule of the net- work, and this increase in mass occurs at the expense of the neighboring tissue, at the expense of the adjoining nerves. In the thickened trabecule of the network of connective substance, we also still see vestiges of the axis- cylinders ; vestiges of varying distinctness, according to the degree of meta- morphosis which they have already undergone. Such a condition is found in tabes dorsalis, in the scleroses of the lateral columns, in ordinary chronic myelitis, in syphilis, in the myelitis of drunkards, 2 and in other chronic forms of disease. In the severe and progressive forms, however, the change does not cease with this thickening of the connective substance. The thickened network of connective substance, and the inclosed nerve-fibres, break down into fibrilla?, as was first shown under my supervision by Dr. Nath. Weiss, in a case of tabes dorsalis. The destruction takes place principally in a direction parallel to the longitudinal axis of the spinal cord. In such places we find the white matter of the cord replaced by a fibrillated tissue. Here and there the bun- dles of fibrillre still have the same arrangement as in the normal tissue. In a transverse section we still recognize the arrangement of axis-cylinders and network ; but they already consist of fibrillar which appear (in transverse sec- tion) as small granules, but which can be followed deeper down (in the longi- tudinal direction) by the aid of the fine adjustment, and are thus recognized as sections of fibres. On one side, these spots border on a tissue with no indication of a fibrillar degeneration, in which we can recognize the swollen network of connective substance and the medullated nerves, and on the other side on a felt of fibrillar, from which every trace of the former tissue has dis- appeared. Here w r e accordingly see again (just as in the case of the muscle) a final result of the chronic process which in its consequences as regards the function of the part, is similar to an acute suppurative inflammation. In the one case, as in the other, the nerve-tissue, as such, is destroyed, and the func- tion of the corresponding nerve territory is lost for ever. Hut from a clinical point of view, the two processes vary in the extent of the destruction. An acute process is, as a rule, limited. In this respect let us consider a cutaneous abscess as typical. Such an abscess, in any particu- lar instance, never spreads beyond its original site. The infiltration limits itself, breaks down in the centre, and therewith the height of the process is reached. If no new abscess is formed in the neighborhood, we may look for- ward with some certainty to the termination of the process. The circum- stances are similar in regard to all abscesses, though the importance of the 1 See my Lectures, page 508. 2 F obtained a view of the appearances in these forms of disease through the kindness of Dr. Nathan Weiss, who prepared the specimens in my laboratory. DISCUSSION OX THE NATURE OF THE FIBRILL.E. 51 organ, the functional value of the destroyed portion, must be taken into con- sideration. Xot such is the course in those chronic forms of inflammation that lead to fibrillar degeneration. Judging from the view now prevalent with regard to tabes dorsalis, these processes are terminated by death only. Slowly but steadily does the transformation, the metamorphosis of the tissue, proceed, and thus destroy the function of the organ. Hence, in their import- ance to the organism, these chronic processes are to be compared with malig- nant new formations. But we must here note the following considerations: As long as the fibrillar degeneration has not taken place, as long as the chronic inflammation has not passed beyond swelling of the network of con- nective substance, from the histological standpoint 1 a cure is still conceivable. Accordingly, if physicians should ever be enabled to arrest the progress of the disease before the fibrillar degeneration had taken place, a complete cure would still be possible. It also appears certain to me that absolute rest, that the absolute avoidance of functional hypenemia, is one of the means by which a return to the normal condition in certain well-marked forms of myelitis may be hastened. But where the fibrillar degeneiation has taken place (and this holds good for the advanced forms of the disease), a return to the normal state is not to be thought of. 2 I shall now make use of this explanation for a further discussion of the fibrillar structure of tissues. The assertion that the white matter of the spinal cord was fibrillar, in the same sense as the cornea or the tendon, would surely be rejected by histologists, and justly so. And yet, under certain circumstances, it breaks up into fibrillse. The objection may be raised that this only holds good in the case of disease. It may be said, indeed, that here a metamorphosis has first taken place ; that the entire tissue has first returned to the embryonic condition ; that it has virtually become something different from what it was. First it became connective tissue, and then only did it break up into fibrillar On the other hand, however, we must consider that the line between pathological and normal processes is drawn arbitrarily, and only with reference to the practical requirements of man. The assertion that the nerve-tissue which has returned to the embryonic condition is now become connective tissue, is also quite arbitrary. True, the axis-cylinders coalesce with the trabecule of connective substance. But these trabecule likewise have returned to the embryonic condition. Now who will assert that they are still connective tissue? And who can claim that the axis- cylinders have been converted into connective tissue? If we wish to judge objectively, we must accept facts as they appear to us. The axis-cylinders break up into fibrillre ; this is a fact ; but what the fibrilla? are we do not know. But this we know — that they are not nerves, and that they no longer perform the function of nerves. ¥ew Observations on the supposed Fixed Cells. Conclusion of the Discussion on the Nature of the Fibrill.e. I have already mentioned that immediately after excision of the normal cornea we can observe in it no trace of structure, but that we can render the cornea-corpuscles visible by means of various reagents. Now the circum- stance that this reaction appeared so regularly — that after staining with gold, 1 This matter is discussed in my Lectures, and I shall treat of it more in detail in a separate publication. 2 Perhaps further information in regard to the etiology of these affections will teach us that the steadily progressive processes are dependent upon some constitutional condition, such as the presence of syphilis or other infectious disease. This has already been conjectured. 52 PATHOLOGY OF INFLAMMATION. for instance, the violet-colored branched corpuscles appeared — made us incline to the belief that these corpuscles existed in the living cornea. Moreover, this conclusion seemed to be supported by the fact that the branched corpus- cles were wont to appear with the same configuration — though isolated — if the normal fresh cornea lay in aqueous humor several hours after excision ; and, finally, by the fact that they were visible in increased numbers imme- diately after the excision of an inflamed cornea. It did, indeed, seem strange to me that in the inflamed cornea they appeared only here and there, and, | moreover, that the specimens stained with gold had a different appearance in winter from that which they had in spring and autumn. If, as has been supposed, the branched corpuscles are arranged in the living cornea exactly as they are in the specimens stained with gold, then, judging from the latter specimens, we must admit that they are differently formed in winter and in spring. According to this supposition, therefore, the branched corpuscles are not fixed in the sense that they continue unchanged during their entire existence. Still another circumstance warns us against drawing unrestricted conclu- sions as to the state of the living tissue from lifeless specimens stained with gold. If we paint the cornea before excision with a stick of nitrate of silver until it has become cloudy, excise it about thirty minutes later, and then expose it to diffused daylight, we obtain a picture which is essentially different from that obtained by staining with gold. In a specimen thus treated, the processes of the cornea-corpuscles appear branched to such a degree that the basis-substance is traversed by an excessively rich network. With a magnifying power of about 1000 diameters, the basis-substance looks like a loosely woven tissue. Since I had observed similar networks in the gray matter of the brain, and since, moreover, similar networks were known to exist in bone, I expressed the opinion that all organs were built up of such a fine network. The network, added to the mass which filled up its meshes, formed, as I thought, the basis-substance, whilst the cells were nothing else than parts of this network with a different density, and a dif- ferent mass filling their interior. In the cells, I thought, there is a fluid {intracellular fluid), whilst the basis-substance has a mass in its meshes which lends it its characteristic physical stamp, different in bone, different in the cornea, different in cartilage — in short, varying according to the nature of the tissue. But the very marked ramification which we see in cornese painted with silver, does not appear in specimens stained with gold, though here also the ramification is at times very extensive. At times, I say, but not always. Accordingly, the reagent must have some influence on the con- formation of the lifeless and fixed condition ; the cornea-corpuscles and their processes must perish in varying shape in consequence of varying influences Drought to bear on them. Besides, after proof had been offered that the cornea-corpuscles became altered in consequence of an inflammatory irritation ; that in the cornea of the frog they appeared essentially altered, even a few hours after the applica- tion of the irritant; that they lost their processes here and there and were transformed into relatively large multi-nucleated masses; after I had made, moreover, the observations on the cornea of mammalia which led me to adopt the theory of inflammation and suppuration already described — the theory that the cells and their processes swell at the expense of the basis-substance — in view of all these considerations, I had all the more ground to doubt the stability of the supposed fixed cells. And yet not until quite recently have I shaken the axiom that the branched cells in the normal condition are fixed cells. During the past year, Dr. Hansell has been engaged under my direction in DISCUSSION ON THE NATURE OF THE FIBRILL.E. 53 studying the keratitis of infection, and in so doing has met with very remark- able experiences in regard to the processes taking place in the cornea of the rabbit. It appeared that, while, on the one hand, the network of cells in- creased at the expense of the basis-substance, there were spots adjoining where the cells disappeared, and where the basis-substance increased in extent. These spots seemed to correspond to a process of healing and cicatrization. However the clinical signification of the process is not in question here. 1 The fact that fixed cells are transformed in a short time into basis-substance, has induced me to take up this question once more. And thus I have been led to examine the inflamed cornea of the frog on the heatable stage, with the result of showing that the branched cells are not fixed, at a temperature of about 36-38° C. [96°.8-100°.4 F.J, but that processes disappear and reappear, and that the cells also alter their entire configuration. In order to make this examination easily, I recommend injuring the cornea of the frog by sewing a thread through its centre, one to three days before the examination, according to the season of the year, and beginning the obser- vations on the unheated heatable stage. As soon as branched cells have been found, begin to heat. At times we hit upon branched corpuscles that change even on the unheated stage ; then again upon others which make only Blight movements in spite of the heating ; then again upon such as are transformed under our very eyes on the heatable stage into bodies without processes, re- sembling migratory cells ; and finally upon such as gradually disappear from view, or, in other words, gradually assume the appearance of the basis- substance. 2 In view of these observations, I can no longer maintain the opinion that the branched cells of the cornea are fixed. Moreover, I can no longer answer with an unconditional "yes," the question as to the existence of branched cells in the normal living cornea. I consider it advisable now to regulate my state- ments rigidly according to the results of observation. In the fresh cornea, I do not see any cornea-corpuscles; therefore it is undetermined whether they exist there at all. My experience admits of the statement that these corpuscles are formed under the influence of inflammation, or of reagents. A definitive conclusion on this subject is reserved for the future. But at all events it is 1 1< >w proved by direct observation that under the influence of the process of inflam- mation, basis-substance is transformed into branched cells, and, conversely^ branched cells are converted into basis-substance; and herewith my theory of inflammation and suppuration is proved even to its ultimate consequences. In the advanced stages of inflammation, still other phenomena may be observed on the heatable stage. Here and there I have seen a network as fine as that described above (page 52), in the case of cornea? painted with silver. But the network did not remain constant; it changed continually; threads appeared and disappeared again. In other places again I saw a fibrillar structure, and the fibrillar, too, were not constant. At one time they would run together at a certain spot, so as to make it appear that there was a cell inclosed in the bundle of fibrillin ; at another time this coalesced mass would divide into fibrillse again. On the strength of these observations, I believe that I can now give a decisive answer to the question as to the nature and the import of the fibrilla?. As soon as I know that fibrillar can appear and disappear again in the cornea 1 Dr. Hiinsell will treat, of this in a separate article. 2 These observations were made by me during the last weeks, just as the manuscript of this article was receiving its last corrections. I consider my observations thoroughly reliable, and for this reason publish them. But I am not quite sure of one thing ; I do nut know bow soon the changes of the fixed corpuscles cease. These changes I saw with certainty (during the days from the 1st to the 20th of October, 1880), only about 15 or 20 minutes after excision. 54 PATHOLOGY OF INFLAMMATION. under our very eyes, then there is no longer ground for the assumption that the cornea is fibrillar in the living state. I can now support my opinion by observation, which teaches that in life the normal cornea is not fibrillar, but homogeneous, and that in certain pathological conditions, or before death, it becomes fibrillar. Whoever now still asserts that the cornea or the cords of connective substance are constructed of fibrillar, must prove his assertion. In accordance with these explanations, I consider it advisable to separate distinctly the expressions fibrillar and connective-tissue-like (bindegewebig). A tissue which appears fibrillar to us, is not necessarily connective tissue. Hence it is also desirable to retain in pathology the plain term " fibrillar." If therefore the spinal cord is transformed into fibrillar, we shall designate this as a fibrillar degeneration, or as a formation of fibrillar tissue. If the con- nective substance in the spinal cord is increased, this has by no means the same signification as fibrillar degeneration. Wherever the tissue has once defi- nitively degenerated into fibrillse, its function is forever destroyed. Swelling of the reticulated tissue of the white matter does not, however, exclude the possibility of a cure, as I have already remarked. This swelling — although, according to our present nomenclature, we call it proliferation of connective substance — is equal in significance to infiltration. The infiltration can degenerate, while the fibrillar on the other hand are products of degeneration. 1 All that I have said here in regard to fibrillar, only refers to their occurrence in bundles. But there are tissues which contain fine isolated fibrillar. Such fibrillse may occur sparsely or abundantly. But each one takes its own direction, and where they occur abundantly they may even form a felt (Filz) of intersecting threads. The nature of all of these threads is by no means a settled question. At times they are processes of smooth muscular fibres, as e. g. many of the fibrillar in the bladder of the frog ; at times processes of transversely striped muscular fibres, as for example in the auricles of the frog ; at times they are nerves, such as likewise occur in the bladder of the frog; at times again elastic fibres, ?'. e. cell-processes which have become resistant ; finally they are very thin bundles of connective tissue (as e. g. in the interstices of the frog's muscle), which form a felt and may be designated as fibrillse. These are indeed not very fine fibrillar, but, as already remarked, very thin cords, which are commonly called (and perhaps justly) connective tissue, because of their wavy appearance and because of their reaction (becoming swollen) with acetic acid. From the results of my most recent investigations, I no longer admit that the very fine networks which I have demonstrated in the cornea by treating it with lunar caustic, are present in the living state. Now, this matter of the reticular structure is a peculiar one. The living matter is nowhere chemically the same, whether in the cells or in the basis-substances. In both there are always mixtures. Besides the living matter, the cells contain a fluid ; the basis-substance of bone contains in addition certain lime salts; and cartilage, probably some other substance which gives to it its peculiar appearance. Now when I mix a soft mass such as dough, with something else, such as shot, the doughy mass must contain pores in which the foreign particles are situated. A mass which has many such pores must be constructed like a network. Whether just these are the nets which I make apparent with silver, or whether there" arc others that only assume a new configuration after the use of the silver, is not a question of material importance. However, the transformation 1 I draw tliti reader's attention here to the fact that the term "connective substance" is not yel sharply defined. I consider it possible that the connective substance of the nervous system represents only an undeveloped state of nerve-tissne, from which new nerve-tissue can be de- veloped under favorable circumstances. I shall treatof this more in detail in the article already referred to on page 51. EPITHELIUM AND ENDOTHELIUM. 55 already described of the white blood-corpuscle into a body resembling a sali- vary corpuscle, teaches us how rapidly such metamorphoses take place within the living matter. I must observe here that Heitzmann was the first to describe the net-like structure of the living matter, and to represent it schema- tically. 1 In principle Heitzmann is right, but practically I consider it unjusti- fiable, now as then, to conclude from the aspect of a network in certain spots of the stained basis-substance that this network was there in the living state. I also do not consider it admissible to conclude that because I can recognize a network in a living cell, all cells must have just such networks. I must moreover mention here that Kassowitz was the first to regard the basis-sub- stance of the cartilage in its entirety as living matter, 2 altogether without reference to the recognition of a reticulated structure. Epithelium and Endothelium. Only two types of tissue still remain to be spoken of: Endothelium and Epithelium. The lining cells of serous membranes we call endothelium ; that is, the lining cells of the peritoneum, of the pleura, and of the pericardium. We may also include here the intima of vessels. In all of these endothelial cells (as has already been described in detail), we can make the boundaries of certain nucleated fields apparent as brown lines, by using solutions of silver. These brown lines are called cement-substances (Kittsubstanzen) and cement- lines (Kittstreifen). As I have likewise already remarked, we may place the cement-substance on a par with the basis-substances. We know but little of the normal function of the endothelial cells. We know that the surface of serous membranes is moist, and we suspect that the endothelium plays a part here. Furthermore, on the basis of experiments by E. Briicke, 3 we suspect that the endothelium of the vessels assists in keeping the blood fluid. On the other hand, on the basis of experiments which Durante 4 has performed under my direction, I suspect that in consequence of disease of the endothelium of vessels after ligation, the coagulation of the blood in the neighborhood of the ligature is promoted. It has furthermore been supposed that the endothe- lium of the serous membranes served the purpose of absorption. However, we know now that the stomata discovered by Recklinghausen in the serous membranes, lead directly into the lymphatics by means of canals, and bring about absorption. Endothelium has been most accurately investigated by E. Klein, 5 who has shown that single groups of endothelial cells proliferate even in the normal condition, besides doing so in a state of inflammation. As a result of inflam- matory irritation, the endothelial cells of the bloodvessels as well as of the serous membranes return to their embryonic condition ; they become softer again and more permeable ; they swell, and their nuclei multiply. In this way suppuration of the endothelium takes place in serous membranes. The serous membrane is deprived of its endothelium. The pus-corpuscles fall into the serous sac, and appear there in the so-called exudation as pus-cor- puscles. Whether and how capillaries suppurate, I know not. But there is not the slightest doubt that the intima of arteries and veins can suppurate. In chronic inflammations, the endothelial cells grow ; they are prolonged so as to form cords, wdiich resemble cords of connective tissue. The cords of tissue produced from the endothelium, form the so-called false membranes. ' Wiener Sitzungsberichte, 1873, Bd. 67 ; 3te Abth. 2 Wiener mediz. Jahrb. 1879-1880. 8 Virchow's Archiv, N. F., Bd. xii. * Med. Jahrbiiclier, 1872, S. 143. 5 Anatomy of the Lymphatic System. Loudon, 1875. 56 PATHOLOGY OF INFLAMMATION. They cause the firm adhesion of the serous membranes, whence is derived the name adhesive inflammation (John Hunter). The fact that the capillaries send out offshoots and thus produce a new vascularization, I have already mentioned. Epithelial Cells are likewise separated, or rather united, by narrow strips of intermediate substance. Here, too, brown boundary lines become visible by staining with silver. On many epithelial cells (cornea, cutis, and others), fine threads have been observed {Prickle cells, Max Schultze 1 ), which are connect- ing threads between two neighboring cells, as has been shown by Bizzozero. 2 Accordingly, epithelium constitutes a tissue similar to the connective sub- stances with this exception, that the amount and structure of the basis-sub- stances, and naturally also the form and function of the cells, are different. The functions of the epithelial cells are extraordinarily varied. In the glands, the main task of secretion falls to their lot. They must therefore be adapted to the multifarious actions of the various glands. The part which is played here by the mechanical action (enlargement and diminution) of the cells, I have already heretofore described. In the intestine, the epithelial cells are certainly concerned in the process of absorption. Spina is about to publish an article in which he shows that in this process also, the mechanical action of the cells (swelling and subsequent diminution) comes into play. But of the function of by far the greater portion of epithelial cells, those of the cutis, the intestine, the air-passages, and the urinary organs, we know very little. In general, it is said that they serve as a cover, as a protective lining, and are present on the mucous membranes for the production of mucus to keep the surface viscid. The ciliated epithelium is believed to serve for the removal of fine particles. But these statements are surely not exhaustive. The pathological processes in the epithelium of certain organs are better understood. Slight stimuli suffice to excite a secretion of mucus in certain epithelial cells, though it is certain that the vascular system co-operates here. Acute catarrhal processes, when they appear in otherwise normal mucous membranes, commence, as a rule, with a profuse, watery transudation, and only at a later period does the secretion of mucus begin. The profuse watery transudations surely come from the blood, and even the mucus must partly come from the same source, inasmuch as we may assume that the cells must draw fresh (fluid) material from the blood in order to secrete as "profusely as they are wont to do in catarrhal processes. But the conversion into mucus of the material drawn from the blood, must certainly be performed by the epithelium. During this conversion, the cells are abnormally active, and as a rule we have cell-proliferation accompanying the process. As a general thing, also, we find single amoeboid cells which are called mucus-corpuscles from the locality in which they occur. If the production of cells increases, the mucus is gradually changed into pus. But there are intermediate stages, in which indeed there are already produced very many amoeboid cells, but in which there is also still a production of mucus. Finally, the production of mucus may cease entirely, and pus alone make its appearance. But then we may presume that the epithelium as such has been destroyed, and that embryonic proliferating cells have taken its place, or, in other words, that the epithelium lias returned to its embryonic condition. In the case of epithelium, this return frequently takes place in a central portion of the cell, when the peripheral portion of its body remains rigid and sterile. This species of cell multiplication is termed endogenous. It was firsl observed by Remak in the epithelium of the urethra, in gonorrhoea. As is seen,< ndogenesis is nothing else than a cell formation by division. Only » Medic. Centralblatt, 1864. « Medic. Centralblatt, 1871, S. 482. HEALING BY FIKST INTENTION AND HEALING BY GRANULATION. 57 here a central portion of the cell divides. The peripheral portion of the body forms a hull, a capsule, a matrix in which young cells lie. But the young cells are nothing else than portions of the old body which have become amoeboid. The capsule bursts, and the young cell or the several young cells which were in it, are liberated and appear on the surface as pus-corpuscles. But I must state here that endogenesis does not always take place in an old resistant capsule. I would recall the fact that, in the embryo, blood-c< >rpuscl< ss are produced by endogenesis. And here the capsule is still a young cell-body, and even will become a contractile vascular wall, as has already been shown. Finally I wish to remark that epithelium does not always reproduce itself by endogenesis. I have already seen, sufficiently often, examples of complete division in epithelial cells, and believe therefore that they can return wholly to the embryonic condition, and undergo total division. The difference probably depends on the condition of the peripheral zones. If these are very resistant, as appears to be the case in cells situated superficially, then endo- genesis prevails. The most superficial layers of epidermis seem to be inca] a 1 >le of proliferation. Here the life of the cells seems to have reached too low a grade, if it be not entirely extinguished. But the next deeper layers of cells show a multiplication of nuclei in conditions of irritation. The principal proliferation (new cell-formation) certainly takes place in the deeper layers of cells in the so-called rete Malpighii. If the suppuration of mucous membrane has proceeded so far as to finally lay bare the substantia propria, and the pus is now produced on this part, we call the diseased surface an ulcer. As long as the epithelium is preserved, the superficial inflammatory process of the mucous membrane may still lie called catarrh, although to do so is not quite correct. In a strict sense, catarrh is present only as long as the secretion consists of mucus. If the (former) mucous membrane produces pus only, it is no longer a mucous membrane, and can no longer be in a catarrhal state. We are not so par- ticular, however, about fixing the limits, because frequently we cannot at all decide whether the secretion is entirely devoid of mucus and consists only of pus. It is therefore preferable to regard the condition of the mucous mem- brane as the determining point, and to draw the line between catarrh and ulceration by using anatomical data as the basis of our judgment. The expression catarrhal ulcer, employed by pathological anatomists, naturally only points to the genesis of the ulcer. A catarrhal ulcer is one which is the result of the catarrhal process. But one and the same spot cannot be the seat of catarrhal and ulcerative processes at the same time. Healing by First Intention and Healing by Granulation. Ulcers as well as cavities of abscesses heal by the formation of granula- tions. We call the new formations "granulations," because of the little warts or protuberances on the surface of the ulcer and the interior of the abscess- cavity respectively. "Why these new formations appear here in the form of little protuberances is not known. These little protuberances consist of cells which are designated as granulation cells. But between the cell- we find layers of intermediate substance — now broader, now narrower. The cells, added, to the intermediate substance, form a young tissue from which the cicatrix is produced. The matrix for this young tissue is in the bottom of the ulcer and in the lining of the abscess-cavity respectively. The granu- lations are not developed from the normal tissue, however, but from the tissue infiltrated by inflammation. We know, now, what the word infil- tration sio-nifies. We know that infiltration consists of a swelling of the 58 PATHOLOGY OF INFLAMMATION. network of cells, produced at the expense of the basis-substance. This swelling means the extension of the cell-borders — a conversion of basis- substance into cell-body. At the same time the cells themselves become capable of proliferation. They divide, and form pus, as long as the process is an acute (stiirmisch) one. Finally, a portion of the infiltrated tissue is disintegrated. The process becomes less intense. The disintegration stops, but the growth of the cells continues. New boundary lines are also formed, but the cells do not separate. At the boundary lines intermediate substances appear, and herewith the genesis of tissue is begun. Suppuration, however, does not cease upon the commencement of tissue- genesis. On the most superficial layers of the new tissue a real cell-partition still takes place, and pus is formed. A moderate production of pus on the surface of the ulcer is, as physicians know, not at all an impediment to recovery. But the suppuration must not become so profuse as to make the newly-formed tissue disintegrate ; for in that case a replacement of the destroyed tissue could not take place. In recent, carefully-nursed wounds following operations, tissue-genesis predominates over suppuration. If the process be hastened by warm applications, we increase the suppuration, indeed, but we also hasten the replacement of the lost tissue, which could not take place were the suppuration to predominate. In old, badly-treated ulcers, suppuration and tissue-genesis are about evenly balanced, or suppuration even may predominate. In such cases the ulcer does not heal, or may even extend more deeply. In other instances, again, the tissue-genesis predominates to such an extent that the granulations grow beyond the level of the normal surface, as "proud flesh" Finally, in other cases, cell-growth in general is but slightly stimulated, and here also the ulcer does not heal, even though it does not suppurate. In this last instance, too, warm poultices can stimulate growth. It is probable that the varied course of the healing process depends at least in part on the fulness of the vessels. New vessels grow along with the tissue-genesis. The new tissue, as it is said, becomes vascularized. I am unable to say anything on the mode of this new formation. Statements in reference to it are indeed not w r anting ; but they are based on such faulty microscopical examinations that I do not consider it worth while to take notice of them. It is not likely that bloodvessels are produced in granu- lations otherwise than in the embryo, and in certain inflammatory and non- inflammatory new growths, in which their genesis has been accurately determined (see pp. 7 ct scq.). That the vessels of granulation tissue consist of young, soft, easily permeable and easily lacerated tissue, may be inferred from the circumstance that granulating surfaces bleed on the slightest pro- vocation. The definitive cure of an ulcer cannot result from the granulations alone. A covering of epithelium must be developed. This covering proceeds either from the margins, that is, from the place where the epithelium is preserved, or from the bottom of the ulcer, if there are glands still preserved there. Finally, the covering may be artificially produced 1 from transplanted pieces of cutis. It is self-evident that the transplanted portion must still be covered with cells of the rete, for the protection of which, moreover, the uppermost cells are also necessary. From a theoretical point of view, the transplantation of rete and epidermis ought in every respect to be sufficient to furnish a new centre for Hie production of a new covering of cells in the ulcer, and this has in fact been confirmed by experiment. But whether it is desirable in prac- 1 As first practised by Reverdin. See Gazette Medieale de Paris, 1866, No. 26. Report of Marc See. REGENERATION. 59 tice to transplant only epidermis cells in place of the entire cutis, I do not know. The rationale of transplantation is to be found in the fact that epi- dermis is more readily developed from epidermis than from the granulation tissue which arises from connective tissue. Hence, if the ulcer be very large; if the pushing forward of epidermis from the margins have become insuffi- cient ; we transplant epidermis to the central portions of the ulcer in order to furnish new starting points from which the healing process can spread. Healing by the formation of granulation tissue is also called healing by sup- puration, or by second intention, in contradistinction to healing by first intention (John Hunter). In the process of healing by first intention, there is no sup- puration; the margins and surfaces of the wound unite directly. Notwith- standing this, however, the old tissue must soften again, and become capable of growth, else a definitive union would never occur. Investigation has also taught that new processes are sent out by the cells from one surface of the wound into the other; and, besides, that in the very small space between the surfaces of the wound there are young cells to be found. Accordingly, from a theoretical standpoint, the difference between healing by first intention and second intention is only quantitative. From a practical point of view, the matter is indeed different. For in healing by first intention the loss of sub- stance is almost imperceptible, and the wounded organ need, therefore, suffer no disturbance of function worth mentioning. But healing by suppuration always presupposes a loss of substance, and the tissue which replaces the old one is of a new kind, is different; is cicatricial tissue, and cannot assume entirely the function of the former one. In the cutis, it is true, the replace- ment of certain small regions by cicatricial formations is of slight import- ance; but in the cornea, for example, if suppuration have occurred, the loss is irreparable. For cicatricial tissue is not cornea tissue ; cords, fibrillre, and cells, are indeed present in cicatricial tissue, but not that homogeneous mass which I have described as existing in the cornea. Regeneration. A real regeneration as regards form and function, is known to us (in man and mammalia) only in the case of nerves and muscle. 1 Divided nerves heal under favorable circumstances in such a manner as to completely restore the connection between the central nervous system and the periphery. In view of new researches made by Jul. Wagner 2 on this subject, I must pronounce the older statements on nerve-regeneration inaccurate. Regeneration of the nerves depends on a chronic inflammation. The medullary layer disappears. Axis-cylinder, network of the medullary layer, and Schwann's sheath, are converted into new morphological elements. This change occurs in the cen- tral as well as in the peripheral extremity. By the growing together of these new morphological elements (just as in healing by first intention), new nerve- tissue originates. The regeneration of nerves gives us probable proof that tissue-genesis can be influenced by the central nervous system. For a return to the normal condition, as it occurs in the case of a nerve, proceeds apparently only under the influence of the central nervous system. If the union of the two extremi- ties be prevented by the excision of a sufficiently large piece, then it is pre- sumed that the formation of new nerve-tissue in the peripheral extremity 1 I do not dwell farther on the regeneration of muscles. It is only a matter of the develop- ment of the old fibres. 2 Not separately published by him ; I have reported thereon in my Lectures. GO PATHOLOGY OF INFLAMMATION. will also be prevented. Positive and unequivocal proof that the growth and nutrition of tissues in general are influenced by the central nervous system, has, however, not as yet been furnished. We are, it is true, acquainted with affections of tissues which are due to diseases of the central nervous system ; such are acute bedsores in certain severe central diseases, and progressive muscular atrophy in connection with disease of the ganglia in the ante- rior horns of the spinal cord (Lockhart Clarke, Charcot). Recently, Ad. Jarisch 1 has discovered a very important relation between diseases of the skin and diseases of the spinal cord, likewise in the region of the anterior horns ; the affection in one instance was a case of herpes iris, and in another a case of pemphigus, though in this the relationship was less pronounced. I have carefully examined the specimens in question. The disease of the anterior horns of the spinal cord was quite evident. These data, it appears to me, are very important for pathology. But whether we have to deal with cen- tres which directly influence the tissues — that is, with so-called trophic nerves — or with vaso-motor centres, is not known. Disease of the vaso-motor centres is certainly adapted to provoke pathological disturbances in periphe- ral organs, i. e., in the region of distribution of the affected nerves. Non-inflammatory New Formations. All tissue-changes which are accompanied by active hyperemia, that is by the clinical phenomena of inflammation, can also run their course without hyperemia. Under such circumstances, we call the tissue-metamorphosis a neoplasm. Since such neoplasms in the majority of cases appear in the form of tumors, they are also simply called tumors. Inasmuch as it was imagined that these new formations were in idea and in structure foreign to the human organism, and not characteristic of it, they have been also called spurious forma- tions or pseudoplasms. From the fact taught by clinical experience, that some of these new formations are more or less injurious to the organism, they have also been divided into benign and malignant. On the other hand, they have also been classified according to form, consistence, location, genesis, structure, and I know not what other principles. The scientific value of such a classi- fication is very slight. In modern times it has degenerated wholly into child's play. It does not seem to me worth while to refer here to the litera- ture of the subject, while we are considering general questions. Neoplasms [non-inflammatory new formations] are much richer as regards forms of tis- sue than are inflammatory new formations. True, we have here again only cells and basis-substances which constitute the new formation; but the size and form of the cells, as well as their mutual connection with and relation to the basis-substance, are more varied. Moreover, the pathological non-inflam- matory new formation can imitate every form of normal tissue, which never happens in the case of inflammatory new formations. In inflammation, pus, fibrillar tissue, cicatricial (issue, and epidermis, can be produced; and, more- over, a regeneration can proceed from a fixed matrix, as in the case of nerves and muscles. Neoplasms, on the contrary, can imitate all forms of normal tissue without proceeding from a matrix of the same kind. In the midst of connective tissue, or of muscle, epithelium cells and even fully developed glandular tubes '-.'in be produced. In ovarian cysts, teeth and hairs may be developed. In the case of inflammatory, as well as of non-inflammatory, new formations, (lie tissues return to their embryonic condition, in which they are capable of proliferation. In non-inflammatory new formations, however, the 1 Sitzungsber. der Wiener Akad. 1880. DEGENERATION OF THE TISSUES. 61 impulses to growth, even if not always more powerful, still appear to be more lasting and more varied than in inflammation. Are these impulses perhaps dependent on residues of intra-uterine life? on residues that were latent, and now have become active from some favorable circumstance? are they perhaps due to particles carried away by the blood or lymph stream, which adhere somewhere, and, as it were, infect the tissue? Finally, is it perhaps the general condition of the fluids which favors the new formations? These are all questions which have until now only been speculated upon. Degeneration of the Tissues. Fatty Degeneration of tissue can be brought about in two ways: — (1) In certain cells fat is developed, and collects to form a drop. This drop of fat presses the cell-body towards the periphery ; of the body, only a peripheral zone, surrounding the drop and also containing the nucleus, remains. The normal prototype of this form of degeneration is shown in the collections of fat in the subcutaneous tissue, and in other normal deposits of fat. 1 Patho- logical types of fatty tissue are presented in the case of the lipoma, and in the excessive development of fatty tissue in normal localities. (2) The normal type of the second form of development of fat presents itself in the. epithelium of the mammary glands. Here the fat is deposited in the form of granules, or little drops, which, relatively to the cell, are very small. The entire cell, at every depth, appears tilled with granules. During the first days of lactation, portions of the cells containing fat-granules separate from their matrix, and are expelled with the milk. Such bodies are called colostrum-corpuscles. Similar fatty degenerations probably occur in the cells of the sebaceous glands. Certain processes in the hepatic cells are on the boundary line between a normal and a pathological production of fat. Here, too, the fatty change consists in the appearance of small fat-granules within the liver-cells. But the hepatic cells may contain a normal quantity of fat- granules, and may also undergo extensive pathological fatty degeneration. In a state of disease, all cells and all living derivatives of cells may undergo fatty degeneration. The essence of fatty degeneration consists in a production of fat by the cell. The cell can transform constituents of its own body into fat, or, differently expressed, constituents of the cell can be converted by chemical decomposition into fat (and into some other products of decomposition). The cell can at the same time continue to live. It is true, the fat-granules act as foreign bodies on the cell-body; hence the presence of fat-granules probably involves a dis- turbance of function ; but it does not exclude a continuation of this function. If considerable portions of the cell are transformed into fat, the disturbance naturally increases. Under no circumstances, however, can we consider the fatty cell, or of course the fatty muscle, as incapable of recovery. The fat- granules can be absorbed ; they can also be expelled, and the remaining living matter can continue to perform its function and can even recover entirely by means of tissue-metamorphosis. I say it can, if the conditions are favorable ; especially if the cause of the progress of the fatty degeneration ceases to act. If the fatty degeneration makes headway, it may finally interfere so much with the performance of function as to cause death ; if, for example, it im- plicates the substance of the heart. 1 It is a matter of dispute -whether adipose tissue is a tissue of its own kind, or whether it is altered connective tissue. 62 PATHOLOGY OF INFLAMMATION. Amyloid Degeneration undoubtedly depends, as was first asserted by Vir- chow, 1 on a metamorphosis of the tissue to that peculiar substance which we call amyloid. Amyloid indicates that it is related to amylum. This suspicion is based on the reaction with iodine, discovered by Meckel and Virchow. 2 The reliability of the iodine reaction has been cmestioned,but Bottcher reasserts that it is the best of all. He employs a mixture of 25 centigrammes of iodine, 50 of iodide of potassium, with 100 cubic centimetres of water, and adds dilute 3 sulphuric acid. More recently, methyl compounds have been recommended. This reagent stains the amyloid substances red, but the healthy tissue blue. But this test has also been reported as unreliable by Kyber. 4 With regard to the chemical composition of the amyloid substance, E. Ludwig has favored me with the following data : — According to the analyses of Friedreich and Kekule, as well as those of Kiihne and RudnerT', it shows a composition very nearly approaching that of the alhuminous bodies. It is soluble in concentrated hydrochloric acid, from which water precipitates a body having the properties of syntonin hydrochlorate. Amyloid substance is soluble in potassa or soda lye, and the solution has the properties of an alkaline albuminate. E. Modzejewski obtained tyrosine and leucine as products of decomposition of the amyloid substance, by acting on it with boiling dilute sulphuric acid ; he supposes that the amy- loid substance gives the same products of decomposition as albuminous bodies. From the putrefaction of amyloid substance Th. Weyl obtained the same products that fibrin yields in putrefaction. It is apparent from all of these observations that the amyloid substance is very closely allied in its chemical properties to albuminous bodies. These data are still too meagre, however, to permit of conclusions being drawn as to the nature of the process. But we may be sure of one thing. The amyloid degeneration cannot be compared to the inflammatory meta- morphosis of tissue. The amyloid constituents of tissue are lifeless.. The cell, the capillary wall, or the basis-substance which has become entirely changed into amyloid matter, can no longer take active part in the functions of the organism. The same, it is true, also holds good for those constituents of the tissue which have undergone fatty degeneration. But it is important to lay stress upon the difference between the two. Fat can be more easily dissolved and absorbed. The amyloid substance, however, seems to burden the tissue permanently. Hence a cure {restitutio ad integrum) of amyloid organs is hardly to be thought of. Calcareous Degeneration. — Just as the tendency to produce fat resides in certain tissues, so other tissues again have the property of depositing lime salts. Bone and cartilage belong to this class. Inasmuch as cartilage is converted into bone, 5 it must deposit lime salts in its basis-substance. But cartilage calcines sometimes (as for example under the influence of slight inflammatory stimuli) without being converted into bone. Of pathological calcifications of other tissues, too little is known besides the mere fact that they do occur, to warrant my considering them here. Colloid Degeneration. — Tn conclusion, T present some remarks with regard to colloid degeneration, for which I am likewise indebted to E. Ludwig. The colloid-substance in its chemical properties approaches most nearly to mucin, but differs therefrom by its solubility in acetic acid. Eichwald regards the colloid ' Charite" Annalen, 1853. 2 Virchow's Archiv, Bd. viii., 1854. 8 Said to be Beve:n per cent. 4 Virchow's Archiv, Bd. lxxxi., 1880. Kyber also praises the reaction with iodine and sul- phuric acid. 5 The occurrence "f a direct transformation <>f cartilage into bone is now probably quite certain : but this is not the only method of its formation. DEGENERATION OF THE TISSUES. 63 material as a modified mucin, representing a transition from mucin to muco-peptone. Wurtz examined the gelatin from a colloid cancer of the lung ; it was insoluble in water, and by evaporating to dryness was converted into a white laminated mass, which gave, after extraction with alcohol and ether, a white powder that in turn again swelled into gelatin. Potassa and soda lye dissolved the gelatin, and acetic acid precipitated it from solution. An elementary analysis of the dry substance gave 48.09 per cent, of carbon, 7.47 per cent, of hydrogen, 7 per cent, of nitrogen, 37.44 per cent, of oxygen. This composition varies considerably from that of all known albuminous bodies ; it approaches the composition of chitin. It is probable that the colloid material can be converted into mucus. INFLAMMATION. BY WILLIAM H. VAN BUREN, M.D., LL.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN TIIE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. General Considerations regarding Inflammation. Definitions. The pathology of inflammation, as interpreted by the methods of the his- tologist, having been fully set forth in the preceding article, it remains to describe this complex but important condition, so constantly under the eye of the surgeon, from the standpoint of clinical observation. The definitions of inflammation furnished by the latest teachings of science, although their correctness is not disputed, do not convey the full significance of the term as employed in the ordinary language of the surgery of the day. In this, supreme importance is ascribed to the objective symptoms of pain, heat, redness, and swelling, as originally enumerated by the Roman surgeon Celsus in his definition of inflammation which has become classical ; and the idea of fiery excitement which suggested the early use of the Greek adjective '• phlogistic," and its Latin synonym " inflammatory," are always present in the mind. Thus, if a wound is described as " inflamed," the idea intended to be conveyed is that some of the cardinal symptoms just mentioned are present, whereas simple primary union may take place, or even granulations and suppuration may go on, without either pain, heat, redness, or swelling in a noticeable degree; and yet primary adhesion, granulation, and suppuration are certainly legitimate features of the inflammatory process as we now com- prehend it. The definitions heretofore proposed are more or less imperfect, in consequence of the obscurity which belongs to the subject. Those entitled to most respect simply describe inflammation as the aggregate of the pheno- mena which are set in action by any lesion of the organism affecting its tissues locally, provided, of course, that the tissues involved have not been killed outright. It is obvious that the phenomena which attend the kindly healing of a simple incised wound are not fully recognized, in the popular sense of the word, as belonging to the same "series of changes" which culmi- nate in the more violent manifestations of inflammation and result in sup- puration, ulceration, and possibly gangrene. These latter are regarded as belonging to true inflammation. To reconcile this absence of conformity, which is readily explained by a glance at the recent advances in the science of surgery, Sir James Paget has employed the phrase " process of repair" to designate the milder phenomena of inflammation as they occur in healthy, healing wounds ; and more re- cently Samuels has described the reparative process of Paget as the " con- structive" phase of inflammation, reserving for suppuration, ulceration, and gangrene the term "destructive." These expressions, which indicate truly the results of the process, recognize fully an identity of nature. vol. i.— 5 ( 65 ) 66 INFLAMMATION. The science of human pathology, which took its origin in the study, after death, of the anatomical changes of the diseased organs and tissues of the body — morbid anatomy, as it is usually called — was inaugurated mainly by the French school, early in the present century. Its first great advances established the identity of what was called inflammation, as manifested on the surface of the body and in wounds, with similar conditions affecting its internal organs, an identity which had never been demonstrated. Under the influence of the plausible theories of Brown and Broussais, inflammation, thus advanced to a more extended domain, came to be considered as the most important of all the pathological forces ; an uniform termination was affixed to the names of inflammatory diseases — itis — significant of the afflux of blood to the inflamed part — " itio in -partes;'' and the treatment of the diseases thus distinguished, which formed, according to their assumption, a large majority of human maladies, was of necessity, following these premises, intrinsically antiphlogistic. The period is within the memory of the writer when it was the dominant doctrine in the schools that inflammation, in some form, con- stituted the essential factor in most diseases. The application of the microscope to the study of morbid anatomy subse- quently demonstrated, by degrees, the existence of a variety of degenerations and other morbid changes constantly taking place in the tissues and organs of the body, which were evidently unconnected in any way with inflamma- tion. Through the advance in more accurate knowledge, inflammation has therefore ceased to be regarded as such an omnipresent disease ; it has come to be considered, in fact, as in no respect an essential disease, but rather a condition liable to be provoked in the organism by certain harmful influences, called for convenience the causes of inflammation ; a condition located mainly in the apparatus of nutrition, affecting a limited area, and consisting in a temporary perversion of the mechanism of nutrition from its natural and regular order, which is characterized by a series of phenomena already de- scribed by the histologist, and to be hereafter considered from a clinical point of view under the title of symptoms of inflammation. It should not be, therefore, a matter of surprise that the terms employed in treating of inflammation, including indeed the word itself, have been gradually changing their signification in accordance with the growth of more precise knowledge ; and, lest the mind should be influenced by the more vague and pretentious meaning heretofore attached to these terms, the fact of this change in signification should be held in constant remembrance. The term inflammation will be employed in the ensuing pages as including the series of textural changes — microscopic, as well as macroscopic — which take place in living tissues after they have been subjected to injury. For the sake of convenience, the term "constructive" will be applied to the phenomena of afflux, exudation, cell germination, the formation of new capillary vessels, and the development of cicatricial tissue— in other words, to the inflammatory phenomena which constitute the simple uncomplicated "process of repair;'' whilst the additional presence of suppuration, ulceration, or gangrene, and all other harmful complications of the process, will be included under the term "•destructive." In this connection it maybe observed that inflammation has heretofore been treated of by systematic writers as a disease^ with certain characteristic features, and tending to certain "terminations." The convenience of this mode of handling the subject is obvious; but its scientific correctness is open to question. In popular, and also in professional language, it is common to speak of "an attack of inflammation" as of an attack of tetanus; and the remedial measures employed in its treatment have been habitually designated as "antiphlogistic." .Now, inflammation, although presenting in some of its GENERAL CONSIDERATIONS REGARDING INFLAMMATION — DEFINITIONS. 67 phases well-marked features which in a popular sense might justify the use of this term, does not possess the essential qualities of a disease in the more precise language of science ; and it cannot be spoken of as a disease ontologi- cally. In very many, indeed in most of its phases, it is a benign, healthful process to which, even in its popular sense, the appellation of disease would be regarded as inapplicable. It is better, therefore, with our incomplete knowledge, to assume that in- flammation is a process more or less abnormal, or a condition — not even in a majority of instances a morbid condition — presenting as its characteristic features a series of textural changes typically uniform in character, although varying widely in aspect, and leading to different results according to the nature and degree of persistence of the causes which have given rise to it. This designation is as proper, and as intrinsically correct, as when the word condition is applied to a local numbness, to intoxication, to pregnancy, or to the moribund state. When the causes which have given rise to inflammation cease to act, the features which characterize the condition disappear; it has no inherent power of continuance beyond that which has been impressed by injury of some sort upon the local nutritive machinery. The textural changes which belong to the condition, as far as they are objective, constitute its symptoms ; as far as these changes are subjective, they constitute its pathology. The means which have been found to modify these symptoms favorably, or which, through a knowledge of their course, may be rationally expected to lead to such a result, constitute its remedies, and will be considered under the head of treatment. These considerations occur naturally to the surgeon familiar with the clinical aspects of inflammation in any attempt to bring them into causal relation with the histological phenomena by which they are explained. Until this relation is established there is no solid basis from which to reason in studying its symptoms in detail, and its treatment is of necessity entirely em- pirical. Histology teaches us that the essential features of the inflammatory process are, an increased afflux of blood to the affected part, with an exagge- rated tendency to cell proliferation and tissue formation. A knowledgeTof the mechanism of this process affords the only rational explanation of the various manifestations which it presents to the unaided eye ; and, when com- bined with clinical observation and experience, this knowledge gives us all the power we can safely exercise in favoring its constructive tendencies, and in averting or controlling its proclivity to destructive results. It may be proper to remark, in this connection, that the destructive phases of the inflammatory process do not apparently arise from any noxious quality inherent in the process itself, but, rather, from the intrinsically defective power of the human structure to resist and repair injuries. Naturalists have taught us that this power of repairing injuries exists in a much greater de- gree in the lower animals than in our complex organisms. The destructive phases of inflammation are also explained in some degree by the degradation in vital quality of our tissues which results from unhealthful habits of life, and surroundings defective as to hygiene; by the more aggravated character of injuries rendered possible by human ingenuity — as exemplified in gunshot rounds; and by ignorance of the real nature and scope of our reparative powers, and the means by which they may be aided and supplemented. The truth of the last averment is rendered probable by the increased power of repair, the greater rapidity with which the reparative process is accomplished, and the remarkable infrequency of the destructive symptoms of inflammation manifested in wounds which have been subjected to judicious drainage and treated early and skilfully in accordance with the antiseptic method. 68 INFLAMMATION. The present account of inflammation will include its causes, symptoms, varie- ties, consequences, and complications — viewed especially in reference to its man- agement in the practice of surgery. Causes of Inflammation. The causes of inflammation determine, in a great degree, the attitude to he assumed by the surgeon in its judicious treatment, for they exercise a direct influence upon its constructive, or destructive, tendency ; there is, therefore, no department of the subject more worthy of careful study. Irritation and Injury. — In accordance with doctrines which were long dominant in medicine, " irritation," acting upon any of the tissues or organs of the body, was held to be the immediate exciting cause of inflammation ; and the development of irritation in any locality was supposed to invite the flow of blood towards it — the first step in the inflammatory process. Hence the apothegm "tTfo" irritatio , ibi affluxus." The term "irritant," habitually employed as synonymous with "an inflammation-producing agent," has in more recent times given place to " injury." The latter has become a technical term in surgical pathology, signifying that ivhich is capable of impairing the vital quality of the tissues. It is used in this sense in a form of definition of inflammation, which has become classical: "the series of changes that follow injury, provided the injury has not been so severe as to cause the death of the part" (Burdon Sanderson). An "injury," then, may be regarded as compe- tent to inaugurate the " series of changes" that constitute inflammation. It is worthy of notice, as illustrating the purposive tendency of inflamma- tion, that, at its inception, if not in its later phases, it is mainly, if not entirely, constructive. It can hardly be doubted that the "series of changes" following a lesion which has not absolutely destined textural life, have for their object the repair of the lesion; this is apparently demonstrated by the result, which, if the inflammation does not transcend certain limits, is almost invariably curative. There is a limited analogy, as to their immediate consequences, between the influence of a surgical "injury," and the fertilizing of an ovum; both stand in the relation of cause and effect to a sequence of changes which lead directly to cell proliferation and tissue formation. Rindfleisch tells us, in fact, that he prefers to study the process of embryonic cell development, under the microscope, in inflamed tissues. Classification of Causes. — As employed in connection with the causes of inflammation, the term injury includes the endless variety of wounds, hurts, and lesions, of every possible nature, to which our organisms are exposed. Tin ■ manifold sources of injury arc advantageously arranged in three classes : — (1) Those arising from physical force or mechanical violence — as cuts, stabs, fractures of bone, dislocations of joints, and laceration, bruising, or crushing of limbs, or <>!' internal organs. (2) Those arising from irritating or destructive chemical action — as from heal in any form, such as burns and scalds from strong acids, or caustic alka- lies, from tin' action of cold, etc (3) Those arising from poisonous infection, as from the venom of insects and serpents, from a virus, as of glanders, or syphilis, from the miasm due to the infinite diffusion of poisonous microscopic organisms, or their germs. Many of the individual injuries thus classified have been recognized in all times as determining causes of inflammation. Others, again, and mainly CAUSES OF INFLAMMATION. 69 those of the third class — the injurious micro-organisms — have only recently been brought under the cognizance of the pathologist as the immediate de- termining causes of the more destructive phases of the inflammatory process. There is promise of great benefit to humanity and of equal credit to surgery in the fact that its pathology has been enriched, though the philosophic acu- men and admirably patient research of one of its own devoted students, by the demonstration of this still novel cause of inflammation; and the gain to hu- manity and to surgery has been incalculably magnified by the correlative discoverv of effective remedial measures, actual and preventive, for the various forms of destructive inflammation thus traced to their source. John K. Mitchell, of Philadelphia, before 1849, expressed a strong belief in the cryptogamic origin of the poisons generally known as miasmata, and ably defended the theory that most malignant fevers were due to this source. 1 Pasteur, in 1865, discovered the cryptogamic micro-organism which caused the epidemic silkworm disease in France, and demonstrated its direct agency in perpetuating the disease. The next year, Lister, assuming by induction that a similar source of poisonous infection might be capable of preventing the normal process of repair of wounds, inaugurated a course of experimental research which has, in the opinion of many, amply demonstrated the propo- sition. As this interesting subject will be discussed in a separate article, it is not necessary to pursue it here beyond the recognition of poisonous germs as a pregnant cause of inflammation in its worst forms. Following the general classification which has been laid down, we shall study, with concurrent details, some of the typical causes which clinical observation has shown to be capable of exciting inflammation, seeking, in each, for indications as to the means by which, ultimately, this condition may be prevented or controlled. In the first place, however, it will be necessary to notice certain general considerations which necessarily form part of a study of the causes of inflammation ; and, also, to define the mean- ing of certain terms commonly used in treating of this subject. Most systematic writers speak of inflammation as traumatic, or idiopathic, in accordance with its origin from obvious injury, or the reverse — and, when there is no discoverable cause for its occurrence, it is assumed to arise spon- taneously. The terms idiopathic and spontaneous, as applied to inflammation, are con- venient, but they are of doubtful accuracy. It is not certain that either of them is in any case correct, in a scientific sense. It is exceedingly improb- able that the series of textural changes of which the inflammatory process is believed to consist can be set in action without a provoking cause. These terms have come to be habitually used under the assumption that inflamma- tion is a disease. In fact, they are only admissible as signifying that the source of origin of the inflammatory condition is not, at the moment, demon- strable. -Again, the terms internal and external inflammation, as applied to the con- dition when it occurs in the interior of the body, or upon its surface, are employed, somewhat vaguely, as synonymous with medical and surgical, in accordance with French nomenclature, which designates medical pathology as internal, and surgical pathology as external. This use of words perpetuates the idea that there is a radical difference between medical and surgical pathology ; an idea which is no longer tenable. There has been a time when the surgeon was content to leave the examination of internal organs to the physician, before as well as after death, but, since the functions of the surgeon and physician have become so inseparably blended as they are at the present 1 On the Cryptogamous Origin of Malarious and Epidemic Fevers. Philadelphia, 1849. 70 INFLAMMATION. day, this fashion has passed away. The expert (as he is now properly styled) in either of these branches of medicine finds his knowledge advantageously supplemented by deferring to the histological pathologist, who, in the exer- cise of his peculiar methods, is also an expert in the more accurate interpre- tation of the appearances of morbid anatomy. To illustrate the correlation of medicine, surgery, and histology, it may be mentioned that Curling first called attention to the relation between burns of the surface of the body and the ulceration of the duodenum which so often accompanies them ; and Erichsen emphasizes the fact that death ascribed to the shock of injury and to exhaustion, is often explained, in the dead-house, by the discovery of laceration of the liver. Jaccoud and Ferrier have obtained most of their illustrations of intra-cranial pathology from well-observed cases of surgical injuries of the head. The histologist has taught us that senile gangrene, formerly attributed to arteritis, is in fact caused by calcific degeneration of the arterial coats, and by thrombosis and embolism ; and that arteritis, formerly supposed to be a common occurrence, is in reality a rare condition. Predisposing and Exciting Causes. — Systematic writers usually lay much stress upon the distinction between what are called the predisposing causes of inflammation and its immediately exciting or determining causes. An example will illustrate the meaning of these terms : A growing boy, overheated by exercise, goes into the water to bathe, or throws himself on the ground in the shade to rest. During the following night he is awakened by a severe pain in the thigh, which is continuous as well as severe, and finally results in a necrosis from limited osteo-myelitis. In such a case, which is of common occurrence, the activity of the nutritive process in the rapidly growing bone of the adolescent, and exhaustion incident to the fatigue incurred, are the predisposing causes ; and the rapid abstraction of heat from the body by the cold water, or the cool earth — the chilling, in fact — is the exciting cause of the inflammation. These two classes of causes are also designated as remote and proximate. Most of the sources of injury classified above are examples of proximate or exciting causes. Predisposing Causes or Inflammation. — The most obvious and important of the remoter causes which predispose a part or an organ to take on the con- dition of inflammation, is defect in, quality of the blood. When we reflect that all the organs and tissues of the body are, as it were, enveloped in an atmos- phere of liquor sanguinis, and that they are continually absorbing from it the materials required to maintain them in a normal state of health, it is easy to comprehend how a variation in the quality of this fluid necessarily disturbs the nutrition of the tissues, and, as a consequence, may diminish their vital capacity of resisting injury, and also of repairing it when incurred. In the language of the older surgeons, "a vitiated state of the blood is a very com- mon cause of the ill behavior of wounds in regard to their kindly healing." Now, habitual excess of food and drink, and also habitual lack of proper food and deprivation of an adequate supply of pure fresh air, which prevents elimination of the products of textural waste, equally tend to impair the quality of the blood, and consequently of the tissues supplied by it; so that slight injuries, which in a- state of health would take on prompt repair, under these unfavorable circumstances linger in healing, and run into suppu- ration, or into partial or molecular gangrene; at other times they become indolent, refuse to cicatrize, or remain indefinitely in the condition known as chronic inflammation. As common examples, taken from clinical observation, the following are cases in point: — CAUSES OF INFLAMMATION. 71 A man of middle age, of sedentary occupation, living too well, in apparently full health hut perhaps slightly defective in complexion and fhibhy in muscle, in consequence of the slight violence caused by straining at stool, is taken with painful swelling in the ischio-rectal fossa, which results in an extensive abscess, followed by tardy and imper- fect repair, and leading to chronic fistula in ano, or even to danger of death. In another case a half-starved child is seized with a hard swelling in the thickness of the cheek, which in a few days turns black at its centre, and results in perforation, constituting the form of disease known as noma, or gangrcenopsis. The presence of a poison in the blood, whether this fluid is otherwise impov- erished or not, may predispose to inflammation. This is seen in the peculiar behavior of lesions, not arising directly from the disease, in persons affected by syphilis: instead of healing in a healthy manner, they are liable to take on the aspect of syphilitic ulcers, and to require anti-syphilitic treatment for their cure. The condition of the blood in diabetes mellitus begets a well-marked , predisposition to hypersemia of the intestinal mucous membrane, and to erup- tions of the skin. An eczema of the genitals may have proved obstinate under the use of ordinary remedies, but as soon as the presence of sugar is discovered in the urine and the patient is restricted to a diet of animal food, the local inflammation tends to get well. Blood of defective quality, especially when certain poisons are present in it, tends to stagnate in limited areas, probably through its lack of full power to stimulate the heart and bloodvessels. The local hyperemia which results from this tendency often constitutes the first stage in the development of inflammation. Hence the frequency of serous effusions in uraemia. Da Costa and Longstreth 1 speak of an "outburst of in- flammation of the serous membranes" — e.g. intense pericarditis, with pleural and peritoneal effusion — the result of altered blood in Bright's disease, the patient having suffered, also, from ursemic coma. The occurrence of eczema in the gouty is directly provoked by the acrid qualities of the perspiration. It is remotely favored by the condition of the blood ; and " the gouty irritability" of the membranes, which is, in other words, a state of nervous hyperesthesia, is caused by the same condition of blood. In proof of this we may point to the marked relief to these symptoms which usually follows "a crisis" of gout, in which the blood has relieved itself of its impurities. Here is a typical example of what is usually spoken of as the influence of a diathesis in favoring the occurrence of inflammation ; and it illustrates what is true of all the so-called diatheses, namely, that their influ- ence, if it can be properly so styled, is recognized mainly in the accidents which result from the peculiar constitutional quality. Another example of the predisposing influence of a diathesis is to be found in the meningitis of early life, which is often excited by tubercular deposit in the vicinity of the bloodvessels of the pia mater; the so-called tubercular diathesis acting as a remote cause of the inflammation. The influence of a defective or deranged nervous supply to parts is in some instances easily recognized as a remote cause of local inflammatory action. Certain inflammations of the skin, especially the herpetic eruptions, furnish illustrative examples of this influence. Thus Von Bserensprung has shown that herpes zoster is always coincident with alteration in the anatomical ele- ments of the intervertebral ganglion situated upon the posterior or sensitive/ root of the spinal nerves supplying the affected parts. This form of skin dis- ease occurs also in regions supplied by the trifacial nerve, and is accompanied by local anesthesia of the inflamed integument, and a tendency to local death. The development of a vesicle of herpes on the cornea has been followed by the 1 American Journal of Medical Sciences, July, 18S0. 72 INFLAMMATION. formation of a slough. In a case in which the ganglion of Gasser was subse- quently found bathed in pus, the whole eye shrank and collapsed. An erup- tion of herpes about the lips after a paroxysm of malarial fever, or as conse- quence of functional gastric disturbance, is a very common occurrence. The formation of abscess in the vicinity of a focus of inflammation, as of a diseased joint, when not the result of a secondary or infectious process, has been attri- buted to reflex nervous irritation. Hyperseniic congestion, with local evidences of altered nutrition, has been observed in parts of which the nerves have been wounded or divided. The rapidity with which bed-sores form on the sacrum after exhausting fevers and surgical lesions of the spinal cord causing paraplegia, is well known; and the occurrence of cystitis in such cases is a constant result. Bed-sores begin by intense hyperemia of the integument, followed by vesicular eruption, or pustulation, so that the lesion is at first distinctly inflammatory ; but it is usually complicated by local death of tissue. The period of life has less influence than has usually been ascribed to it as a predisposing cause of inflammation. Examples are frequently cited in favor of this cause, which are not, in reality, inflammatory affections. The effects of malnutrition in infants, or of the senile atrophy or degeneration of tissue incident to age, have been attributed to inflammation. In childhood, the pro- cess of nutrition is in its period of greatest activity, and the condition of acute hyperemia — the first step towards the inflammatory condition — occurs promptly from any exciting cause. Any interruption of nutrition is followed by exaggerated results in derangement of healthy condition. Fever occurs readily, and from slight causes of provocation. It is not rare to see a weak, puny infant with a tendency to pus formation from the most trifling causes ; this is usually traceable to a defect in the quality of the blood, the result of inadequate nourishment, or to the eft'eet of poisonous influences upon the tender organism, by which it is more likely to be affected than in after life. But when positive inflammation is provoked in early life, if its processes are rapid in their evolution, they are more likely to be limited to the constructive stage ; and there is in the infantile organism a fund of vital energy available to resist and to repair injury which is very remarkable. Evidence of this is to be seen in the results of very early operations for hare-lip, and in opera- tions for imperforate anus ; and in the striking cures effected in infantile syphilis by the judicious use of mercury. On the other hand, in the aged, affections peculiar to this period of life, often referred to as inflammatory, are really of a different nature: neither prostatic disease nor senile gangrene is due to inflammation. The former, like the uterine tumors of the other sex, is, for the most part, due to fibroid over- growth, and the latter is a result of degeneration of the arterial coats. The catarrhal affections of age, such as cystitis and conjunctivitis, are truly inflam- matory, and tend to pus production. They arise from weakness in worn-out tissues by which the power of resistance to exciting causes of inflammation is impaired. It is to be remarked that the power of repair, although some- what slower in its manifestations, rarely fails through age alone. This is noticeable in the constancy with which a good immediate result is obtained after tlic removal of epitheliomatous cancers so common at this period of life. In middle life, the greater degree of exposure to traumatism, to the influence of poisons, and to the consequences of excess, explains the greater frequency of inflammatory affections at this period. Here, also, are encountered the contingencies attending "pregnancy and lactation, which so often tend to inflam- matory phenomena, whether by traumatism, the poisons to which the puer- peral stale exposes the patient, or the peculiar and rapid changes to which the blood is liable in these conditions. It would be wrong to omit the curious CAUSES OF INFLAMMATION. 73 perturbations of the nerve force which also attend them. There is a remark- able tendency to pus formation developed in exceptional instances, 'post parturn, which affects the joints by preference, and of which there is no satisfactory explanation. Habit of bod}/, etc. — It was formerly a common belief that stout and full- blooded persons were especially liable to inflammation ; that they were in a " state of plethora'' — a condition of morbid fulness of the bloodvessels, indi- cating necessity for depletion. But, unless habitually over-fed, there is no foundation for this opinion. Moderate polysarcia is a constitutional pecu- liarity of many persons who enjoy good health. The habitually ill-fed, and those who from any cause are below their normal weight, are more likely to do badly after a serious injury or a surgical operation, through the superven- tion of some of the unhealthy complications of constructive inflammation. Parts which have been already the seat of inflammation are more likely to fall into that condition subsequently, from slight provocation, than tissues whose vessels have never been subjected to previous over-distension. In com- mon phrase, "their vitality has been weakened." This is also true of parts which have been exposed to prolonged or extreme cold, or which have been frozen. The habitual congestion, the itching, and the proneness to vesication and ulceration so commonly observed in chilblains, illustrate this predisposing cause of inflammation. It is probable that in addition to impairment in quality of the vascular tissues in parts thus "weakened," their nerves have also suffered in a similar way. Every organ whilst in active use receives more blood, and is, for the time, hypersemic. Habitual functional hypercemia, especially when associated with fatigue from prolonged or excessive use of an organ, is a not uncommon pre- disposing cause of inflammation. Thus, reading all night is liable to be fol- lowed by suppurative inflammation of one or more of the Meibomian follicles — the ordinary hordeolum, or sty ; and if this excess be frequently repeated, the tissues of the eyeball itself are pretty certain to suffer from inflammation in some form, if exposed to an exciting cause. A young gentleman fatigued and heated by active ball play seated himself to rest by an open window where he was exposed to a draught of cool air. The next morning the muscles of* the shoulder and arm were the seat of excessive pain on the slightest motion, in consequence of the development of a condition of " subacute inflammation" of the muscular tissues. In regard to the influence of climate, and of meteorological phenomena, in predisposing the organism to inflammation, certain facts have been observed. In tropical regions, inflammations of the eyes of a serious character are very common and prevalent. So, also, is dysentery ; and abscess of the liver is a frequent occurrence. The latter affection is very rare in cold, or even in tem- perate climates. In the latitude of New York, the summer heats predispose to inflammations of the intestinal canal, especially in children, tending to culminate in ileo-colitis. In cold weather, the air passages are more prone to inflammatory affections, of which the most common is bronchitis. March winds, as was pointed out over two thousand years ago by Hippocrates, were, in the Morea, as they are with us, the frequent causes of acute phlegmasia — of tonsillitis, bronchitis, and conjunctivitis; evidently because they favor sud- den chilling, and give rise to irritation by producing clouds of dust. In our climate, the seasons of the year which have been found most favor- able for surgical operations, as regards freedom from inflammatory complica- tions, are the midsummer and autumnal months. This is explained by the 74 INFLAMMATION. freer access of fresh air. In the comparatively severe cold of the winter, and the changeable weather of spring, it is more difficult to secure healthy con- ditions as to ventilation. Erysipelas occurs more frequently in the late win- ter and early spring months. Exciting Causes of Inflammation. — Strictly speaking, there is but a soli- tary cause for inflammation, and that is irritation of the living tissues by something which is called an irritant ; and this act constitutes, technically, an injarij. But there is an endless variety of irritants which may be sepa- rately recognized and classified for study of their nature and mode of action, with the ultimate purpose of modifying their influence and controlling their injurious effects. This constitutes etiology, the, practical value of which lies entirely in its bearing upon treatment. We have enumerated certain of the remote influences which tend to invite and favor the action of irritants in causing inflammation ; and we have next to examine more closely the nature and qualities of the more immediately exciting causes of the inflammatory movement, so that we may be able to intelligently aid and favor it, as far as it is reparative or constructive, or to avert or control any of the destructive phases which it is liable to assume. The proximate or determining causes of inflammation, more commonly spoken of as exciting causes, may act upon the body from without, as when a bullet strikes it ; or they may take their origin within the body, as in epididymitis from tubercular deposit, or eczema from diabetes. This sub- division of the causes of inflammation, which has been already mentioned, is followed by the French school. The external causes are more obvious and easily recognized ; the internal more obscure, and these cases are likely to be regarded as " spontaneous" or "idiopathic." It may be inferred from what has been already stated concerning the inflammatory predisposition, that the latter is more commonly present in connection with internal causes, for in them the pre-existence of some morbid condition of the organism is almost necessarily assumed. External causes of inflammation are for the most part either traumatic or (to adopt a parity in nomenclature) toxic in their nature, the locality in which the inflammation develops itself being determined more or less entirely by chance. Internal causes, on the other hand, are not only aided or invited by some predisposition on the part of the organism, but the part or organ in which the inflammation locates itself is in most instances also determined by it. Coll and Sudden Chilling as Causes of Inflammation. — There is a frequent cause of inflammation which cannot be strictly included under either of these Lends — cold or chilling — as applied to the whole body, or to a part. The ordinary hyperaeniic and catarrhal symptoms which so commonly follow chilling of the body, especially of the feet, are familiar to all. They are caused by sudden changes in the constitution of the blood from the temporary arrest of function of the skin as an emunctory, whereby certain effete and presumably noxious materials which should be eliminated are retained and net iis blood-poisons. In this manner ;i species of temporary intoxication is produced. The resulting inflammation is not usually of a serious character, and shows a certain preference lor the air-passages, although it may affect any part of the body especially a part that has been previously weakened. A genera] chilling varies greatly in the degree of gravity of its effects; it may involve any internal organ of the body, and to such an extent as to prove mortal. A gentleman of 28, in full health, stripped himself entirety on returning home from business, on an exceptionally hot day, and threw himself on a lounge before an open CAUSES OF INFLAMMATION. 75 window to cool off before dressing for dinner. He fell asleep, heedless of a thunder- storm accompanied by a decided fall in the temperature, and awoke thoroughly chilled. On the same night he was seized with a rigor which proved to be the initial symptom of an acute general peritonitis, which terminated fatally within the week. Severe chilling of a part is also a frequent cause of inflammation. \Vliat is known in England as " railway paralysis" is the result of inflammation of the facial nerve, or its neurilemma, from sitting in the draught of an open window when the cars are in rapid motion. A gentleman had a severe inflammation of the epididymis and testis which led to complete atrophy of the organ. It followed a chilling of t lie testicle from sitting for an hour upon a cold stone doorstep, in thin clothing, after being heated in walking. The pendulous organ rested upon the cold seat and had become sensibly chilled, as he noticed at the time. The next morning it was painful and swollen. The inflammation subsided in a week, but continuous shrinkage in volume of the organ followed. There was no urethral lesion. Inflammatio a frigore, as the ancients called it, has always been regarded, popularly as well as professionally, as a very common occurrence — cold being universally received as a sufficient and satisfactory cause of the inflammation. It is not improbable that mortal injury, or actual necrosis, of some of the anatomical elements of a chilled organ may set in action the series of changes which, according to our view of its pathology, constitute inflammation ; the blighted elements may degenerate, or liquefy, and undergo absorption ; or the inflammation which their presence has excited may culminate in abscess, and thus effect their expulsion from the organism. Reverting to the classification of causes which have been recognized as competent to excite the inflammatory process, we shall proceed to examine in detail the most typical of them. Incised Wounds. — There is no form of mechanical violence that excites inflammation, in which the process is developed more Uniformly in its benign or constructive form than in division of the tissues with a sharp knife so as to produce an " incised wound," such, in fact, as that made by the surgeon in cutting operations. And yet a scalpel with the keenest edge cuts on the principle of the saw, and invariably leaves in the wound myriads of micro- scopic particles of lacerated tissue. These are carried away in part by the flow of blood and the subsequent liquid exudation, and the rest undergo liquefaction and absorption by the lymphatics. They do not apparently interfere with the kindly succession of changes which, when the cut surfaces are quietly retained in proper apposition, bring about prompt union " by the first intention." These changes are exudation, cell-proliferation, the genera- tion of new capillaries which inosculate across the breach of continuity, and the organization of a film of cicatricial tissue, often hardly visible, by which Nature's "first intention" is completed. This happy phrase by which Hunter described the phenomenon of " primary union," was applied to a result accom- plished by what he called " adhesive inflammation." The discovery of the microscopic mechanism of this process has not impaired in any degree the aptness of the phraseology of the great observer. It is for us to notice that, in its most perfect results, our senses detect, in the process of primary union, neither pain, heat, redness, nor swelling ; simply the healing of a textural breach by a nutritive act, effected without excitement, and by an apparently competent mechanism. Whilst admiring the perfection of this typical expression of the reparative act, our part is to detect, if possible, the causes which lead to such frequent deviations from its simple effectiveness, and, if possible, to prevent obstacles to its uniform accomplishment. The sources of 76 INFLAMMATION. injury next to be considered — stabs and punctured wounds — often present features and complications by which a result so desirable as that just described is prevented. Punctured Wounds. — Puncture by a smooth polished instrument resembles an incision, and, if the track of the wound be kept at rest, and subjected to gen- tle pressure in order to keep the divided surfaces in contact, it generally heals kindly. Wounds made by surgical needles for suture, exploration, or aspiration, are examples ; even trocar wounds heal promptly. Thus, when the tissues are simply divided and thrust aside, there is no cause for compli- cations ; but from a puncture made by a rough instrument, as where a rusty nail perforates the sole, larger particles of tissue are liable to be killed, and foreign matter is apt to be left in the wound. 4 Hie presence in a wound, of foreign material is a very common source of interference with the healthy process of repair. Hence the formal rule enjoining its careful removal before dressings are applied. In the first place, it prevents accurate contact of divided parts, a condition absolutely necessary for prompt healing. In the second place, the presence of a foreign body in contact with the living tissues, as a rule, acts as an irritant, and ushers in a series of phenomena which have for their purpose its expulsion from the organism. These are, afflux of blood to its vicinity, the germination of em- bryonic cells, their accumulation in the form of pus, and ulceration in the direction of the nearest free surface, by which a free vent is gained, and the foreign substance is thus thrown oft". These phenomena are attended by pain, heat, redness, and swelling, and they constitute a phase of inflammation which attains a degree of intensity that involves destruction of tissue. Tins forms at once a contrast with the simple process of repair. There are excep- tions to the rule that foreign bodies act as irritants, and provoke suppurative inflammation. Some of the metals, such as lead, silver, and iron, are in a cer- tain degree tolerated by the tissues, causing only a grade of inflammation which ends in tissue formation, and they become finally enveloped by a sac of connective substance called technically a cyst ; they are said to be encysted. But these exceptions serve only to prove a rule. This is exemplified by what Furbringer, of Jena, sa} r s of hypodermic injections of metallic mercury : that " they are well borne, but within twenty-four hours inflammatory symptoms set in, and frequently result in abscess." Our own tissues, when from any cause deprived of life, become foreign bodies and constitute the most common examples of irritants, even when the dead masses are quite minute. The ordinary boil is due to this cause, which may be demonstrated by examining its core microscopically. The core of a boil consists of a little slough of connective substance, mainly of the yellow elastic fibres, containing in its meshes some leucocytes or pus cells. This small mass has become necrosed, and its white fibrous element has liquefied and mingled wi.h the pus; but its yellow fibres, one of the most indestructi- ble of all the simple tissues, remain unchanged and constitute the foreign body the presence of which has excited the suppurative inflammation. Ne- crosis of connective substance in minute masses is not a rare occurrence. It i- due to some detect in nutritive quality of the blood, or of the nervous sup- ply transmitted to the tissues. Its cause is obviously central, and not local; for boils often occur in indefinite succession in different localities ; and their tendency to recurrence is distinctly controlled by the internal use of certain drugs which modify favorably the blood and the nerve force, such as arsenic, sulphide of calcium, and the nypophosphites. Certain blood jwisons give rise to disseminated tissue necroses. In smallpox, each pustule is evolved for the CAUSES OF INFLAMMATION. 77 expulsion of a disk of dead true skin. Hence the depressed cicatrices or '• pits" which these minute abscesses leave behind them. The death of a portion of osseous tissue, from scrofulous malnutrition, or from a traumatism, as when a scale of bone, giving attachment to a muscle, is torn off in some violent effort, or, in fact, necrosis from any cause, is a common source of ori- gin of deep abscess. Foreign substances liable to provoke inflammation by lodging in the body include bullets, cloth, splinters of bone, of wood, and all the materials liable to be associated with gunshot projectiles and explosive compounds of every variety ; and, with the exceptions mentioned, the inflammation provoked by them is attended by suppuration. Gunshot-wounds are, in a certain sense, rough punctures. In considering lesions of bone by mechanical force, in their relation to in- flammation, we encounter at once a remarkable clinical feature — not, indeed, peculiar to this tissue, but typically illustrated by its behavior under injury. In a large proportion of lesions of bone, simple fractures, for example, the in- flammatory condition is limited entirely to its constructive phenomena, very rarely transcending the boundaries of the process of repair. On the other hand, in a comparatively small proportion of them — the compound fractures — the inflammation often assumes its most destructive aspects; and these constitute a grave and critical class of surgical cases. In the former, uncomplicated and satisfactory repair is the usual result; in the latter, there is frequently loss of limb and loss of life. Formerly it was held that the additional vio- lence inflicted on the soft parts accounted for the difference in the amount and character of the inflammation occurring in compound fractures ; this complication being regarded as a sufficient explanation of their increased gravity. But we have gradually learned from clinical experience, largely from the success of Stromeyer's operations upon tendons and fascire — in which these parts were cut across by a small knife inserted through a minute wound which was promptly closed and sealed — that the subcutaneous character of the lesion affords the true explanation of the greater safety in simple frac- ture, and that exposure of the injured parts to the air is the source of danger in compound fracture. Surgical operations for the relief of deformities, as previously practised, had proved so dangerous that they were rarely resorted to, until the German surgeon demonstrated that the method just described was uniformly safe. It has become a received doctrine in surgery that, not only in fracture, but in any lesion whatever, when the external air is excluded, the phenomena of inflammation that follow are restricted to those of the be- nign or constructive order. The explanation of this interesting fact, that subcutaneous lesions are uni- formly repaired by constructive inflammation, the discovery of which has added vastly to the safety and utility of operative surgery, has been sought for in various directions. Addison ascribed it to the uniformity and to the elevation of the temperature at which the injured parts were preserved during the subcutaneous process of healing. He recognized the close resemblance between the vital phenomena of reparative inflammation and those of embry- onic development, as studied in the egg of the chick during incubation, and correctly inferred that the conditions which nature always secured for the latter (in warm-blooded animals) would be most favorable to the process of repair; and that liability to frequent chilling would be as harmful to the pro- gress of healing as it was in the process of incubation. Afore recently Lister is seeking to demonstrate that the apparently noxious influence ascribed to the air is not due to any intrinsic qualities of the air, but to the presence in it, under almost all conceivable circumstances, of mi- croscopic germs of micro-organisms. He asserts, in accordance with Pasteur's 78 INFLAMMATION. demonstration of their habits, as ascertained by their cultivation in different media, that these organisms iind in the raw and exposed surfaces of our tis- sues avenues of entrance, and that they at once encounter materials which constitute a suitable pabulum for their germination and development. The j>resence, in the soft vital materials of a recent wound, of myriads of micro- organisms multiplying, at their expense, with the inconceivable rapidity of cryptogamic fungi, accomplishes the destruction of their vital and chemical properties, and entirely unfits them for use in the process of repair. Repara- tive inflammation fails, therefore, for want of material, and is replaced by the condition which constitutes destructive inflammation. Pasteur's dis- covery of the fermentative nature of putrefaction, and his proofs of the pro- duction of this process by the struggle for life of minute organisms like the torula of the yeast plant, lends verisimilitude to the doctrines advocated by Lister. At the present time they afford the most probable explanation of the habitually more favorable results, as to healing, of wounds excluded from contact with the air, and of the greater mortality of compound fractures as heretofore treated. The evidence upon which this conclusion is based is de- rived from clinical observation of the more favorable results obtained by treating compound fractures in accordance with the antiseptic method, which aims to destroy or exclude all microscopic aerial germs. The germ theory of disease, and its bearing upon inflammation, is a subject which presents a degree of importance at the present time, to which it is dif- ficult to place a limit. No study of the exciting causes of inflammation can approach completeness without a full consideration of its claims to credence, and a due estimate of their value. It will be necessarily discussed hereafter in connection with the toxic exciting causes of inflammation. Mechanical violence that results in wrenching, straining, dislocation of joints, affecting principally the white fibrous tissues composing the ligaments, and the tendons with their sheaths, produces, for the most part, lesions not exposed to contact of the air. The inflammation that follows. is, therefore, rarely otherwise than simply reparative. Compound dislocations, however, present most of the unfavorable features of compound fractures. Contusion of living tissues involves not only a possible breach of continuity, but also, to a variable extent, entire or partial destruction of textural life. In every contused wound of any severity, there are liable to be sloughs, or parts entirely killed, which must be separated, or thrown off, by a vital process before final healing can take place. There are, also, parts often described as half-killed, that is, so tar injured as to render their survival a matter of doubt — certainly, of delay. This complex condition includes several exciting causes of inflammation besides the general stimulus to repair that follows every in- jury. To this stimulus the tissues which have been simply divided, but not otherwise seriously damaged, are alone in a condition to respond. Hence the rule, in dressing contused wounds — to bring the surfaces together as for pri- mary union, but with very moderate retentive force, in order to test the capacity of the doubtfully injured portions to undergo the changes which ac- company constructive inflammation, and to secure any advantage that may be attainable. ( )!' the parts in a contused wound which have been damaged, but not en- tirely killed, a portion may recover and participate in the healing; whilst the rest, sooner or later, die. The delay required to determine the fate of the doubtful part- renders suppuration, under ordinary dressings, unavoidable. The process of separation of dead from living parts, under ordinary cir- cumstances, has heretofore rendered granulation and suppuration inevitable. CAUSES OF INFLAMMATION. 79 The presence of dead tissue in a wound, before a granulating surface lias be- come organized, involves a certain danger of septic poisoning. The necessary occurrence of these several sources of irritation in a contused wound, as conse- quences of its nature and mode of production, explains the greater liability to inflammatory complications of this form of surgical injury. In lesions of the internal viscera from mechanical violence, when they are of moderate extent and do not implicate large bloodvessels, it is probable that healing often takes place without any recognition, or even suspicion, of the existence of such a lesion — the uniform high temperature of the injured part favoring prompt repair, as in a subcutaneous wound. This is rendered probable by the discovery of recent cicatrices in the lungs, liver, and kidneys in patients who have died from the later consequences of coexisting external injuries. It is evident, from this brief survey of the exciting causes of inflammation arising from mechanical violence, that, as far as we can learn from clinical observation, these causes act primarily, and, in fact, mainly, by stimulating the process of repair. Deviations from the simple constructive process which may manifest themselves subsequently, in the progress of a case, are explained : first, by the conditions peculiar to the injury, e.g., the necessity for getting rid of matters foreign to the economy in order to accomplish healing, and by other causes of delay in the process; secondly, by the accidental interference of noxious agents which, by acting directly upon a wound, impair the quality of the materials furnished by the organism for healing it. The j)resence of a clot of blood of any size in a wound has always been re- garded as a possible cause of at least partial failure of union, and of pus forma- tion-. Thus, bleeding in a stump after the ordinary mode of dressing, in consequence of failure to secure a vessel which has bled after reaction, or from inadvertent bruising, or injudicious pressure, has often been the cause of pro- longed heat and pain, and of fever protracted beyond the usual limit, and finally of suppuration, abscess, and sinus. To prevent repetition it may be stated here, that this very frequent cause of inflammation which, combined with the presence in the wound of ordinary ligatures of silk, has been, hereto- fore, one of the most common causes of ill behavior in wounds, has been found by recent clinical experience to be preventible by the use of antiseptic dressings and ligatures of prepared catgut. When these precautions have been care- fully employed, clots even of considerable size have been observed to shrink and lose their color, and to become organized by the appearance in their sub- stance of embryonic cells and newly-formed capillaries, and to assist directly in forming a bond of union. The prevention of putrefaction by the antiseptic method, a result which can always be commanded, apparently favors the more perfect accomplishment of the constructive process. In recent experiments on animals, masses of living, and even of dead (but not putrid) tissue, have been successfully included in the peritoneal cavity, and have become organized. 1 1 A paper was presented at the Berlin Medical Congress of April, 1SS0, by Dr. A. Rnsenherger, of Wurzburg (Archiv fur klinische Chirurgie), on this subject. Having observed that foreign bodies and ligatured portions of tissue, e. ehavior of most chemical irritants as excitants of inflammation. Their action is limited to that of a simple stimulus to repair; and, when severe enough to produce death of tissue, the sloughs are thrown oft' without suppuration, pro- vided that the air has been excluded, or that antiseptic dressings have been employed. Burns by phosphorus would seem to constitute an exception, as the acid generated by the combustion of the phosphorus acts as an additional irritant to the raw surface. Heat produces results similar to those of the potential cautery, but in greater variety. It may cause a simple blush of transient hyperemia, or vesication, CAUSES OF INFLAMMATION. 81 or death of tissue — superficial, or deep. The inflammation following simple burns, or scalds, if no eschars have been formed, is limited to simple repair, especially if the air is excluded from the seat of injury. When there is death of tissue, the separation of the eschars, as a rule, involves suppuration. Re- pair by the second intention, that is, by granulation and suppuration, often fails, in extensive burns, through lack of cicatricial power, and from other causes; but, if we except pyaemia during suppuration, inflammation, as such, rarely leads to a fatal result in burns. There is an opinion prevalent amongst practical surgeons that the unhealthy forms of inflammation are less likely to follow in wounds to which the actual cautery has been applied, or where incisions have been made by the incandes- cent knife. It is also a common belief that healthy reparative inflammation is promoted by the application of the caustic acids and alkalies. This is probably founded, at least in a measure, upon their efficiency in destroying poisoned surfaces, e. g., venereal and phagedenic ulcers, and parts attacked by hospital gangrene. Of the escharotics in vogue of late, the chloride of zinc enjoys much reputation through its reputed antiseptic quality; and there is evidence that the liberal application of an eight per cent, solution, which is decidedly escharotic, to a recent wound, does not interfere with its subsequent union by the first intention — certainly under antiseptic dressing. The mode which we have adopted of studying inflammation, by scrutiniz- ing the causes which have been proved to be capable of producing this condi- tion in our tissues, and the manner in which these causes act, has led, thus far, to the recognition of two well-marked grades of the inflammatory pro- cess. One of these is the simple form of repair which constitutes Hunter's union by the first intention; the other is the process of healing by the second intention, or by suppuration and granulation. It has also been recognized that tissues which have been damaged by injury sometimes die in the effort at repair, and apparently in consequence of it. The exciting causes which next present themselves for examination, namely, the sources of jwisonous in- fection, are more various in their nature, and also, in some of their forms, more obscure in their mode of action than those heretofore under considera- tion. Although the existence and the noxious influence of some of these sources of injury has long been suspected, they have, until recently, escaped general recognition. The effects of the inflammation-producing poisonous agents upon the organism cover a wider range than those exciting causes which act only mechanically, or chemically. In addition to their action upon the tissues generally, some of these poisons exert a specially noxious influence directly upon the nervous centres. Many of them possess, also, the peculiar power of perpetuating their poisonous influence, after their introduction into the organism, by a process allied in its nature to that which causes fermen- tation. The poisonous agents capable of producing inflammation fall naturally into several distinct classes, according to their origin and nature: (1) the mineral poisons; (2) those elaborated by the vital chemistry of plants; (3) the poison- ous secretions of animals ; (4) the poisonous infection arising from the action of microscopic cryptogamic parasites; and (5) putrid substances. The Poisonous Action of Certain Minerals — arsenicand mercury, for example — gives rise to inflammation in a manner quite different from the chemical irri- tation produced by the primary contact of these metals, or their salts, with the living tissues. The peculiar nature of the inflammation is generally con- veyed by the use of the term specific, and its action is only developed after the mineral poison has entered the blood-current and is circulating, to all ap- vol. i. — 6 82 INFLAMMATION - . pearance, harmlessly in it, when, as soon as the ingestion of a certain amount has been reached, an active gastric hyperemia attended by vomiting super- venes, if the poison be arsenic, or an inflammation of the mouth attended by salivation, if the poison be mercurial. These inflammatory phenomena may be produced with equal certainty if the poisonous substances are introduced into the blood-current through the skin, or through the mucous membrane of the rectum, which may be done without necessarily producing any inflamma- tion of either absorbing surface ; so that there is no question of local chemical irritation from direct contact. The poisonous action upon the stomach, or the mouth, is something different from that produced by a chemical irritant, and it is effected by a different mechanism; it is "specific." The tissues of the stomach, or of the mouth, are, for reasons unknown to us, more sensitive to the action of these mineral poisons than the tissues of other organs; and this poisonous action manifests itself by producing the phenomena of inflam- mation. The renal congestion and hematuria which result from persistent inhalation of volatilized turpentine is readily explained by the irritating action of this substance upon the tissues of the kidney during its elimination from the blood, and the same mechanism has been supposed to explain the desqua- mative nephritis that follows scarlatina, and the follicular intestinal ulcera- tion of typhoid fever. I3ut neither arsenical gastritis, nor mercurial stoma- titis, has been accounted for in this way; and the preferences of these mineral poisons for certain particular organs must be regarded, for the present, as ultimate facts. But they are not facts without parallel, for it will be found hereafter that certain septic poisons, when they gain access to the blood, give rise to congestion and inflammation of serous membranes, and at certain pre- ferred localities of the intestinal mucous tract. Poisonous Action of Plants.— -The effect of the contact of the "stinging" nettle (Urtica), in producing a papular eruption, of the poison vine (Rhus), in causing a vesicular irritation of the skin, of croton oil, in bringing out a crop of minute abscesses, are familiar examples of inflammation resulting from the simple contact of substances of vegetable origin. A search for the explana- tion of these phenomena leads us also to the ultimate fact that these sub- stances are in some way hostile to textural life or well-being, and that their contact, probably through some injurious influence exerted upon the nerves of the locality, temporarily perverts or arrests the nutritive process. Poisonous Secretions of Animals. — Under the third class — of poisonous secre- tions elaborated in the living animal body — we have positive clinical evidence that inflammatory action may be directly excited by the contact of pus, or of other products of pre-existing inflammation, that is of simple, non-specific in- flammation, in the products of which there is no suspicion of the presence of extraneous poisonous matter derived from any other source. The contagious quality of so-called healthy pus, taking this secretion as a typical product of inflammation, is, at the present day, so generally admitted to exist, within certain limits, that we may dispense with a formal demonstration of the fact. The evidence collected by Simon, who contended for its existence in I860, 1 showing that in examples of inflammation attributed to sympathy, the inflam- mation is in reality due to the contagious quality of pus ; and the more recent researches of Chauveau 2 and others, leave nothing to be desired in the way of confirmation of the fact. As to the nature and quality of the inflammation • Holmes's System of Surgery, 1st ed., 18G0, vol. i. p. 68 ; id. op. 2d ed. 1870, vol. i. p. 46. 8 Revue des Cours Scientifiques, 2 e serie, l r0 auntie, 14 et 21 Octobre, 1871 ; 2 C anuee, 13, 20, et 21 Juillet, 1872. CAUSES OF INFLAMMATION. 83 thus incited, we will speak farther under the head of " varieties" of inflam- mation ; but it is as well to remark here that although the subcutaneous in- jection of pus in the lower animals is capable of inducing febrile action of the simple inflammatory type, with great certainty, the fever thus produced, as a rule, subsides spontaneously ; and the local inflammations excited by the con- tact of inflammatory products, when the latter are fresh and unmixed v\ith other sources of poison, are, for the most part, of the simple catarrhal variety, and neither unhealthy nor destructive. 1 The practice of inoculating pawn us of the conjunctiva and cornea with fresh pus to provoke inflammation for a curative purpose, employed on a large scale in Germany, illustrates at the same time the contagiousness of fresh healthy pus, and the comparative harin- lessness, in a general way, of the inflammation thus excited. The poisonous qualities of certain living insects, not to speak of dead insects such as cantharides, find their most common examples in the Inosquito, the bee, the wasp, etc. The introduction of the poison of the mosquito into the substance of the skin of a person who has not acquired an immunity from its action, is followed within a few minutes by all the cardinal symptoms of in- flammation in miniature. The pain takes the form of itching; the redness forms a well-marked areola produced by the afflux of blood from every direc- tion , towards the point of puncture — with an appreciable increase of local heat; and the swelling, from rapid exudation, is often so tensive as to arrest the capillary circulation at the centre of the affected area by its pressure, causing a distinctly pallid spot, or wheal, at its apex. After a short time all these symptoms disappear, leaving a point of ecchymosis, recognizable with difficulty on account of its minuteness. This gradual and entire disappear- ance of the symptoms of inflammation affords an example of the phenomenon generally described as "delitescence" or "resolution." Isot unfrequently a little thickening of the tissues remains at the seat of the injury just described, and, from time to time, a slighter degree of itching may recur. In persons of an irritable habit an ulcer may possibly be established by the repeated scratching thus provoked. There is, in fact, a certain amount of persistent impairment or degradation of vital quality incurred by the nerves and other textural con- stituents of a part by the contact of an animal poison — which is a noteworthy characteristic of this form of injury. The apparent reluctance to heal, and the tendency to ulceration, manifested in some cases after vaccination, is an example of the effects of local tissue poisoning ; and the same phenomena are still more frequently noticeable in the behavior of the contagious venereal ulcer usually called "chancroid." Thus the lesson is to be learned from so trifling a poisoned wound as a "mosquito bite,"' that a poison is a noxious agent capable not only of directly exciting the condition of inflammation in our tissues, to a degree of intensity apparently out of all proportion to the injury as regards its magnitude or gravity, but, also, of leaving after it a more or less permanently damaging effect upon those tissues, by which their vital quality is invalidated. In addition to the general conclusion that this source of injury is competent to cause a local derangement of the nutritive machinery, which manifests itself by the phenomena of inflammation, it may be remarked that this development of the inflammatory condition has, apparently, no reparative purpose. It is an extravagant outbreak, on a limited scale, of excessive action on the part of the local nutritive apparatus, by which, as far as we can see, no object is 1 Simon concludes "that the contagiousness of communicable inflammation seems to he in some special way relative to corpuscular development, and the contagium to he inherent in grow- ing forms ; whereas, the contagiousness of the specific inflammation seems rather rela'ive to their destructive acts, and the contagium to reside in defunct and dissolving organic compounds." (Loc. cit. ed. 1870, p. 51.) 84 INFLAMMATION. to be attained. Heretofore, the inflammatory changes provoked by the ox- citing causes which have been under consideration, have had an unmistakable purpose, namely, of healing a breach of continuity, or of getting rid of a foreign body ; and when this purpose was attained, the abnormally excited nutritive action subsided. But in the examples of inflammation provoked by poisonous contact or influence, there has been no such object discernible — either reparative or eliminative — as far as we have evidence. The honey bee, we are told by Huber, often leaves his serrated weapon in the little wound through which the poison has been injected in the act of stinging; and here a foreign body is to be got rid of; but there is no such cause for eliminative inflammation apparent in the "mosquito bite." We may adopt the additional conclusion, therefore, that a poison, as an excitor of inflammation, possesses a novel injurious quality as regards the tissues — something superadded to the cutting, crushing, or burning of the mechanical and chemical lesions — the essential nature of which eludes our grasp. We are compelled to characterize this noxious quality by its effects upon the nerves and bloodvessels of a part, and we therefore speak of the part as poisoned. The poisoned condition is a local manifestation of the same nature as the more general influence upon the nervous centres already attributed to this class of injurious agents. Prof. Agnew gives an example of this poisonous influence in a case in which it followed a wound inflicted by a centipede, a poisonous myriapod common in warmer regions, "sometimes brought to Eastern cities concealed in hogsheads of sugar. I have seen," says he, "a stevedore suffer for weeks from violent local and constitutional symptoms in consequence of a sting received on the hand while handling one of these hogs- heads on the wharf. The fingers remained purple, and the hand and arm weak, for a long time. His general health was seriously impaired by the in- jury ; and when I last saw him he looked like a man who had passed through a tedious and wasting spell of sickness." 1 Within the experience of the writer, a naval officer stung by one of these insects on the hip, was subject for a num- ber of years to an annual eruption of angry papules at the seat of the poisoned wound. The influence of the poisoned condition upon the grade of inflammation developed in tissues thus affected should not be overlooked. For the nerves and capillaries of parts thus degraded in the quality of their vitality, as we have already shown in the examples of delayed healing after vaccination, and the sloughing of certain venereal ulcers, do not respond in a healthy manner to the stimulus to repair. Such poisoned tissues manifest a distinct tendency to suppuration, and to molecular disintegration. Effects upon the living tissues somewhat similar, but far more serious in degree, are produced by the venom of the poisonous serp>ents. The more active of these poisons, when introduced into the circulation, cause death quite promptly by the direct action of the venom upon the nervous centres and the heart. Singularly enough, the full noxious influence of serpent venom, as the researches of Weir Mitchell have shown, is transitory. Like the effects of the woorara, it lends to decline, and, after a certain interval, to disappear. 2 In tlie cases in which its immediate mortal effect has been escaped, the local influence of serpent poison upon the tissues is that of an inflammation-} ad- ducing agent, of great power. The local symptoms following the bite of a rattlesnake are intense pain, with rapid swelling attended by surface discolo- ration and mottling. Incisions of the affected part give issue to scrum, colored 1 Prin ciplcs and Practice of Surgery, vol. i. p. 227. Philadelphia, 1878. 2 Researches upon tin- Venom of the Rattlesnake; with an investigation of the Anatomy and Physiology Of the organs concerned. Published by the Smithsonian Institution. Washington, 18U0. CAUSES OF INFLAMMATION. 85 by blood ; the physiological condition of the vascular walls, and also of the blood itself, is manifestly altered by the immediate contact of the poison, the blood giving early evidences of putridity. There is a strong tendency to local gangrene. When this form of danger is escaped — wholly, or partially — sup- puration in the connective tissue follows. Tins suppuration is diffuse in its character, that is, it tends to travel along the planes of connective tissue, as in phlegmonous erysipelas, without limitation by organizing barriers of granula- tion tissue, the poisoned condition of the tissues preventing their formation. At a later period, when these barriers form, it becomes evident that the in- tensity of the inflammation-producing action of the venom has become less, and that the reparative grade of inflammation has established itself in place of the destructive ; in other words, that the vital nutritive process is no longer overpowered by the influence of the poison, and is again working normally. In a case of rattlesnake bite (by an imported snake), reported by Sir Everard Home, the victim, having escaped the earlier effects of the poison, died ex- hausted by suppuration in the third week. This clinical evidence shows that there are exciting causes capable of giving rise to the inflammatory condition in its most destructive phases — causes more intense and effective than any heretofore examined. These latter, in- deed, might have been regarded as exaggerated examples of a stimulus to repair, demanding, simply, an increased effort in nutritive activity. The former, on the other hand, exert a directly damaging effect upon the apparatus of nutrition itself, threatening extinction of textural life; and it is only after this first influence has been recovered from, mainly in consequence of the evanescent quality of the noxious agent, that the reparative act comes in play. "What it interests us especially to learn concerning inflammation, is, whether there is any essentially destructive quality that belongs intrinsically to the condition ; or if its destructive phases are always traceable to the influences by which it has been excited. This question is important in view of its direct bearing upon the practical subject of treatment. If the nature of its exciting cause determines in any degree the grade of the inflammation, we cannot study the nature and mode of action of exciting causes too closely. More light may be thrown upon this question by observing the several modes in which inflammation is produced by the sources of poisonous injury yet await- ing consideration. The grosser parasites, mainly of an animal nature, such as acari, trichina?, echinococei, lice (as in the disease known as phtheiriasis), and intestinal worms, produce various injurious effects upon our tissues and organs, but they excite inflammation only incidentally as foreign bodies. They are mentioned in this connection as suggestive of the liability of our bodies to parasitic invasion. It is the mode of action of the multiform microscopic fungi, and their germs, that affords most interest to the surgeon, because there is reason to believe that these invisible particles of organized matter are competent to act inju- riously by direct contact with the tissues when exposed in wounds. The germs of the vibrio septica — one of the most active and dangerous of the bacteria, according to Pasteur — are singularly indestructible by extremes of heat and cold, and by most of the powerful chemical agents ; but the organisms into which they develop, under favorable circumstances, are not so tenacious of life ; they have the peculiarity of not being viable when exposed to the influence of free oxygen. Wherever oxygen has no access, they germinate, however, with inconceivable rapidity, supporting life by appropriating from the animal materials by which they are surrounded — wound-fluids and granulating surfaces, for example — the sustenance they require. In the changes, chemical and vital, to which these animal materials are subjected in the struggle for existence of the vibrios, the result is putre- 86 INFLAMMATION. faction. The presence of the vibrio septica begets putrefaction in a mod in in of animal matter by inducing a process of fermentation. It is asserted that the vibrios evolved from the germ's first deposited upon the surface of a wound, die from exposure to the oxygen of the air, and afford a protection to the surviving germs beneath, which are thus enabled to germinate indefinitely. In the chemico-vital changes incident to the process of putrefactive fermentation thus begotten, certain poisonous combinations are formed. These are designated as septic poi 'sons, and they are regarded as the source of the dangerous diseases which take their origin in wounds. The wound diseases thus produced comprise all the unhealthy and destructive forms of local wound inflammations, as well as the consequences of the ab- sorption of septic poisons into the general circulation, namely, septicaemia and pyaemia. This micro-organism, the vibrio septica, is considered to act as a poison, first, by spoiling the materials provided for repair, and thus inter- rupting the constructive process in a wound ; and, second, by acting as a putrefactive ferment and elaborating septic poisons which cause the subse- quent destructive phenomena. ' These are the facts which Pasteur asserts that he has demonstrated, and upon them, mainly, Lister has based his antiseptic method of treatment for wounds, believing that they afford an adequate explanation of the mechanism by which destructive inflammation is caused by the agency of cryptogam ic parasites. The apparent success which has followed the practical application of the antiseptic methods in surgery, has invested these micro-organisms with much interest, and at the present time they are the subjects of patient and careful study in many quarters. Those who have pursued this study most success- fully assert that there are, probably, numerous other organisms possessing poisonous qualities, each of which has its own peculiar mode of action. This, in fact, has been recently demonstrated by Koch, a most patient and able investigator, whose statements are singularly lucid and apparently judicial in their fairness. 1 This author, premising that generalizations of new facts frequently lead to mistaken conclusions, insists that, in the study of this subject, every individual infective disease, or group of closely allied diseases, attributed to bacteria, must be separately investigated. He holds that the bacteria capable of producing disease are limited in number, and that these pathogenic bacteria comprise different and distinct species ; that the only correct practical method of studying such bacteria as seem capable of producing constant noxious results, is by cultivation "from spore to spore." There is no better cultivation apparatus for pathogenic bacteria, he asserts, than the body of an animal. By this method, and the employment of certain improved optical appliances by which these particles which border on the invisible can be more readily and certainly recognized, this observer avers that he lias demonstrated the certain existence of at least five artificial trau- matic infective diseases. These are: septicemia, in mice; progressive destruc- tion of tissue (gangrene), in mice; spreading abscess, in rabbits; septicaemia, in rabbits; pymmia, in rabbits; and, partially, en/sy?e£as, in rabbits. His investi- gations show, also, that these artificial traumatic infective diseases, both as regards their origin from putrid substances, their course, and the results of post-mortem examinations, bear the greatest resemblance to human traumatic infective diseases. The most important demonstrated result attained by Koch, by using 1 Investigations into the Etiology of Traumatic Infective Diseases. By Dr. Robert Koch (Wollstein). Translated l>y W. Watson Cheyne, F.R.C.S. London, The New Sydenham Society, 1880. CAUSES OF INFLAMMATION. 87 staining materials with an improved optical apparatus, is the discovery of the specific differences which exist between pathogenic bacteria and the constancy of their characteristic features, not only as to form, but as to the nature of the noxious effect produced by each. "A distinct bacteric form corresponds," as he says in his conclusions, " to each disease, and this form always remains the same, however often the disease is transmitted from one animal to another." In regard to septicaemia, he says : "I have performed these experiments on fifty-four mice, and always obtained the same result. . . . Further, when we succeed in reproducing the same disease de novo by the injection of putrid substances, only the same bacteric form occurs which was before found to be specific for that disease." This statement, if confirmed, marks an important advance in our knowledge as bearing directly upon the exciting causes of destructive inflammation. The concluding words of Dr. Burdon Sanderson's " Report on the Causes of Infective Diseases," in 1875, marked the limit of justifiable assertion at that time. " If these infinitely minute organisms are present in every intense infective inflammation," says Sanderson, " we may be quite sure that they stand in important relation to the morbid process." It has now been appar- ently demonstrated that these organisms are present in every intensely infec- tive inflammation thus far brought under sufficiently close investigation, and that they are not present in normal blood when tested as to its power of causing development by cultivation methods, excluding all sourees of error, by Pasteur, Burdon Sanderson, and Klebs ;* that they bear the relation to the disease following their inoculation of cause to effect ; that there are different and distinct species of noxious bacteria; and that a positive and constant causal relation exists between certain infective diseases and distinct species of bacteria. Dr. Koch, by the employment of his improved methods, has arrived at a conclusion which is sufficiently important to justify repeti- tion — " that bacteria do not occur in the blood nor in the tissues of the healthy living body either of man or of the lower animals." One of the novel and original results attained by this observer is of great interest. By the aid of an improved optical condenser he was able to verify at will the presence of exceedingly minute bacteria of the species bacillus, but much smaller than the bacillus anthracis, in the blood of mice artificially in- oculated with putrid fluids, and dying, invariably, with symptoms of septi- caemia. Along with this bacillus he observed in the neighborhood of the point of inoculation, another bacterium — a micrococcus — characterized by a very rapid increase, and the formation of regular chains. This micrococcus was never present in the blood. When a healthy mouse was inoculated with the blood of a septicsemic mouse, only the septicsemic bacilli were trans- mitted, and these were invariably found in the blood of the inoculated animal ; but, when putrid fluid was injected, the bacillus was always found in the blood, and the micrococcus was always present in the tissues near the infected point — the other bacteria contained in the putrid fluid, and injected at the same time, dying out promptly because they did not find in the tissues of the living mouse a congenial soil. By studying the local effect of the micrococci after an inoculation in the tissues of the ear, which is found to be a favorable locality for observation, it is discovered that these tissues are killed by their contact, and even by their proximity. In the tissues thus deprived of life, the parasitic growth is seen to multiply and spread more vigorously, extending itself especially towards living parts. As it advances, all of a sudden a densely agglomerated mass of leucocytes appears — 1 Koch, op. cit., p. 14. 88 INFLAMxMATION. " . . . forming, as it were, a wall against the invasion of the micrococci, and this is the limit up to which these organisms may be found. They do not extend, even in the (dead) bloodvessels, beyond this line, the wall of nuclei (leucocytes) has no great breadth, and immediately beyond it comes the normal tissue. By the aid of high magnifying powers it becomes apparent that the micrococci do not reach quite up to the nuclear layer. On the side directed towards the micrococci the nuclei are undergoing destruction. . . . There almost always remains between the last remnants of the nuclei and the micrococci a line of considerable breadth, consisting only of gangrenous tissue, in which neither micrococci nor nuclei can be found." Dr. Koch assumes that the action of these parasites in causing this spread- ing gangrene is somewhat as follows : — " Introduced by inoculation into living animal tissues, they multiply, and, as a part of their vegetative process, they excrete soluble substances, which get into the surround- ing tissues by diffusion. When greatly concentrated, as in the neighborhood of the micrococci, this product of the organisms has such a deleterious action on the cells that these perish and finally completely disappear. At a greater distance from the micro- cocci, the poison becomes more diluted, and acts less intensely, only producing inflam- mation and accumulation of lymph corpuscles. Thus it happens that the micrococci are always found in the gangrenous tissue, and that in extending they are preceded by a Avail of nuclei which constantly melts down on the side directed towards them, while on the opposite side it is as constantly renewed by lymph corpuscles deposited afresh." Various efforts were made to isolate these parasites — the minute septicemic bacillus, and the gangrene-producing micrococcus — from each other, so as to study each separately by cultivation in different animals. But for a long time the efforts did not avail. " Either pure septicaemia, or septicemia along with progressive gangrene, was attained, never the latter alone. Chance led me to the proper method. A field mouse — which, as I formerly pointed out, possesses an immunity from septicaemia — was inoculated with septicemic bacilli and chain-like micrococci. The experiment was made in the expec- tation that neither parasite would develop. This expectation, however, was not ful- filled, for, although the bacilli, as usual, underwent no development, the micrococci increased and spread exactly in the same manner as has been described in the case of the house-mouse. Beginning at the place of inoculation on the root of the tail, the gangrene spread onwards along the back, passing deeply among the dorsal muscles, and downwards on both sides to the abdominal wall. The animal died three days after the inoculation. The parts affected with the gangrene were partially denuded of epidermis and hairs, and contained chain-like micrococci in extraordinary numbers. The same micrococci were also found on the surface of the abdominal organs, although there was no visible peritonitis. The blood and the interior of the organs were, on the other hand, quite free from them. From this animal other field-mice, and from these again house- mice in various successive series, were subsequently injected, and always with the like result, viz., that only chain-like micrococci and, in their train, progressive gangrene, were obtained." The ingenious observer who is responsible for these statements found equally interesting and positive results on investigating the spreading cheesy abscesses produced by putrid subcutaneous injections. He found a specific form of bacteric vegetation, proved its peculiar qualities by cultivation, and produced the same artificial infective disease at will. He discovered also another distinct variety of micrococcus which developed habitually in blood- vessels, and which possessed the unique quality of spinning around the blood corpuscles and inclosing them so as to beget thrombosis and positive embolism. The Bame growth also caused, by its contact, purulent (not cheesy) infiltration of the connective tissue. This new infective material was also propagated by cultivation, and proved competent- to produce pyemia, at will, by separate inoculation. CAUSES OF INFLAMMATION. 89 These results, demonstrating the agency of bacteria as the source of septic poisoning, to which, in searching for causes competent to excite the phe- nomena of destructive inflammation, we must give due consideration, have certainly much weight as evidence in favor of the antiseptic method of treat- ing wounds. They are in accord with previous advances in the same direc- tion. The connection of the bacillus anthracis with malignant pustule, and of the spirilla with relapsing' fever, in man, established on the evidence of reliable observers, is generally received. It is a matter of recent history that the theory on which Lister based his antiseptic method, first promulgated in 1866-67, encountered, at first, very general scepticism. It has been followed by results, even in the hands of many who tried the method in practice with- out accepting the theory on which it was based, which, by their apparent confirmation of the theory, have led to a wider acceptance of its scientific truth. The results of the experiments on animals just quoted are of a nature to strengthen this belief. It may seem out of place in this connection to speak of the practical re- sults of antiseptic surgery, but, in the present attitude of this important question, the most available evidence as to the truth of the theory is furnished by the very considerable degree of success which has been attained by the antiseptic method of treatment. In striving to reach a correct estimate of micro-organisms as exciting causes of destructive inflammation, it is proper, therefore, to recognize that clinical experience tends to prove that the means which have been found hostile to the development of these organisms, are also growing steadily in reputation as remedies for the destructive phases of in- flammation. Beyond these exciting causes of destructive inflammation, what others offer themselves as worthy of serious eonsideration ? Amongst the causes hereto- fore examined, the most worthy of notice in this connection are persistent local irritation from mechanical causes, and constant motion of an injured part, or the absence of the degree of quiescence necessary for the successful accomplishment of constructive repair. Hospital patients have been known to apply irritating powders — as of cantharides — to their ulcers, with the purpose of preventing their healing, and of delaying the time of their dis- charge from what they found comfortable quarters. But hindrances to heal- ing of this character cease to act as such as soon as they are withdrawn, unless the predispositions of the patient are exceptionally unfavorable. Surgical pathologists have heretofore sought for an explanation of wound diseases and wound infection in poisons generated under the circumstances of disturbed nutritive effort incident to every wound, and their formation has been ascribed to the decomposition and recomposition taking place, under these circumstances, in the unstable albuminous compounds forming the fluids of a wound. Robin has asserted that poisons of great virulence may be thus generated without the intervention of micro-organisms, basing the opinion upon the purely chemico-vital origin of the potent serpent venom. 1 In ac- cordance with this view, Billroth of Vienna formed his hypothesis of the generation in the fluids of a recent wound of a "phlogistic zymoid" — a something capable of causing destructive inflammation, which acts like a ferment; and Verneuil, of Paris, suggested the theory of the formation of a "traumatic virus," by which deviations from the healthy process of repair of wounds is to be explained. Lister, of London, adopting Pasteur's views as to the agency of micro-organisms, finds a phlogistic zymoid in the conse- 1 According to Mitchell the pure rattlesnake venom when freshly ejected contained no figured elements whatever. (Ut supra.) 90 INFLAMMATION. quences of the struggle for life of the product of aerial germs. The position of Lister is less assailable because lie has found means of destroying the vitality of the germs and of protecting wounds from their septic action, as- serting, and demonstrating, that it is in the power of surgery to preserve a wound in an absolutely aseptic condition, and to protect the process of repair from interruption or complication by intrinsic causes. For the soluble poisons of chemical origin, no such antidote has been found. As regards wound infection, the gross results furnished by clinical exped- ience prove that subcutaneous wounds, and those which heal under a seal), and wounds protected by antiseptic dressing, are infinitely more secure from interruption of the simple process of repair than wounds which are not thus protected from the external air. The most probable explanation of this immunity from injurious complications is the exclusion of noxious organisms floating in the air. The converse of this proposition, that the unhealthy and destructive phases of the inflammatory process are directly due to contami- nation by these omnipresent aerial organisms, seems also for the far greater proportion of cases infinitely probable ; but it awaits final confirmation. Before the recent discoveries of Pasteur and Koch, the antiseptic theory pre- sented a sufficient basis of probability to have secured its acceptance by trained observers. Witness the evidence of Professor Tyndall as to the cause of the ill behavior of an abrasion of the leg which befell him on an Alpine expedition, and the experiments detailed in his paper on " Dust and Dis- ease -," 1 witness the recorded experience of practical surgeons in all parts of the world, to be found in current medical journals. Of these latter witnesses, a certain proportion testify with reserve, and strive, in the true spirit of scientific skepticism, to explain their confessedly greater success otherwise than by the exclusion of poisonous germs. This success has been attributed accordingly to improvements in hospital hygiene, to the isolation of cases, to the observance of scrupulous cleanliness in dressings, and to more intelligent and careful nursing — all of which would rationally conduce to a greater degree of success in the treatment of surgical cases. Put evidence such as that furnished by Nussbaum, of Munich, is more positive in its character. This eminent surgeon testifies that pyaemia and hospital gangrene, which had been prevalent in his hospital wards for years, disappeared as soon as the antiseptic method of dressing wounds had been adopted, without any other material change as to the surroundings and nursing of his patients. Similar testimony has been given by many other hospital surgeons in Germany ; and more recently, after noticeable reluctance and some ridicule of, the new method, we have evidence that it has been seriously adopted in France, and the greater success following its use has been acknowledged by prominent Parisian hospital surgeons. 2 The noxious influence of putrid substances, animal or vegetable, and their power when introduced amongst living tissues of producing various phases of destructive inflammation, has been long known, but the evidence as to their mode of action has been heretofore obscure, and even in some respects contradictory. The directly depressing effects of putrid exhalations upon the nervous centres, as proved by the nausea they produce, is due mainly to the hydro-sulphuric acid gas which is always present, Its action is some- what like thai of hydrocyanic acid, but less intense. Bernard injected this gas into the veins of a dog with the effect of causing utter prostration; but ' Fragments of Science for Unscientific People. London, 1871. 2 Chirurgie antiseptique, etc. Par J. Luoas-Championniere. Paris, 1880. It seems proper to: give due consideration to these incidents of current history in attempting, at the present time, to form a just estimate of the degree of importance of cryptogamic organisms as causes of the more grave forms of inflammation. CAUSES OF INFLAMMATION. 91 after a short time the symptoms of poisoning passed away, and the discolora- tion of a sheet of white paper saturated with a solution of a salt of lead and held before the nostrils of the animal, showed that the gas was being elimi- nated from the blood, through the lungs. There is no evidence that any phlogogenic power is exerted by this gas which so constantly accompanies putrefaction. The notoriously dangerous effects which are liable to follow inoculation with the fluids of a recently dead body, as exemplified in wounds received in post-mortem examinations, have been ascribed to a poison formed by chemical action taking place just before or just after death. It is proved by experience that wounds received in examination of recently dead bodies, are more likely to be serious in their poisonous effects than those received after decomposition has set in. Hence the assertion, formulated by Robin, that putrefaction destroys animal poisons. Nevertheless, according to Mitchell, the venom of the rattlesnake, a typical animal poison, is equally deadly and characteristic in its action after it has been kept for weeks and has become " horribly offensive" and full of living organisms, as when perfectly fresh and containing, as he asserts, no figured elements whatever. This leads to the question, which has been so much disputed, as to the nature of the putrid poison — Whether it is a soluble substance of chemical origin, or whether its poisonous qualities are due to the presence of living organisms? The much-quoted researches of Bergmann, and more recently of Panum, affirm the existence in putrid matters of a soluble substance of the nature of an alkaloid active principle, to which the name of sepsin has been given; and the validity of this conclusion has not been successfully disputed. But the still more recent researches of Pasteur, of Burdon Sanderson — into the nature of the cause of infective inflammation — and latterly of Koch, justify the belief that bacteria of many species — some of which are noxious and phlogogenic, some doubtful, and others entirely innocent — are also to be found in all putrid substances. At the present time, therefore, we must admit that putrid substances contain both chemical and bacteric sources of poisonous action. In the well-known experiments of Dr. Anders, of Dorpat, 1 in which he showed that complete destruction of the organisms in a liquid which had been proved to be septic, in no way impaired its virulent action, the conclusion Avas to all appearances indisputable. Although the bacteria were removed from the virulent putrescent fluid by filtration through porcelain — a method not absolutely certain — yet no evidences of bacteric life could afterwards be disrovered in it by the cultivation test, that is, by adding a drop of the filtered fluid to Pasteur's or any solution offering congenial soil. But these experi- ments are not final ; the bacteria before their removal may, as a part of their vegetative process, have excreted certain soluble sul (stances of a poisonous nature which remained in the filtered solution. Such sul (stances, tor exam- ple, as were diffused into the surrounding tissues by the gangrene-producing micrococcus discovered by Koch. 2 The latter observer evidently recognizes the presence of poisonous agents of both chemical and bacteric origin in putrid fluids. In his researches under- taken to test the correctness of the conclusions of Coze, Felt/, and Davaine, putrid fluids, e. g., putrefying blood, putrid meat infusion, etc., were injected under the skin in mice. " The result of such an injection," he says, " differs much according to*the nature of the putrid fluid, and according to the quantity which is introduced. Blood and meat ' Detailed in the first article in the seventh volume of the Deutsche Zeitschrift ftlr Chirurgie. 2 Op. cit., p. 42. 92 INFLAMMATION. infusion, which have putrefied for a long time, appear to act less injuriously than fluids which have putrefied for a few days only. Of these latter fluids, as, for instance, of blood which has not putrefied too long, five drops is sufficient to kill a mouse within a short time. In this case marked symptoms may be observed in the animal immediately after the injection. It becomes restless, running about constantly, but showing great weakness and uncertainty in all its movements ; it refuses food, the respiration becomes irregular and slow, and death takes place in four to eight hours. In such a case the greater part of the fluid injected is found in the subcutaneous cellular tissue of the back in much the same condition as before it was injected. It contains bacteria of the most diverse forms, irregularly mixed together, and as numerous as when examined before injection. No inflammation can be observed in the neighborhood of the place of injec- tion. The internal organs are also unaltered. If blood taken from the right auricle be introduced into another mouse no effect is produced. Bacteria cannot be found in any of the internal organs, nor in the blood of the heart. An infective disease has, there- fore, not been produced as the result of the injection. On the other hand, there can be no doubt that the death of the animal was due to the soluble poison, sepsin, which has been shown by the researches of Bergmann, Panum, and various other investigators, to exist in putrid blood. The animal has accordingly died not from an infective disease, but simply from the effects of a chemical poison." This poison is, apparently, of the same nature as serpent venom, producing its deadly effect in a few hours by acting directly upon the nervous centres, without the intervention of bacteria. Subsequently when, in other experi- ments, a smaller dose of the putrid fluid was injected under the skin of a mouse, the symptoms made their appearance more slowly, and they were strikingly different in character, causing death in from forty to sixty hours, instead of from four to eight. Here the symptoms were evidently those of an infective disease, for the blood was found swarming with bacteria. "When the blood of a mouse dying in this way was injected under the skin of a healthy mouse, death followed with precisely the same symptoms, namely, those of septicaemia. So that we are justified in concluding from these ex- periments that inoculation with putrid fluids may produce poisonous effects by a soluble chemico-vital poison analogous to serpent venom, acting in its peculiar way; and, also, by the slower action of living organisms, acting in an entirely different way. Modes in which Poisons are Absorbed. — It is proper that, as surgeons, we should be familiar with the modes by which the poisons last under considera- tion gain access to the organism, with the view of possibly averting or pre- venting their effects. The human body enjoys a certain conservative protec- tion against the influence of noxious agents. The action of all poisons is incidental and exceptional, and, it maybe assumed, preventible, by the use of intelligence to supplement these conservative means. Foremost amongst them is the phenomenon of life itself, which has been defined as the power of resist- ing the tendency to chemical decomposition. It is matter of general belief that diminished vitality from any cause invites the invasion, and favors the development of parasites; and that the healthy and robust are more likely to ivsi>t causes of disease. Whilst this may be the rule, there are frequent ex- ceptions to it. These exceptions arise from personal peculiarities conferring immunity, or from other conditions not yet within our grasp, which enable the organism to resist causes of disease at one time, Avhilst at another time it yields unaccountably to the same poisonous influences. Thus, the man who habitually handles dead bodies, as in the dissecting room, often enjoys excellenl health, and the pathologist, in the daily habit of making post-mor- tem examinations, acquires an immunity from poisons derived from this source, which could not be counted on by another individual, even in appa- rently better physical condition, and perhaps, fresh from country life. CAUSES OF INFLAMMATION. 93 The main avenue through which absorption of extraneous materials into the blood takes place is, as in the process of nutrition by food, the lymphatic vessels. Absorption may also occur through the walls of the bloodvessels. The epidermis is provided for the protection of the external surface of the body, and usually prevents absorption through the skin; but not under all circumstances. Substances, like mercurial ointment, which may be possibly forced by friction into the open mouths of the sweat ducts, are very certainly absorbed, as proved by the specific action of the drug which is constantly pro- duced in this way. The same result undoubtedly follows baths containing corrosive sublimate in solution. Some of the subtle poisons lately under con- sideration may penetrate the unbroken cuticle, and, thus gaining access'to the blood, give rise to infective diseases. This occurred to the eminent English surgeon, Sir James Paget, who suffered from spreading inflammation of the cellular tissue extending to the trunk and resulting in abscess, from which he barely escaped with his life after three months' illness. He gives a detailed account of his own case, 1 and attributes his illness to infection by a material absorbed from the dead body of a patient who had died from pleuritic effu- sion and pysemia after lithotomy. During the post-mortem examination, the surgeon's hands were long soaked in the pleuritic fluid. He says : "What- ever the virus was, it soaked through my skin ; I had no wound or crack of any kind." This is an exceptional case, as the epidermis, when unbroken, is usually an efficient protection. ISTevertheless, as we have seen, the simple contact of a " poison vine" will, with many persons, cause a crop of vesicles. But, as a rule, a puncture, however slight, or an abrasion, is present, and this offers an avenue of entrance to the poison. In the case of the late Dr. Hayward, of Boston, described also by himself, 2 he simply touched the mucous surface of the intestine to determine the existence of ulceration, at the post-mortem examination of a child dead from tubercular meningitis, and afterwards pricked his finger slightly in aiding to sew up the body, and within the week his finger had become gangrenous. Lawrence 3 details the case of a surgeon who died after similar infection, and who was not conscious of any lesion whatever until he discovered, by the aid of a magnifying lens, a minute puncture of the finger at a point which had become painful. An abrasion of the male genital organ is a recognized avenue of entrance of the syphilitic virus; and a crack of the lip, in a healthy person, may become the seat of an infecting chancre, through inoculation by the saliva of another person who has the secondary mucous patches of syphilis upon the mucous membrane of the mouth. The mode in which absorption is effected in these cases, is no doubt through the open orifices of the minute lymphatic canaliculi of the integument ; although it may take place through the walls of capillary bloodvessels, even when they are free from lesion. The absorption of the vaccine virus after partially scratching away the epidermis is a familiar example. The epithelium of mucous membranes is inferior to epidermis as a protective. ]N"evertheless, the pavement epithelium of the mouth being sound, it has proved safe to suck the venom from a serpent wound. Virulent substances undoubtedly become lodged in the minute mucous follicles, and are subsecniently absorbed. In subcutaneous injections, as of morphine, absorption is accomplished by the lymphatic canaliculi which open upon the surfaces of the connective tissue meshes. This method is usually employed in introducing putrid poisons into the bodies of the lower animals ; but in many of Koch's experi- 1 Clinical Lectures and Essays, 2d edition, page 320. London, 1879. 2 American Journal of the Medical Sciences, N. S. vol. vii. p. 04. s Lectures on Surgery. London, 1808. 94 INFLAMMATION. ments on mice, the slightest incision by a scalpel charged with putrid matter was followed by infection, just as in the operation of vaccination. Any recent wound, therefore, which has not become covered by granulations, pre- sents an absorbing surface through which poisons enter as instantaneously as after a subcutaneous injection. The internal surface of the uterus, after throwing off its contents, possesses the same quality as to capacity for absorption as a recent wound. With regard to the absorbing power of a granulating surface, less clear opinions are held. Billroth dressed granulating wounds in dogs with putrid matter, and reports that after prolonged contact no infection followed. He infers, therefore, that granulations when perfectly healthy do not absorb. This conclusion, however, is contrary to what analogy would lead us to expect from surfaces consisting of living protoplasm capable of absorbing, and capillary vessels so accessible as to bleed at the slightest touch. It is matter of demonstration that a poultice of garlic applied to a granulating ulcer will affect the breath ; and that dressings containing morphine, or stramonium, produce the specific effect of those drugs. This result is undoubtedly less certain than absorption through a recent raw surface, as of an incision; and the difference is mainly to be accounted for by the presence of the outward current of pus continually flowing from a surface of granulations, which tends to wash away foreign matters applied to it. But it would not be safe to rely implicitly upon the protective power of a granulating surface, even when perfectly healthy, although it possesses a certain degree of efficiency. All are agreed, however, that when granulations are unhealthy, or when the surface has been destroyed, even to a limited degree, their protective power against poisonous infection by absorption is not to be trusted. The barrier of granulations set up by the constructive inflammatory effort to limit advancing suppuration, or gangrene, has its true explanation in the fact that the noxious influence which is causing a spreading suppuration, or gangrene, has diminished in power, and is no longer able to keep up the destructive process. It is not correct to assume that the primary purpose of such a con- structive barrier is, as it may at first glance seem to be, simply to resist the progressive absorption and injurious effects of a poison. Very many poisonous substances gain access to the blood through the lungs, with their enormous absorbing surfaces designed — as regards gases and vapors — especially for this purpose. Carbonic oxide gas reaches the blood, and exerts its detrimental influence upon its red globules, as readil}- as the oxygen that vivifies them, and, to estimate correctly the promptness with which this process of absorption takes place through the lungs, we have only to recall the phenomenon, witnessed daily, of the production of anaesthesia by inhalation of the vapor of ether or chloroform. How far does this power of absorbing by the lungs include solid pulverulent and soluble substances ? Hap] lily it is limited to the transmission of the gases and vapors which can gain entrance through the glottis, and as to all other materials is exceptional. That it is within the range of possibility, is proved by the presence of finely pulverized carbon in the connective tissue outside of the air-tubes and in the bronchial glands, which must have traversed the lining membrane of the respiratory passages. But nature has furnished this membrane- with a vibratile ciliated epithelium, with the especial design apparently of extrud- ing solid materials from the air-passages, and of preventing them from reach- ing the air-cells. The elder Mitchell does not dispute the belief that the impalpable crypto- genic germs to which he attributes contagious and epidemic fevers, get into the blood along with the air we breathe; and this question is also applicable to the germs which give rise to infective surgical diseases. This general be- SYMPTOMS OF INFLAMMATION. 95 lief has not been seriously denied, nor even very carefully examined. It is probably, in the main, destitute of any serious foundation in fact. Apart from the argument derived from [Nature's evident intention to protect the organism from the invasion of noxious agents, generally, and to prevent the passage of solid substances through the bronchial passages to the ultimate air cells of the lungs, especially, there are other considerations opposed to the belief that our bodies are so greatly exposed to harm through this avenue. As regards noxious micro-organisms, Pasteur asserts that one of them, the Vibrio septica, cannot develop when exposed to free oxygen, and infers the ex- istence of the same peculiarity in other members of the family, describing them by the name— significant of this peculiarity of non-viability when exposed to oxygen — of anaerobies. Here, at once, is a valid source of j)ro- tection against their noxious influence as introduced by the lungs. The ova of the echinococci gain access to our tissues through the digestive passages, and, undoubtedly, penetrate and traverse their walls, effecting their ultimate lodgment, by preference, in the liver. "We can hardly assert that the more minute and indestructible bacteric germs — the dauersporen — might not reach the blood through the air passages. It has been held, and with probability, that the malarial poison becomes entangled in the saliva and introduced into the blood with the food ; and the same avenue of entrance is of course avail- able for bacteria and their germs. Here the well known power of the diges- tive secretions comes in play as a protective influence ; but if they are impotent as to the ova of the taenia echinococci and the trichina, surely the same immu- nity may be assumed for the indestructible bacteric dauersporen. Possibly the germs of other noxious microscopic fungi may not be so tenacious of life as those of the vibrio septica, but it is evident that we must await a more extended knowledge of their nature and habits in order to pursue this sub- ject intelligently. The facts, however, which tell most strongly against the probability of the habitual introduction of infective poisons through the lungs, unless, indeed, they may exist in the form of gas, or vapor, are derived from clinical expe- rience. When a case of infective disease, erysipelas, for example, is intro- duced into a surgical ward, as a rule, the patients with open wounds, alone, receive the infection. Alphonse Guerin states concerning his wound dressing of cotton-wool, so largely tried at the Hotel Dieu of Paris, that patients whose wounds were thus protected escaped pyaemia, whilst their unprotected neighbors breathing the same air, almost invariably became victims of this disease. ISTussbaum gives evidence that pyaemia and hospital gangrene have disa} ipeared from his surgical wards since he adopted the practice of protecting all wounds antiseptic-ally. Trelat states, before the Surgical Society of Paris, that since the advocates of Listerism have introduced their manifold antisep- tic precautions into the hospital wards, pyaemia is no longer to be encountered there. Lister himself says freely that he cares but little how foul the air of a hospital ward may be, as regards its power of inducing infectious diseases, provided that antiseptics are thoroughly employed in dressing the patients' wounds. Now, if the infective poison of pyaemia habitually reached the blood through the lungs, protective means applied to open wounds, whilst the patient was constantly breathing the same infected air, would not prove thus effective in preventing it. Symptoms of Inflammation. The ordinary symptoms which characterize the condition of inflammation are mainly included under the cardinal signs recorded by Celsus : redness and 96 INFLAMMATION. heat, with swelling and pain. To these, modern pathology adds impairment of function of the inflamed part, and the presence of more or less fever. The symptoms of inflammation with which daily experience renders us familiar, are readily explained by the subjective phenomena which character- ize the process, as revealed by microscopical study of tissues in which in- flammation has been artificially excited in the lower animals ; and by studying the causes which have been found, by experiments upon the lower animals, competent to give rise to the condition. Thus, Redness, one of the most obvious and characteristic signs of inflam- mation, and the symptom, perhaps, most rarely absent, is explained by the increased amount of blood flowing into the vessels of the part, and for a time remaining there. The phenomena of afflux of blood to an inflaming part, and the temporary dilatation of the bloodvessels by which the increased amount of blood is accommodated in them, are the earliest and most striking of the changes which follow injury, and which constitute inflammation. With the explanation of the causes of these phenomena we are not at present concerned, beyond a recognition of the following facts. Redness may arise from }mssive hyper&mia, or congestion following any cause which impedes local circulation, whether the cause be a simple mechanical obstruction, or a func- tional failure, on the part of the vessels, as a consequence of an impaired quality of blood, or of defective vaso-motor nervous action. Redness may also arise from active hypercemia, as in blushing, or in the flushing of the face which has a reflex gastric origin, or as provoked by any of the more common exciting causes of inflammation, which have proved incompetent to produce the condition beyond causing an afflux which has ceased at the stage of active hyperemia. In neither of these cases is the redness regarded as a symptom of inflammation. The line of distinction between persistent active hyper- emia and inflammation, is usually considered to be marked by the occurrence of exudation. Nevertheless we should deceive ourselves if this view were regarded as final. There is a certain degree of identity between hyperemia, or congestion, and inflammation ; and the reason why the redness produced at will by roughly applying friction to the conjunctiva, or to the skin, disappears shortly, instead of going on to exudation and cell germination, is not entirely clear. After hyperemia of long duration, serous exudation does take place, not rarely, and previous to its occurrence there is increase of bulk, and also of heat, in the congested part. After death, capillaries which have been thus subjected to distension are found to present fusiform or ampullar dilatations. 1 Phenomena attributed to hyperemia occur in a lower extremity after a suc- cessful ligature of the femoral artery. The collateral circulation, even when ample, is at first retarded by cutting off the arterial vis a tergo, and although for a day or so the heat of the limb is distinctly greater than that of the sound one, this difficulty is shortly adjusted, and the occurrence of inflam- mation from this cause is almost unknown. The redness, from capillary distension, that follows pressure of any duration which has been suddenly re- moved, is usually called hypersemia, which, in this form, causes overgrowth of the epidermis, and explains the production of corns on the feet. The com- plete removal of the contents of a habitually distended bladder is in most instances followed by passive congestion, which terminates in patches of ulceration and gangrene of the vesical mucous membrane. The systematic use of a local li<>t air bath to stimulate the growth of a wasted limb, in a child, has resulted in the production of a distinctly stronger growth of hair upon it, evidently the result of the surface hypersemia provoked by the heat. 1 Comil and Kanvier. SYMPTOMS OF INFLAMMATION. 97 It would seem, therefore, even from these few facts, that the condition of hy- peremia has both a constructive and a destructive aspect, determined by the circumstances which give rise to it. Redness is usually light in tint, at first, and it becomes deeper as the in- flammation increases in intensity. When a poison is present in the blood, the redness may assume a livid tint, as in certain grave phases of the eruptive fevers. The eruptions of syphilis are, for the most part, copper colored ; after a snake-bite the redness is usually mottled. When the over-distended capillaries of an inflamed surface rupture, the redness shows darker points of extravasation. The blood may be removed from an over-distended vascular network by temporary pressure, as in the earlier stages of a conjunctivitis, and the redness, for the moment, entirely removed, the white sclerotica show- ing through. Its dependence upon the presence of blood in gorged blood- vessels is thus demonstrated. The term arborization is applied to a vascular area or network of vessels, thus distended with blood, when the outline of the vessels is still distinguishable. When redness presents itself as an uniform sheet, as in scarlatina, or erysipelas, it is not easily distinguished from stain- ing by extravasation or by transudation of blood-colored serum through the capillary walls, especially when the redness cannot be made to disappear by temporary pressure. In the beginning of inflammation in the non- vascular tissues, such as the cornea and cartilage, redness is not recognizable. The increased Heat of an inflamed part is to be ascribed to the greater amount of red blood present in the part, and to the greater activity of the vital processes, normal and abnormal, which are taking place in it and evolv- ing a corresponding increase of the local temperature. When fever is present, the higher temperature of the blood aids in increasing the local heat. The presence of increased heat in an inflamed part, when not too far re- moved from the surface, is usually recognizable by the patient, but not so readily and certainly as by the hand of another person. It is verified by comparison with the temperature of another part of the body. Thus, in a knee-joint, when inflammation is suspected, its surface temperature is com- pared with that of the opposite knee. It has been proved by experiment 1 that this increase of local heat is mainly the result of the local causes already mentioned ; it has rarely been found to exceed, and in most cases it has not reached, the temperature of the blood. Since the very general clinical use of the thermometer this fact has been amply verified. Ingenious instruments have also been employed for accurately measuring local temperature. There is reason to believe that the temperature of inflamed parts is not so readily lowered by evaporating lotions, or the application of ice, as that of correspond- ing sound parts. The Swelling in inflammation is due in part to the greater quantity of blood present in the dilated vessels, and in part to the materials, liquid and solid, which exude through their walls, as well as to extravasation from rupture, which often occurs in consequence of the force attending the afflux of blood to the inflammatory focus. It is also due in part to cell germination and to the formation of new capillary vessels, which, as the injured tissues revert to their embryonic state under the incitement to constructive inflam- mation, contribute materially to their increase of bulk. The occurrence of swelling in a part, without other signs, is not very significant of inflammation, for it is liable to occur frequently from other causes. ISTor is it always [ire- sent in inflammation, especially at first, as, for example, in simple osteitis, 1 John Hunter ; Andral and Gavarret ; Marey. VOL. I. — 7 98 INFLAMMATION. and in inflammations of serous and mucous membranes, before exudation lias taken place into the connective tissue underlying these membranes. In fact, the looseness of texture and distensibility of the connective tissue of an in- flamed part is a condition necessary for the production of this symptom in any considerable degree. The Pain so rarely absent in inflammation is explained by the local irrita- tion of the nerves of a part by the causes which have excited the condition, as by the contact of a splinter, or an acrid poison, or by a burn, and also by the tension and partial laceration of nervous filaments by any of the causes which beget swelling. The sudden darting pains which are felt in an abscess approaching maturity, mark the rupture of small nerves stretched beyond their capacity of resistance by the growing bulk of the collection of pus. Pain alone is often a valuable sign of a deep-seated local inflammation, where its distance from the surface of the body has prevented the recognition of heat, redness, or swelling. The first symptom of a subfascial abscess of the iliac fossa is pain in extending the thigh. The knotted hardness and keen sensitiveness over the track of the lymphatic trunks precedes the redness in lymphangeitis. The extreme tenderness to the touch of the lymphatic gland in front of the ear, is one of the characteristic prodromata by which we are able to foretell an outbreak of erysipelas of the face. The exemisite sensi- bility on pressure over the vein, is the earliest diagnostic symptom of a phlebitis. Pain varies much in character according to the nature and ordinary sensi- bility of the parts affected. When they are unyielding, as in periostitis in the socket of a tooth threatening abscess, or in whitlow — which involves the dense fibrous structures surrounding the bone at the end of a finger — or in a crisis of gout, the pain amounts to torture. In inflammation of the substance of the testis, enveloped by the unyielding tunica albuginea, or of the tissues within the globe of the eye, or in the external meatus of the ear, or in the interior of bone, pain is notoriously severe. Pain of a pulsatile or throbbing character is caused by the increased force of the smaller arteries bring- ing blood to the focus of inflammation, and by the obstruction to free circulation caused by the swelling, and possibly increased by stasis, at the centre of the inflamed area. The condition of strangulation, in which the pain is excessive, takes place when the veins of an inflamed part are obstructed by the pressure of the swelling, so that the blood cannot escape through them whilst it is still being brought by the arteries. This is liable to occur in epididymitis and acute orchitis, in which the turgid vessels of the spermat ic cord are encircled by the unyielding borders of the external abdominal ring. On the other hand, pain is not rarely trivial, or even entirely absent', in grave inflammations where the parts affected are of soft consistence and have free room to swell, as, for example, in pneumonia, Pain presents variety in quality as well as in degree, and expressions are in common use for indicating certain of its varieties. Thus where a nerve of any size is subjected to pressure, as from a collection of pus, the pain is aching, sometimes tingling, ;is when the ulnar nerve where it lies behind the internal condyle of the humerus has been bruised. In many skin inflamma- tions pain takes the form of itching; in others, again, this form of pain is entirely absent, as in the eruptions of syphilis. An abscess forming in the head of the tibia causes a boring pain, which is distinctly worse at night. An abscess forming slowly in soft parts produces a sen.se of weight, or a tensive pain ; when about to point it gives rise to lancinating pain. The pain of an erysipelas is described as burning or sore. Thus the pain of inflammation has a language of its own, a familiarity with which is useful in diagnosis, espe- TRAUMATIC OR INFLAMMATORY FEVER. 99 cially in determining the seat of an abscess. As pain is a common symptom in other and non-inflammatory affections, its value as a symptom of inflam- mation is to be determined in many cases by the coexistence of other corrob- orative signs. Impairment, or more or less Entire Abolition of Function, is almost always present when a part, or an organ, is the seat of serious inflammation. The function of the eye is suspended in iritis ; in mumps there is dryness of the mouth on the side of the parotid gland affected, from arrest of its secre- tion ; the voice is lost or impaired when the chordce vocales are involved in the local inflammation in a laryngeal catarrh ; muscle contracts with difficulty when inflamed, and its contraction is accompanied by peculiar and severe pain. The " stitch in the side" of a pleurisy impedes respiration, and the ex- udation in pneumonia, if sufficiently extensive, extinguishes this function. In peritonitis, the diaphragm contracts imperfectly, and the respiratory move- ments are limited to the thorax. In short, in every severe local inflammation there is a certain degree of interference with function throughout the whole economy, and this is especially marked in connection with the condition of fever, which, under such circumstances, is rarely absent. Locally, the conditions of textured life are altered in a greater or less degree by their participation in the changes which constitute inflammation. These changes involve, as we have seen, the conditions of local blood supply, and therefore nutrition is disturbed as w T ell as innervation. They include at first increase of local heat, and arrest of glandular and follicular secretion, the re- sult, apparently, of the intense active hyperemia, causing dryness. In certain phases these earlier changes are well shown in simple cutaneous erysipelas. After this disease has run its course in the scalp, the epidermis exfoliates, and the hair falls, showing that the function of the hair bulbs has been sus- pended. It is to be noticed, however, as illustrating the characteristic quality of the inflammatory condition — the absence of an intrinsic destructive ten- dency — that old surface-ulcers, which have been lingering in an indolent con- dition and resisting means of cure, often get well promptly after an attack of erysipelas involving the integument around them. The explanation of this a purely reparative effort in the tissues involved in the pre-existing lesion. The ultimate tendency in all tissues when involved in inflammation is, as we know, to revert to the embryonic condition, as a preliminary stage to recon- struction; and the parts involved in an indolent or languidly granulating ulcer, having already attained this stage, in a degree, are appropriately stimu- lated, by the incidentally increased blood supply accompanying an invasion ot cutaneous erysipelas, to take on a new and successful effort at recon- struction. Short of complete reversion to the embryonic condition, that is, the state of " indifferent" or " granulation" tissue, there are endless phases of local textural change resulting from inflammation which are daily recognizable by the clinical eye. These changes affect inflamed parts variously, as regards their bulk, their consistence, and their general aspect and quality. Traumatic or Inflammatory Fever. As a symptom of inflammation, fever, in some degree, is rarely absent after a wound or injury of any gravity; and its more common form is known 100 INFLAMMATION. as "traumatic" or "simple inflammatory" fever. It is more likely to be slight in its manifestations, or even to be entirely absent, after simple and uncomplicated injuries, such, for example, as an incised wound which is uniting promptly by the first intention. After a contused wound or a partial crushing, traumatic fever would be more certain to occur and to be well marked, and to merge, possibly, into a graver form of surgical fever. As a rule, fever makes its first appearance in the evening of the day on which a serious injury, say a compound fracture, has been received, following the reaction from the collapse or shock of injury which takes place more or less slowly according to the gravity of the case. If a wound involve per- fectly healthy tissues, and has been promptly and properly cared for, or if it be a subcutaneous lesion, such as a simple fracture, febrile symptoms may not show themselves for twenty-four hours, or even a longer time, or they may, possibly, not appear at all. In a healthy young man whose hand was utterly crushed between cog-wheels, re- quiring primary amputation, fever did not manifest itself for thirty-six hours, and was then limited by a temperature of 100° Fahr., the wound uniting by the first intention except where the ligatures of silk prevented ; and before the sixth day the symptoms had disappeared. In an amputation at mid-leg for a crushed foot, through parts not entirely sound, fever showed itself the same evening, and continued until the beginning of the second week. In a similar case, in which the operation, through reluctance to submit to mutilation, was delayed, fever came on within a few hours ; by the end of the week it had assumed a septicemic character, and before the end of the second week it had terminated fatally, the temperature having risen to 104°+ Fahr., the blood, after death, coagulating imperfectly. This case affords an example of an unfavorable termination of what seemed to be at first simple traumatic or inflammatory fever, and it illustrates the mode in which traumatic fever reaches this exceptional termination, as observed clinically, in fatal cases, namely, by merging into another form of surgical fever attended by greater danger to life. This difference in the character of the accompanying fever marks also the distinction which is assumed to exist, in the language of the day, between a health}- or construc- tive inflammatory process and an unhealthy or " infective" inflammation. As a rule, traumatic fever is moderate in character, and terminates early and spontaneously. In connection with subcutaneous wounds and injuries, as in a case of simple fracture, it is either entirely absent or very mild and tran- sient ; and the same is true, for the most part, of wounds which have been thoroughly protected by antiseptic dressings, and in which catgut ligatures have been employed. The aspect of a patient on the invasion of traumatic fever becomes slightly altered ; his countenance is somewhat pinched and anxious ; he is a little restless, apt to resent disturbance, and awakes frequently from his sleep, lie is conscious of feeling fatigued, hot, and thirsty, and has usually a dry mouth. The tongue gradually becomes coated, and there is little or no desire for food. Tlir urine is scanty and deeper in color. The pulse is more frequent than it should be, and the thermometer, under the tongue, shows a decided increase of temperature. Although the patient may feel slightly chilly on exposure, simple traumatic fever is not usually ushered in by a rigor, and the tempera- ture rarely exoeteds 102.5° Fahr. The fever reaches its climax in about thirty- six hours; it may continue, with a slight remission in the morning and a corresponding increase towards evening, for two, three, or four days. About this time the fever begins to decline, the temperature diminishing, and the pujse -i-adually. returning to the natural standard; so that, at the end of a TRAUMATIC OR INFLAMMATORY FEVER. 101 week, the febrile movement has ceased. Not infrequently, when suppuration takes place in a wound at the usual period, say from the third to the fifth day, the traumatic fever declines coincidently with the appearance of pus and the diminution of the local swelling and tension. This is the typical course of traumatic or inflammatory fever. If it does not disappear promptly within this limit of time, there is reason to suspect deeper suppuration, or some other complication of the local inflammation, to account for the continuance of the febrile symptoms, which can no longer be ascribed to simple traumatic fever, but threaten to assume the character of septicaemia, pyaemia, or hectic. These phases of febrile action will be considered here- after ; at present we shall confine our remarks to the simpler affection. The personal quality of the patient as to constitution, condition of health, and surroundings, besides the extent and locality of the injury, have their influence in producing the various phases of traumatic fever encountered by the surgeon, and in determining their gravity ; but this influence, like the cause and nature of the fever itself, is both complex and obscure. When an inflammation is rapid in its development, characterized by strongly marked symptoms, and attended by much local excitement, it is said to be acute, and, under these circumstances, the symptoms of the accompanying traumatic fever are well marked and more intense. The term sthenic is used to designate fever of this type ; its occurrence is not incompatible with a previous high grade of sound health. Its acme or fastigium is rapidly attained, and its defervescence or lysis is usually prompt and complete. On the other hand, in an organism which has been previously the seat of chronic disease, a new injury is not likely to be resented by a high grade either of inflammation or of traumatic fever. A boy, aged 17, was subjected, at the New York Hospital, to amputation of the thigh at its lower third for " chronic synovitis" of the knee-joint. The next day his habitual aspect of depression had distinctly improved ; his tongue was noticeably less red ; his pulse was less frequent than the day before the operation ; he had slept more continuously during the night — apparently in consequence of entire relief from the aching joint pain. In this case no febrile movement occurred until the evening of the third day, when there was slight heat and tension of the stump and a moderate rise of temperature. On the next day there was a flow of pus along the track of the ligatures, the tension of the stump had subsided, the general temperature had fallen, and all evi- dence of traumatic fever had disappeared. Subsequent recovery was unusually rapid and complete. Except where the presence of the ligatures had provoked suppuration, the inflammation following the amputation was limited entirely to its constructive phase. Primary amputation of the thigh rendered necessary by injury is rarely followed by a result so innocent, as regards inflammatory or febrile reaction, as in this amputation for disease. Even in health, the suddenness of an injury favors subsequent febrile reaction. Within certain limits, previous training by illness and pain renders the organism more tolerant. The signifi- cance of these facts is embodied in the surgical doctrine that secondary ampu- tations for disease involve less danger than primary amputations for injury. They are introduced here as illustrative of traumatic fever from a clinical point of view, awaiting a solution, from physiology, of the difficult problem ol the nature and immediate cause of fever, by which they are to be ulti- mately explained. ^ hat actually constitutes the condition to which we give the name ot fever, may be stated, in plain terms, without speculation. ^ Clinical observa- tion, aided by research and experiments on the lower animals, has led to cer- tain conclusions which are admitted by all. The essential feature of fever is an increase in the temperature of the blood; and this increase may reach 102 INFLAMMATION. eight, or even, in extreme cases, ten degrees Fahrenheit. With the certain knowledge that the organism possesses a self-regulating power as regards its temperature, which, under all the varying circumstances of climate, preserves the blood at or about the same degree of heat — 99° Fahr. ; when, shortly after the infliction upon the body of a physical injury, this temperature is observed to rise, as indicated by an instrument of precision, a certain number of degrees, and to retain its abnormal elevation for some hours, this phenom- enon, alone, justifies the observer in the conclusion that fever is present. All the other features of the state of fever arrange themselves around this central phenomenon, which is pathognomonic. The injured person may not be con- scious of this increase of heat. He may, in fact, and generally does, at first, feel distinctly chilly. What is technically called a chill, or rigor, that so commonly occurs at the onset of fever, coincides with a rise, more or less sudden and rapid, in the temperature, as indicated by a thermometer placed beneath the tongue of the patient. He may be shivering with cold, and yet the thermometer may indicate a rise of three or four degrees. This shows that the subjective sensations of the patient cannot be trusted. His skin may be biting hot to the hand of the surgeon, and yet he may be shivering. At a later period he becomes unpleasantly conscious of the increased heat of his body ; but even now chilly sensations may alternate with the consciousness of intense heat. These phenomena accompany the invasion of most of the graver forms of surgical fever. Indeed there is a certain significance of gravity always con- ve} 7 ed by the occurrence of a chill in a surgical case ; and the intensity and duration of a chill is properly regarded as an indication of the degree of dan- ger present. But, as a rule, in the milder forms of traumatic fever the chill is slight, and often entirely absent. Coincidently with the increased temperature of the blood in fever, there are other evidences of derangement in the heat-producing machinery of the body, besides the somewhat illusory sensations of the patient himself. There are evidences that tissues are undergoing premature destruction by combustion, which, in the ordinary balance of nutrition, escape in consequence of the daily provision of an adequate supply of material for keeping up heat, by food. In fever, appetite is wanting, digestion and assimilation are reduced to a mini- mum, and yet heat production is kept up to the standard of health. Hence the excretion of urea is almost if not quite tripled, as a result of the combus- tion of albuminous materials, e. g. , blood plasma, blood corpuscles, the sarcous element of muscular tissue, etc. Hence the increase of potassium salts in the urine, the doubled excretion of carbonic acid, the absorption of adipose tissue, and the consequent emaciation which always accompanies fever. In the dogs, so carefully watched by Weber in his valuable experiments undertaken to elucidate the nature of fever, emaciation took place more rapidly in dogs with fever, eating as much as they could be made to eat, than in dogs, under simi- lar circumstances, but without fever, who were deprived of all food. In other words, emaciation took place more rapidly from fever, than from inanition. Clinical observation affords confirmation of this statement. It is thus evident that heat production in the human body, during fever, is, so to speak, an expensive process. Although the heat in fever does not transcend tin- aggregate of health, it is kept up by the forced consumption of substances in the body too valuable to be consumed for the purposes of fuel — the supply of heat-producing food from without, through the ordinary chan- nels, being cut off. We are forced to conclude, therefore, that fever, like in- flammation, is essentially a disorder of nutrition. 1 This position, based on the 1 The following quotation contains the conclusions as to the nature of fever readied by Prof. Wood from his recent experimental researches, which constitute the latest as well as the best evi- TRAUMATIC OR INFLAMMATORY FEVER. 103 best evidence thus far attained, brings us however but little nearer to a know- ledge of its essential nature and immediate cause. As throwing light upon the causes of surgical fever, it is worthy of notice that, in his elaborate experiments, Senator resorted to a subcutaneous injection of fresh healthy pus for the purpose of producing the state of fever in his do<:'s artificially. He habitually employed this pyrogenic device, and it always succeeded. In two or three hours after the injection of the pus, the tempera- ture of the blood began to rise until it reached a certain figure, at or about which it remained for two days or so, and then, unless the injection was re- peated, it subsided; meanwhile the animal manifested all the symptoms of fever. This affords a demonstration of what has been recognized as the fever producing, or " infective" power of the products of ordinary inflammation. On the basis of these and similar experiments, Dr. Sanderson 1 formulates, very concisely, the conclusion that "fever is the product of a fever-producing cause contained in the blood or tissue juices, the morbific action of which on the organism is antecedent to all functional disturbances whatever." He also employs the term " infective agent" as synonymous with " fever-producing cause" and speaks of fever as "from first to last a disorder of protoplasm." Prof. Wood, in his conclusions, expresses the following opinion concerning the causes of fever: "In most cases of fever, and probably in all cases of se- rious fever, there is a definite poison circulating in the blood, the poison sometimes having been formed in the system, sometimes having entered the organism from without." This may be regarded as a fair exposition of the doctrine of the day as re- gards fever. The theory so long prevalent that fever took its origin in dis- order of the nervous centres, has been given up by recent authorities in surgical pathology. Billroth has rejected it; so also have the French encyclopedists. All avow a belief in a material cause; and the search for this material cause, which includes also the cause of inflammation, is, at the present time the fore- most problem of surgical patholog}-. It has been thought to exist in the " infective quality of the products of inflammation ;" in putridity — as in the soluble "sepsin" of Bergman — the analogue of serpent venom; and finally, in the micro-organisms which have been proved to be so intimately associated with putrefaction. There seems to be no valid reason why there should be a solitary material, pyrogenic, or phlogogenic principle. There may be, and judging from clinical experience there are, probably, multiple material causes both of surg-ical fever and of inflammation; and some of them are, apparently, being identified. It is questionable if it be wise to reject the influence of the nervous system so entirely in the search for these material causes of fever. That its influence has been heretofore vaguely exaggerated, is proven, as one of the direct results of more certain and accurate knowledge; but, as in all fluctuations in human opinions, there is danger that the opposite views may be carried to ultraism, and that belief may become a matter of fashion. The writings of the great English masters of surgery in the early part of this century offered little that the mind could grasp in explanation of the nature and causes of inflammation denoe mi the subject since the lectures on calorification of Claude Bernard, in 1876 : " Fever is a complex nutritive disturbance in which there is an excessive production of such portion of the >"> lily heat as is derived from chemical movements in the accumulated material of the organism, tin- surplus being sometimes more than the loss of heat production resulting from abstinence from food. The degree of bodily temperature in fever depends, in greater or less measure, upon a dis- turbance in the natural play between the functions of heat production and heat dissipation, and is not an accurate measure of the intensity of the increased chemical movements of the tissues." (Fever : A Study in Moibid and Normal Physiology, p. 240. Bv H. C. Wood, A.M., M.D. Pub- lished by the Smithsonian Institution, Washington, D. C, 1880.) 1 Report on the Causes of Infective Diseases, ls?5. 104 INFLAMMATION. and fever. Abernethy, Cooper, Wilson Philip, Travers, whose doctrines and phrases were on the lips of all teachers, and dominant in the schools, referred the obscure phenomena of these conditions to sympathy, and constitutional irri- tation — somewhat empty phrases; and Hunter, the greatest of all, evidently — to us of this generation — owes his pre-eminence to his close and able observa- tion of Nature, whom he questioned through experiments upon animals; and to his fidelity to her teachings. This most fertile of all our sources of exact knowledge, that is, knowledge which has proved reliable, and of practical value in physiology and pathology, namely, experiments upon animals, was undervalued by these contemporaries of Brown and Broussais, because it was the fashion to believe that the phenomena ascribed to the influence of the mind and nervous system, e.g., "sympathy," "constitutional disturbance," and " constitutional irritation," could not be adequately developed in the lower animals, and that the knowledge thus acquired could not therefore be profit- ably applied to man. In fact there are a few of the descendants of these sen- timental recusants still raising their voices in opposition to vivisection. If we omit Hunter, the real value of the writings of the authorities just cited, and a certain charm which they undeniably possess, will be found in their great ability as clinical observers and vivid portrayers of the symptoms of disease, and not in the interpretation of the phenomena they witnessed. Their opinions were too often warped by theories prevalent at the time, which have since passed away. The material results of the more practical researches of the present generation, promise to form permanent additions to our know- ledge; as, for example, the fact just cited from Senator that the injection of a little fresh pus will invariably produce fever in dogs, or that of the production of more intense and fatal fever by injection of putrid matter, as proved by Billroth and O. Weber. But it is still regarded as possible that substances may be elaborated within the organism, by abnormal chemico-vital changes, under the influence of temporarily perverted nervous action, which may give rise to fever, or to inflammation, as certainly as the injection of fresh pus be- neath the skin, or of putrid matter into the veins. The clinical facts are undis- puted that the simple passage of a sound through the urethra may cause a chill and fever, and that a sudden fright may so affect the quality of a nurs- ing woman's milk as to produce a poisonous effect upon the nursling. If an influence transmitted through nerves is competent to cause a change in a glandular secretion, begetting a poison, why may not the blood be similarly affected in the collapse following a severe injury, in which the generation of nerve force by nerve cells is temporarily suspended ? It is not easy to submit such a question to the test of experiment, and it is not desirable to speculate; but it is certainly wise not to lose sight of these, and similar phenomena, as bearing upon the causation of fever. 1 Mr. Savory has quite recently entered a plea for consideration of the claims of the nervous system as bearing upon " constitutional disturbance," which may possibly be referred to with profit in this connection. This eminent surgeon contends that fever may arise from "nervous" as well as from "ma- IcniiI" sources, and that the formsof fever thus produced present many symp- toms in common, such as malaise, and rise in temperature ; but that, where there is actual blood-poisoning, chills and sweats, with great and sudden rises 1 In his " Ti<'f;mis snr la Chaleur Animale" (Paris, 1876, p. 445), Claude Bernard concludes that fever is nothing more than an exaggeration of the physiological phenomena of comhustion, in consequence of interference with the nerves whose office it is to control and regulate these pheno- mena. This interference may !><■ reflex — as from a wound or injury ; or direct — as from section of the spinal cord. On this point Prof. Wood (ui supra) concludes that "the maintenance of the normal temperature and its rhythm is dependent upon the nervous system which, within certain limits, controls both the production and dissipation of animal heat." TRAUMATIC OR INFLAMMATORY FEVER. 105 of temperature are present, ending in congestion, inflammation, and suppura- tion. 1 Aided by clinical evidence, we may conclude, concerning the duration of ordinary traumatic or inflammatory fever, that whether it arises from a ner- vous, or a material infective cause, or from a combination of both, in the great majority of cases it tends to get well spontaneously, in a few days; the vital powers being competent to set to rights the nervous constitutional disturbance, or to resist and prevent the propagation, within the organism, of any material or infective fever-producing agents. This point, that is, the tendency of traumatic fever to spontaneous and speedy recovery, should be clearly con- ceived, in view of its bearing upon the question of treatment. In accordance with the doctrine of the day already recognized, and leaving nervous influence out of the question, the theory which best explains the oc- currence of traumatic fever is the absorption of poisonous material from the wound into the circulating current, the presence of which poisonous material in the blood causes its rise of temperature. If the traumatic fever persist beyond the five or six days assigned as its usual duration, or if it recurs in the form of u secondary" fever, the most probable explanation of these pheno- mena will be found in lack of power in the organism to prevent the propaga- tion within it of the infective material. The terms infective and non-infective, introduced by Simon and Sanderson, have been so generally adopted in treating of surgical inflammations and fevers as to require special definition. They involve a belief in a simple form of inflammation which never occurs without a cause, and which tends to disappear spontaneously as soon as its cause is withdrawn. "An inflam- mation," says Sanderson, 2 " which is more or less exactly limited in duration and extent by the limits of the injury which has caused it, may, with scien- tific precision, be designated a simple or normal inflammation," that is, non- infective. On the contrary, " an inflammation which spreads and endures beyond the direct and primary operation of its cause, which induces similar inflam- mations in other parts, and disorders the vital functions of the whole body, has in it something beyond the effects of the injury, and may be properly termed infective. ," 3 In the latest English systematic work on pathology 4 this is spoken of as " one of the most important divisions of inflammation ;" and it is stated that, " in all infective inflammations the formation of the infective substance appears to be due to the presence of minute organisms, these organisms, in the ordinary non-specific inflammations, being the com- mon septic bacteria." It cannot be said to be demonstrated that the infective properties undoubtedly possessed by fresh healthy pus, as the typical product of inflammation, are due to micro-organisms. If so, the vital quality which 1 In his opening address, as President of the Surgical Section of the British Medical Association, in August, 1880, Mr. Savory expresses himself as follows : " For many years the helief prevailed that disturbance of the whole body, or the illness produced by local mischief, was evoked through the nervous system, and hence the phrases 'sympathetic inflammatory fever,' and 'constitu- tional irritation ;' and this great doctrine naturally grew in force as the functions of the nervous system came to be better understood. The discovery of reflex function went very far to explain tin mode of action of the nervous system as the channel of sympathy between the various struc- tures and organs of the body. But then came the knowledge of what is now known as ' blood- poisoning;' and from the time, not far distant, when this first dawned on the minds of surgeons, it has become so rapidly developed that now it threatens to, nay actually does, exclude the elder view ; so that with many, at the present time, constitutional disturbance, in this relation, means, always, the phenomena of blood-poisoning, in some one or other of its various forms." He then proceeds to show that both these forms of constitutional disturbance occur, and that although they are often confused, it is of the highest importance to distinguish each of them. 2 Report of an Experimental Study of Infective Inflammation, 1S72, ». 48. 3 Ibid. p. 49. in cq. Au 1,ltrodu(;t i ori to Pathology and Morbid Anatomy, p. 215. By T. Henry Green, etc. London, 1881. 106 INFLAMMATION. enables a healthy organism to resist disease is competent to prevent their multiplication ; for the infective quality, as in Senator's clogs, is not always persistent. But this reasoning would not apply to the inoculations of mice by the septicemic bacillus, as recently described by Koch. Thus the exist- ence of an indefinite number and variety of infective agents is again- suggested as probable. The preceding remarks include all that can be properly said here con- cerning the more' serious forms of surgical fever. When the ordinary trau- matic or inflammatory febrile movement begins to assume more grave symp- toms, and persists, taking on the aspect of what the older surgeons, after Abernethy, called " irritative fever," with a dry tongue, more rapid pulse, more altered aspect, and more positive emaciation, and possibly diarrhoea, with or without a coincident unhealthy condition of the wound, and with efficient provision for drainage of the wound — for this category of symptoms we have no more probable explanation to offer than blood- poisoning. When putrescent material has been absorbed into the blood, in larger quantity than the organism can resist or throw off, as from a con- tused or unhealthy wound from which there has been no ready avenue of escape by drainage, the symptoms which have been ascribed to traumatic fever become intensified in the manner just described ; then septic poisoning has almost certainly taken place, and the condition of the patient comes within the definition of septicemia. Or, after an interval during which the trau- matic fever may have almost or entirely ceased, during the second week after the injury, or later — even as late as the second month — the wound, mean- while, showing, perhaps, no serious change from a healthy aspect — a chill may suddenly occur, followed by profuse sweating and the •characteristic chill- recurrence of pycemia. Under the titles of septicaemia and p3^8emia, these phases of surgical fever will form the subject of a separate article. Inflammatory Exudations. Clinically, there are conditions and appearances of surgical disease resulting more or less directly from the presence of inflammation, and belonging to the category of its symptoms, which are caused by transudation or exudation of materials through the capillary vessels. Exudation has been aptly described as the connecting link between the infra-vascular and extra-vascular manifes- tations of inflammation ; and it has also been spoken of as the material limit by which hypersemia is distinguished from true inflammation. The mate- rials which exude through the walls of the capillary vessels, vary much in character. They appear on the surface of membranes, as in diphtheria; in the interior of the body, as in local oedema, or in hydrocele; or on the surface of' recent wounds, as in the form of plastic lymph, where the exudation tends distinctly to the formation of new tissue. Pathology does not explain the difference between transudation and exudation with sufficient accuracy to justify an}- clear or positive distinction between the terms. As a rule, the more fluid transudations consist of a phosphatic, saline liquid, containing albumen in variable proportion, together with some few leucocytes and red blood-corpuscles, and they are ascribed to mechanical hypersemia, or to in- flammation of a low grade; whilst the exudations, containing solid elements, e.g., white blood-corpuscles in any quantity, and fibrin — or the materials capable of readily forming it- and, possibly, other organic products, are desig- nated as" inflammatory, and ascribed to a more positive condition of inflam- mation. INFLAMMATORY EXUDATIONS. 107 In all cases these exudations are derived from the blood. An apparent exception is the cell germination that takes place so actively outside of the vessels, either of wandering cells or tissue cells, when stimulated by the direct contact of the capillary exudation. As a general rule, afflux of blood causes capillary distension, and, as a result, exudation through the capillary walls follows — a sweating — as the term implies ; or, capillary distension from me- chanical obstruction, as from a tight bandage, may be followed by a similar result. A collection of fluid in the meshes of the subcutaneous connective tissue constitutes oedema ; and this fluid may be thin and watery, or rich in albumen. Passive exudation through the walls of capillaries altered by malnutrition, as in convalescence from acute disease, will be reabsorbed by the lymphatics as the quality and tone of the vascular walls is restored ; but the more active exudation through over-distended capillaries whose walls are altered by acute or persistent inflammation, will be more likely to go on to tissue formation, or, this failing, to suppuration. Organic chemistry has not as yet taught us enough concerning the organic constituents of these so-called inflammatory exudations to aid us in classifying them. The microscope has done some- thing more ; but our knowledge of the subject, for practical purposes, is far from complete. Clinical illustrations of their different forms may serve to explain certain symptoms and phases of the inflammatory condition. The cardinal symptom of swelling is for the most part due to exudation. Under some circumstances, as, for example, after certain poisoned wounds, it is so rapid and extensive as to suggest that, if not purely serous, the poison must have suddenly altered the walls of the capillary bloodvessels as well as their contents. And yet the sudden and rapid swelling that sometimes fol- lows the sting of a Wasp, or the bite of a rattlesnake, may subside in a limited time and leave scarcely a trace. The swelling of the leg that takes place during the growth of a popliteal aneurism, is at first, apparently, simple oedema ; but the leg subsequently becomes warmer than natural, and brawny to the feel, as though the exudation were becoming organized; and, in view of the slow recovery from this condition after the aneurism has been cured, as though by atrophy of the new tissue, it would seem that this apparently inflammatory condition has really been caused by the blood-stagnation. A similar brawny thickening of the legs occasionally follows the oedema due to hepatic disease, to obesity, to failure of the heart's action from age; and it sometimes accompanies varicose ulcers. Although mainly the result of mechanical hyperemia, the swelling is often attended by increase of heat. Under the name of acute oedema, Sir B. C. Brodie described a rapid swell- ing of the scrotum by infiltration of its lax subcutaneous connective tissue, causing gangrene of the integument, apparently by cutting off its blood- supply through over-stretching of its nutritive vessels. This was probably an acute necrosis of the connective substance, such as occurs in phlegmonous erysipelas. The fluid of an ordinary hydrocele is slightly viscid and sticky, of a light amber color, with an alkaline reaction. It is so rich in albumen that the addition of nitric acid will often convert the fluid into a solid mass, by neutralizing the soda which keeps the albumen in a fluid state. Serous exudation oceurs more readily in localities where the bloodvessels are surrounded by lax connective tissue. Hence the danger of infiltration of the thyro-aiy tenoid folds, and consequently of obstruction of the glottis — an example of the oedema always present in a greater or less degree in the meshes of the connective tissue of the outlying area surrounding a focus of inflam- mation. When confined to a limited surface, this form of exudation consti- tutes a valuable indication of the presence of an abscess beneath. It has been 108 INFLAMMATION. called collateral oedema, and its fluid contains white cells and iibrogenous material. Of these so-called serous exudations, it is stated by a recent authority 1 that the assertion that they contain only dissolved albumen " has been assumed, rather than chemically demonstrated. In reality, these fluids," exuded mostly under the influence of obstructive hyperemia, or a low grade of inflammation, " almost always contain variable quantities of iibrogenous matter, of fibrin, or of mucus, according to the part affected." In this way we explain the occasional coagulation of the exudation following a blister, and the coloration sometimes caused by the presence of red corpuscles or of their coloring matter in a state of solution. The free watery discharge from the nose after " taking cold," by which the congested Schneiderian membrane relieves itself, often leaves the handkerchief stiff as if it had been starched. The distended bloodvessels in inflammation not unfrequently relieve them- selves entirely and finally by exudation, thus bringing the crisis to a close. In a case of abdominal dropsy, which followed peritonitis after a miscarriage, the patient experienced a complete cure by tapping. She returned some months later with no fluid whatever in the peritoneal cavity ; but there was a hernial protrusion at each femoral opening, and a third at the umbilicus. In this case the peritonitis had evidently relieved itself — had "terminated," technically — by free serous exudation. In an ordinary gum-boil, the intense pain usually ceases as soon as the external swelling begins. The quantity of the apparently watery exudation which escapes from the cut surfaces after an amputation, subsequent to the arrest of hemorrhage, is very considerable ; after an amputation at the hip-joint, it has been estimated at from a pint to twenty ounces. It is generally tinged by dissolved blood- clot, and often stains and saturates the dressings so as to suggest the idea of hemorrhage. It is not for us to determine the source of the fibrin which constitutes so large a proportion of the coagulum deposited by this exudation. Organic chemistry has left this question still in the region of theory. It evidently approaches in its nature, or is identical with, what is styled by a recent authority 2 "the well-known inflammatory effusion," and is derived directly from the liquor sanguinis, to which it approaches in quality. This exudation, according to the same authority, contains " more albumen, phos- pl uitos, and carbonates" than serous exudations, and "has a much greater tendency to coagulate, due to the white corpuscles it contains ;" forming thus a hot-bed or compost admirably suited for promoting cell germination, and for furnishing nutritive materials for young cells. The white corpuscles are regarded as emigrants or wandering cells which have escaped through the capillary walls. It has been observed that the exudation in inflammation which occurs early is always more fluid; at a later period it contains more cells. The exudation in healthy or constructive inflammation, generally called 'plastic or ctunjalable lymph, which makes its appearance on the surface of a recent wound, or in the form of swelling around an inflammatory focus, is, as lias just been stated, a bland and unirritating product of the nutritive machinery ; its obvious use is to aid in forming a growth of new tissue for a reparative purpose. This purpose may find its result in the organization of cicatricial tissue, whereby a breach of continuity is healed; or in forming a limiting barrier to suppuration, which is always, in some degree, destructive; ' Cornil and Ranvier, Manual of Pathological Histology. Philadelphia, 1880. 2 Green, ut supra. I INFLAMMATORY EXUDATIONS. 109 or in aiding the separation of parts which have lost their vitality. In the attainment of these objects, the organization of a new growth of tissue is indispensable. When this tendency to organization is opposed by any obstacle, as where the cicatrization of a wound is prevented by the presence, for example, of a sequestrum of bone not yet separated, then the new growth remains indefinitely, or until the obstacle is removed, in the inchoate stage of indifferent or granulation tissue, and the redundant supply of exudative material is wasted in the form of pus. There are varieties of inflammatory exudation closely allied to plastic or coagulable lymph, if not identical with it, and ecpially remarkable for their prompt tendency to organization, which are encountered especially in wounds and inflammations of serous membranes. The apposition of serous surfaces after injury is immediately followed, under favorable circumstances, by adhesive inflammation; and this means the organization, in plastic lymph, of a new growth of tissue which forms a bond of union between them. The " false membranes," so often found in the shape of abnormal bands of tissue binding together free surfaces of the pleura or of the peritoneum, have the same origin. They are the result of constructive inflammation following some injury, which, but for the binding and restraining influence of the new formation, would have gone on to the destructive phase, that is, to pus forma- tion. In still more purely fibrinous exudations, their coagulation is said to take place suddenly and in successive layers. 1 The dense, bulky, sometimes stratified layers of fibrous tissue in which the testis is found enveloped after an old injury, are sometimes organized blood-clots within the cavity of the tunica vaginalis, and sometimes organized exudation from the surface of this membrane, by which it has become enormously thickened. In a man of 35, whose testicle had been suspected to be the seat of malignant disease, but who had a previous history of contusion and consequent hematocele, a healthy testicle was found in a cavity lined by what seemed to be tunica vaginalis, also appa- rently healthy, and containing no appreciable fluid, the walls of Avhich were an inch in thickness throughout its whole extent, and resembled cicatricial tissue. A similar mechanism has been assigned as an explanation for the appear- ances often presented in the interior of the sac of a cured aneurism. They are described by Robin 2 as u eaillots actifs jibrineux" in contradistinction to the soft spongy coagula which are liable to form in aneurisms, and which possess no curative value. Inflammatory exudations from the free surfaces of mucous membranes are said by Cornil and Ranvier 3 to contain mucus, and a substance called mucin which appears in the form of filaments, insoluble in acetic acid, and which " may form thick layers upon the surface of articular cartilages, notably in the case of white swellings." What is called croupous exudation, as met with on the surface of mucous membranes in the air passages, in the bladder, and, somewhat rarely, in the intestines, is said to consist of filaments of fibrin, and sometimes of mucin, felted together with pus corpuscles and epithelial cells — according to the re- gion — in their interstices. The false membranes of true croup, according to the best authority, 4 are not composed of true fibrin, but of altered and over- grown epithelial cells. Fibrin is present in the exudation from an inflamed mucous membrane only when its epithelium has been partially or completely destroyed. 5 1 Cornil and Ranvier, op. cit., p. 64. Philadelphia, 1880. 2 Leqons sur les humeurs. 3 \Jt supra. 4 E. Wagner, Manual of General Pathology. New York, 1876. 5 Weigert, Article on Inflammation. Real-encyclopsedie der gesammten Heilkunde, Band i. S. 642. 110 INFLAMMATION. Plastic or Coagulable Lymph. To return to the well-known inflammatory effusion which exudes from recently divided living surfaces, and deposits upon them the plastic or coagu- lable lymph by the organization of which their union is effected, this form of exudation, and the steps by which it undergoes the organizing process, are worthy of careful study. It is the characteristic product of the " adhesive" inflammation of Hunter, the normal type of the true, healthy, constructive process. Hunter describes the aspect presented by the pale jelly-like coagu- lable lymph as it appeared to his unaided eye upon an exposed surface of bone ; he could easily have wiped it away, but did not ; the next day, to his surprise, it had become pinkish in color, and bled when touched by the probe. It had become organized. The mechanism of this curious change — one of the changes which constitute the condition of inflammation: that is, the organization of plastic lymph, which histology and embryology have since rendered plain to us — it is the surgeon's duty to supervise; and to do this intelligently he must be familiar with it. Hunter wisely withheld his hand and watched the process with the eye of genius. At the end of another century, with the advantage of the microscope, we enjoy the privilege of seeing more clearly the minute appearances which attend the organization of plastic lymph, and can recognize with certainty what Hunter only assumed. The substance of coagulable or plastic lymph affords by its chemico-vital constituents the best possible pabulum for cell germination and sustenance, and the leucocytes or white corpuscles already present in it begin, at once, to germinate. In a few hours after the receipt of a wound, the process of cell germination has converted the jelly-like material deposited upon its surface into a mass of granular cells, all of the same size, and so numerous as to touch each other on all sides, leaving only minute angular interspaces filled with intercellular substance. These granular cells are minute spherical masses of protoplasm, called by Huxley "embryonic" cells. He gives them this name because they are the first formed and most constant features that make their appearance in the jelly-like substance — plastic lymph, it might be called — that constitutes the human embryo when it first becomes manifest under a magnifying power. They are almost if not quite identical with white blood corpuscles, with lymph corpuscles, with young pus cells, with young epithe- lium, with so-called granulation cells, and with young connective tissue cor- puscles; and to all these cells, undistinguishable from each other in their earlier stages by any means at present under our command, the common ap- pellation of leucocytes or indifferent cells is applied by histologists. And now, as soon as the j^lastic lymph has been thus converted by the ger- minal ] lower into a mass of living cells, another strange phenomenon takes place: a minute stream of cells, differing in appearance from those just de- scribed, may be seen coursing its way through the crowd of leucocytes, which seem lo flatten out and make walls, apparently to keep the slender current within bounds; and this tiny stream of pinkish } T ellow cells, curving upon itself, assumes, forthwith, the outline of a loop. It is, in fact, a newly formed capillary, containing red blood-corpuscles, which are readily distinguishable as such by their faint color, and their characteristic shape — that of flattened bi-concave disks. The new capillary loops shoot into the cell mass from the surfaces of the recently divided tissue, projected, as it were, from its over- distended capillaries by a process of budding and growth of new vessels, or by simple rupture and "channelling." However formed, they shortly con- stitute myriads of delicate connecting threads running into the mass of recently germinated cells which, thus furnished with a blood supply, begin PLASTIC OR COAGULABLE LYMPH. Ill to undergo another change. The cells, heretofore " indifferent" embryonic corpuscles, begin to alter their aspect, and to develop into connective-tissue cells ; the intercellular substance undergoes the process called fibrillation ; and thus the embryonic substance becomes converted into young connective tissue. The office of the newly-formed tissue now becomes apparent: it is truly connective, for, having filled the breach, it straightway draws and binds to- gether the opposite sides of the wound, and thenceforward takes the name of cicatricial tissue. Thus, the adhesive, cement-like material furnished by the inflammatory exudation becomes organized into new tissue that forms a bond of union by which a breach of continuity is healed. This is the mechanism by which constructive inflammation fulfils its repa- rative office in its most simple and typical phase. The stages of the process are appreciable by the naked eye, and at the bedside, by the symptoms already detailed, which vary in intensity according to the size and depth of the wound. The result constitutes union by the first intention. The cicatricial bond becomes invested with epidermis by the same process of cell growth and development. At first the scar is redder than the neigh- boring integument, in consequence of the larger proportion of vessels carry- ing the red blood necessary for its organization and growth. But afterwards its succulence diminishes; the capillaries, no longer required, shrink or dis- appear; so that the cicatrix diminishes in bulk, and becomes paler in color, forming, after the primary union of an incised wound, a simple white line, in many cases scarcely visible. In the case of an abrasion, or a surface wound of limited extent, the exuding plastic lymph dries upon the raw surface when it is left at rest and exposed to the dessicating action of the air, and covers it with a crust. By this me- chanism, which is the common mode by which Nature cures the slighter wounds of animals, a tough and somewhat flexible scab is formed, which pro- tects and seals the raw surface from external contact, Beneath this natural dressing, if undisturbed, the breach of continuity is repaired very perfectly by the organization of plastic lymph. The dried scab, in due time, falls sponta- neously, revealing a smooth, slightly reddish surface invested with epidermis which, subsequently, becomes paler in color, and often scarcely distinguishable. This is a mode of repair in which the symptoms which ordinarily attend in- flammation are usually very slight, and often seem to be entirely absent. It is called healing under a scab, and is, in fact, Nature's favorite method of cure, and should always be promoted when circumstances are favorable. In superficial wounds of mucous surfaces, a similar prompt result of con- structive inflammation is accomplished under the sheathing protection of the mucous secretions. Wounds and lacerations of internal organs often leave cicatrices behind them, discovered on post-mortem examination, as the only evidence of their previous existence. A rupture of the tendo Achillis, or a simple fracture of bone, undergoes repair by the process of tissue formation just described as "healing under a scab." The part played here by the leuco- cytes which germinate in the plastic lymph justifies the title conferred upon them of " indifferent" cells, for they develop with equal facility into tendinous or bony substance, as into connective tissue. All these examples of the inflammatory process, usually spoken of as "ad- hesive," "constructive," or "reparative" inflammation, representing the mode in which are cured the great multitude of simple lesions which never come under the cognizance of the surgeon, serve to illustrate the natural healing powers possessed by the organism. It is only when this benign process, which we have described as simply an unusual effort on the part of the ordinary local nutritive apparatus, is interrupted or interfered with in any way, that 112 INFLAMMATION. we are liable to encounter the symptoms of the more serious forms of inflam- mation which have been designated as destructive. The more common sources of interruption to the normal process of repair have been already enumerated, under the title, heretofore in common use, of "predisposing" and "exciting causes of inflammation." Now it is obvious that these expressions are strictly correct only in the limited sense which regards the causes of inflammation as obstacles to the continuance or completion of a normal process, or as opening the way for, and favoring, as it were, the bad consequences which necessarily follow stoppage or interruption of the nutritive machinery of a part, or its failure to repair an injury in a natural way. In any other sense, a conclusion could be assumed as logical that these causes provoke destructive inflamma- tion as an essential and an aggressive disease, a doctrine which in the early part of this article was distinctly denied. Destructive Inflammation. Pus Formation. In accordance with this view, the symptoms of destructive inflammation, which we have next to consider, are to be regarded as the consequences of some cause or causes which, by their influence upon the organism, have had the effect of interrupting or impairing normal local nutritive action, in con- nection with the series of changes following injury. This doctrine will be illustrated by the study of suppuration, or pas formation, the most common and important of the changes liable to follow injury. Suppuration is prop- erly treated of as a symptom of inflammation of the destructive sort, because, although commonly associated with the mode of healing by granulation and suppuration, known as "healing by the second intention," it never takes place without a distinct and positive loss of substance. Healing by the adhesive process — "by the first intention" — does not necessarily involve any, or an almost imperceptible, textural loss; but whenever pus is formed, there is at least an equivalent furnished in nutritive material, or in tissue already existing. Suppuration and Granulation. — To describe the mode of pus formation in its most common aspect, let us recur to the condition of an open wound, the .-i i rface of which has become glazed by a deposit of plastic lymph, but in which from loss of substance, or the presence of foreign material in the wound, its surfaces cannot be brought together, in accurate contact, so as to secure union by primary adhesion. Here the object of the exaggerated effort on the part of the local nutritive apparatus to repair the lesion in the most simple and effective way, is rendered unattainable; the purpose for which the inflamma- tory exudation has been poured out, is baulked. But Nature has other re- sources at command by which the end can be reached; not so promptly and readily, with more delay and expense, but still repair of the injury can be ac- complished. Her next effort towards this end is, after the delay of a day or two, and with a certain amount of local soreness and swelling, and more or less general disturbance or distress, to generate a red velvety surface upon the wound, and clothe it with a bland, cream-like yellowish fluid. Under these new conditions, if circumstances are favorable, the wound goes on to heal, in the manner to be described. The soft red surface is coagulable lymph which has become organized into indifferent or embryonic tissue — henceforward to be spoken of as " re- ducing quality of pus resides in its solid elements ; for injections of filtered liquor puris were found to be innocuous. These facts, and many others of similar import and equal interest, are to be kept under advisement; but inferences from them, as applicable to the human organism, are hardly as yet justifiable beyond the general admission that, in a certain degree, the products of healthy inflammation possess the itifcr-tive quality. Where a wound, or an ulcer, is partly gangrenous, or phagedenic, in fact, up to the time when a complete layer of health}' granulation lias formed upon its surface, its pus will always contain more or less dead or dissolving tissue ■ — detritus, as it is called. The yellowish-gray flocculent or leathery adherent material which cannot be washed away from the bottom of a wound or ulcer, in this condition, is simply dead tissue not yet cast off, because granulations are not as yet completely organized beneath it — the organization of a healthy layer of granulation tissue upon the living surface being absolutely requisite to insure the safe separation, in the normal order, of dead from living parts. But there are certain circumstances under which pus does acquire poisonous properties which do not belong to it per se, as when it becomes, accidentally, the vehicle of a virus, as, for example, the virus of the contagious venereal ulcer called chancroid. Under these circumstances it is properly denominated "virulent pus." Here there is no difference whatever demonstrable by the 124 INFLAMMATION. microscope, as yet, nor by the strictest chemical analysis, from pus of ordi- nary quality. The virulence of pus thus contaminated belongs neither to its corpuscles, nor to bacteria, but to certain unknown substances soluble in its serum, analogous to those which exist in the blood in syphilis, in the nasal mucus of glanders, or in the saliva of hydrophobia. 1 Pus Involves Waste of Tissue. — It has been rendered sufficiently obvious by the preceding considerations that pus production involves destruction of tissue. As Strieker asserts, " where pus is formed in the midst of the tissues, the tissues must be disintegrated ; it is the tissue itself which is transformed into pus-corpuscles." In addition, adjacent parts are damaged by interrup- tion of their function, and by pressure; and local death is produced by ulcera- tion. Pus production, in the case of wounds, therefore, involves not only delay as to healing, but positive destruction and waste of material in the consummation of the healing process ; and suppuration is properly regarded as a symptom of the destructive phase of inflammation. These conclusions will become more obvious if we examine a little more closely into the uses of pus. Tses of Pus. — For what purpose is this secretion furnished by the blood at the expense of the tissues? AVhat are really its uses? These questions are readily answered. Many and different uses have been assigned to pus, some of which are entirely fanciful. James, of Exeter, who wrote in 1832, embodies the general sense, at that date, in the opinion that the secretion of pus is a necessary auxiliary to the process of granulation, for "the newly-formed parts have no protection to defend them against the injurious impressions of exter- nal agents;" this "appears to be its legitimate use." James judiciously remarks, concerning pus, that " if we can sufficiently protect the wound from the irritation of external agents it will heal without it ;" referring to " scab- bing," in proof. At an earlier date, the flow of pus was supposed to exercise a dcpiirative influence both upon the wound and upon the system at large. It was thought to cleanse a wound, and to prepare it for healing ; and means were commonly employed to promote its flow. The popular mind still attaches importance to the idea that suppuration purges the body of something injurious ; and the term "corruption" is still applied to pus, and a certain satisfaction excited by its free discharge. Hence one of the sources of confidence in the remedial power of setons and issues. But at the present day, the conviction has gradu- ally come to prevail that these uses of pus are imaginary. The} 7 certainly have not been confirmed by the increasing accuracy of our knowledge, and the opinion of Robin is now generally received. This writer asserts, broadly, that "it cannot be demonstrated that under any circumstances suppuration does good, or that it exerts any salutary influence by depuration." 2 We may safely regard suppuration as simply an exuberant overflow of plastic material. The leucocytes which are washed away from the surface of a wound arc evidently not necessary for the success of the constructive pro- They are in excess of the demand. Their fellows, which remain behind, develop into tissue — tiny subserve a useful purpose; but those which are washed away as pus-corpuscles are wasted — they arc abortions. The truth of tliis view is confirmed by what happens when healthy granulating surfaces are brought in contact and kept carefully in apposition. We know by daily experience that they unite at once and grow together. The question was asked in connection with this mode of adhesion of granulations, or secondary • Robin, op. cit., p. 414. 2 Op. cit., p. 384. VAKIETIES OF PUS. 125 adhesion — " What, in this event, becomes of the pus ?" The answer is obvious : It ceases to be produced the moment that the granulating surfaces are success- fully brought together. The immediate demand for development into tissue, in the new attitude of the wound, affords ample scope for both the force and the material hitherto wasted ; and the overflow, as pus, is at an end. It is by this same mechanism that an abscess heals, after its contents have been discharged. The walls of the cavity, lined by granulations which have formed around the central cause of irritation by which the abscess was pro- voked, tend to come into contact as its contents are voided. The force that brings them together is the contractility of the tissues which form the walls of the cavity. If this tendency is intelligently favored, prompt adhesion fol- lows, and the discharge of pus ceases. Just in proportion as this natural termination of the constructive inflammation is in any way prevented, the abscess is liable to result in a sinus. There is available evidence that suppu- ration is not only useless and wasteful, as shown by these examples, but that it is, in other ways, positively injurious. And yet it may be remarked that, as far as the eliminative theory as to the causes of abscess formation is true, pus is to be credited as an adjuvant in floating out foreign substances lodged in the body, and noxious materials be- gotten within it. A flow of pus has also, a certain usefulness in floating away foreign and dead matter from a foul surface, as, for example, from that of a contused wound, taking a helping part in what the older surgeons called " digestion" of the wound. To this extent, therefore, it may be regarded as as eliminating agent ; and in the lower animals, after granulation has fairly begun, pus aids in forming a crust by which cicatrization is favored. Mean- while it is to be observed that, when it cannot be cut short by promoting the adhesion of granulating surfaces — a possibility which the surgeon should always keep in view — the normal termination of suppuration is reached through the repressive influence of cicatrization. Varieties of Pus. The constitution of pus, as heretofore remarked, is subject to constant variety, not only in different individuals and forms of disease, but in different conditions of the same individual, and in different localities of the body. Under the influence of an attack of indigestion, for example, the character of the pus from a healthy granulating wound will give evidence of tempo- rary change ; and after a chill, as of pysemia, it usually becomes scanty, thin, and watery. The sudden disappearance of the purulent discharge from a wound, simultaneously with the chill by which grave symptoms were ushered in, naturally suggested to the surgeons of the last generation that the serious change in the patient's condition was caused by "absorption of pus," and the abscesses in the internal organs which followed, seemed to lend support to this idea. But these facts are now explained differently. In chronic and cold abscesses the pus-corpuscles have often a pallid, drop- sical appearance, and sometimes their nuclei cannot be made apparent by adding acetic acid ; these corpuscles have long since ceased to live, and are, in fact, beginning to undergo solution. The serum of this variety of pus is, consequently, rarely transparent ; it is generally turbid. With these water- soaked pus-cells, others are found in a condition of fatty infiltration. In pus from abscess of the female breast, during lactation, milk-globules may be found, and in these, as well as in abscesses of the lymphatic glands, cells of pavement epithelium from the ducts, and also glandular cells, are often pre- sent. If we knew more of the subtle processes of organic chemistry carried 126 INFLAMMATION. on in the tissues and fluids of our bodies, we should, doubtless, find many products derived from chemical changes in these unstable albuminous com- pounds, capable of acting as local irritants, and of causing these abscesses. Even thinner and paler than the pus of a cold abscess is that from cavities containing dead bone left behind after an abscess has failed to eliminate it ; here we find sometimes drops of oil from dissolving marrow, as well as mi- nute granules of osseous detritus which can sometimes be felt between the finders. Careful scrutiny may, therefore, in any case, aid in diagnosis. Pus from varicose and indolent ulcers, from ulcerated epithelial tumors, from the true syphilitic chancre, and also from phagedenic ulcers, is thin, serous, and " sanious," and contains more or less detritus of tissue — qualities significant of the absence of healthy effort in the way of repair. The type of sanious pus, of what is called ichor, is found in the discharge from an open cancer ; it contains much already dead, or liquefying, cancer tissue. If, on the other hand, a cancerous tumor be removed, freely and entirely, and the wound left open, the surrounding healthy tissues will shortly eject cream-like pus, significant of active cell formation and rapid repair. Cancerous ichor is often excessive in quantity and exhausting to the strength of the patient ; it is given off by the new vessels of the cancerous growth which are impotent to furnish true exudation, and simply exhaust vital force in the effort. Substances Mistaken for Pus. "We have said that pus in a solid form has been mistaken for tubercle, when developed under pressure in bone. Solid pus occurs also, habitually, in other localities: in the sulci between the convolutions of the surface of the brain and spinal cord, in meningitis ; on the iris, where it can often be seen in the form of little rounded masses, in iritis ; in the cornea ; and in other tissues of the eye. On the other hand, there are fluids in the body, and even solids, which are often miscalled pus, in which the microscope fails to reveal its characteristic elements. As examples, we have the fluid effused in peritonitis, or pleurisy, called purulent, but often nothing more than the serum of those cavities with a few leucocytes in suspension. An exaggerated flow of mucus from any of the mucous canals, with an increase in number of the leucocytes which it normally contains, often forms an imitation of pus — as in the fluid of bronchorrhoea, and of some forms of gleet, and especially in rectal mucus when colored yellow by bile. The fluid found in the pelves of the kidneys after death, resembles pus, but is only urine holding in suspension epithelium from the urinary tubules. A similar explanation applies to the fluid which can be pressed out of the prostatic ducts. The secretion of the tonsils collected in its crypts, is not unfrequently mistaken for pus, and ulceration assumed to be present, when it is not. Clots of blood which form in arteries after ligature, or after embolism, are liable to break down into a soft yelldwish fluid strongly resembling, pus j 1 and a similar puriform liquefaction is liable 1o take place in other tissues, as in lymphatic glands, sometimes in the tes- ticle, and, more rarely, in the interior of fibrous tumors. Injurious Consequences of Suppuration. The vital effort which results in the formation of pus amongst the solid tis- sues of the body, just as in wounds and on membranous surfaces, only in a ' Virchovv, Cellular Pathology. Translated by Chance. London, 1860. PURULENT INFILTRATION WITH CONNECTIVE-TISSUE NECROSIS. 127 greater degree, inevitably involves a destruction of existing tissue, besides the wasteful overflow of anatomical elements which we have already recognized. Wherever healing has followed suppuration, there is evidence, in the depres- sion of the cicatrix, and in the general shrinkage in volume of the parts in- volved, that there has been loss as to bulk — certainly, also, as to quality — of pre-existing tissue. A cicatricial surface never contains sweat-glands, nor hair-bulbs, and only after a good deal of delay, according to Paget, the yellow elastic fibres. " But," it may be asked, " is not the healing of the wound to be credited to the suppuration ?" By no means. A moment's reflection will recall the fact that the most prompt and solid healing with least loss of sub- stance, is accomplished in primary union, in the subcutaneous consolidation of a divided tendon, and in that of a simple fracture, where there is no pus formation whatever; in short, that new tissue is freely generated without its aid. Again, examples are occurring constantly, in practice, of patients wasting with suppuration who are benefited by cod-liver oil ; and of amputation for injuries of limbs in which repair has failed, and where improvement in the patient's condition has begun at once after the removal of a source of exhaust- ing and impotent suppuration. Daily experience tells us that hectic fever is coincident with, if not caused by, suppuration from surfaces incapable of heal- ing. We have to add, also, to the injurious effects resulting from pus produc- tion, the possibility of amyloid degeneration of the arteries and the viscera ; for modern pathology has recognized prolonged suppuration as one of the most common causes of this grave and obscure affection. The conclusion, therefore, seems to be unavoidable that the secretion of pus is not only, in a general way, useless and wasteful, but that it is, in many cases, positively in- jurious; while the benefit to be derived from it is uncertain, and in some degree, hypothetical. It is desirable that the surgeon should recognize these truths, and assume it as a duty not only to favor rapid union in wounds, and a prompt cure in abscess and sinus, wherever this result is feasible, but under all circumstances to avoid suppuration as much as possible, and to arrest it always as soon as he can, keeping in mind the fact that the formation of pus involves the ex- penditure of vital force just as much as the construction of tissue. Purulent Infiltration with Connective-Tissue Xecrosis. Three ways have been thus far described in which pus formation takes place in the organism: (1) on the surface of wounds healing by granulation; (2) on serous, mucous, and tegumentary surfaces ; and (3) in the form of a collection imbedded in the tissues and bounded by well-defined walls, as an abscess. There is a fourth variety in which pus formation is not unfrequently encoun- tered, namely, as an infiltration into the substance of a part — mostly into the meshes of the connective tissue, or into the cellular interspaces occupied by this substance— with a tendency to spread or travel, and showing no disposi- tion to self-limitation as in abscess. From abscess, which is always charac- terized by limitary walls, this mode of pus formation is distinguished as purulent infiltration, and it is also often spoken of as "diffused inflammation" This^ obscure term was first applied by Duncan, of Edinburgh, 1 to the pus formation formerly so common in the axilla, and deeply amongst the muscles of the arm and thorax, after dissection wounds, and after venesection, in which 1 Cases of Diffuse Inflammation of the Cellular Texture, with the Appearances on Dissection, and Observations. By Andrew Duncan, Jun., M.D., etc. Edinburgh Medico-Chirurgical Transactions, vol. i. p. 470, 1S24. 128 INFLAMMATION. the tendency to self-limitation was noticeably absent. It has since been ap- plied by English surgeons to the diffuse and spreading suppuration attending erysipelas when this disease affects the parts beneath the surface. The French surgeons speak of this variety of inflammation as diffused phlegmon. The relation it bears to erysipelas has always been vaguely defined ; but our ideas are clearer since modern surgical pathology has recognized that each of these forms of spreading inflammation, as well as simple cutaneous erysipelas, has for its cause a peculiar infective poison analogous to that discovered by Koch, by which he produced spreading gangrene in mice. The common effect of these poisons, in man, is to cause more or less rapid death of the connective tissue when brought in contact with its meshes by the lymphatics, or other- wise. The effect produced by putrid or altered urine, when extravasated into the connective tissue, illustrates the liability of this structure to die promptly in consequence of such noxious contact. It is the putrid element in this case that kills, for experience has demonstrated that the contact of healthy urine with the tissues does not necessarily impair their vitality. 1 A contused wound of the hand in a mechanic, in which prompt healing has been prevented by neglect or exposure, is liable to become complicated by a diffuse swelling of the forearm, with purulent infiltration of its muscular in- terspaces. This complication has been described as "subfascial inflammation ;" in reality it is a connective-tissue necrosis from poison brought by the lymph- atics from the festering wound of the hand. Dr. Weir Mitchell, in his study of the effects of the venom of the rattlesnake, describes in detail the influence of this poison upon the tissues at and near the wound. When the victim sur- vives the first eifects upon the nerve centres, the suppuration that follows a snake-bite is of the diffuse variety — the half-poisoned tissues in the neighbor- hood seeming, for a time at least, unequal to the task of getting up a barrier of healthy granulations to limit its advance and serve as a basis for repair; and, before final healing, sloughy masses of dead tissue are always thrown off. This latter phenomenon is mentioned by Dr. Duncan in those of his cases of "diffused cellular inflammation" in which the patients survived; and it is a well-known feature in phlegmonous erysipelas, and " subfascial inflam- mation." In a word, then, the pathology of the present day does not clearly recog- nize any especial significance in any of these terms, and tends to substitute for them death of tissue from contact of a poison, and pus formation for the pur- pose of eliminating dead tissue. The effort at pus formation is weak and dif- fuse, simply because the influence of the poisonous contact impairs in a greater or less degree the vitality of the neighboring tissues, and weakens their capacity for prompt and healthy repair. As soon as the poisonous influence ceases, more vigorous and healthy granulations are formed, and the production of new connective tissue goes on as in ordinary constructive inflammation. The characteristic symptoms of this variety of inflammation are a peculiar doughy, boggy feel, attended by deep soreness on pressure, but rarely a dis- tinct sense of fluctuation, with a variable amount of surface redness, perhaps a brawny thickening of the skin over the atfected part, and a tendency to surface gangrene, in patches, from cutting off of the vascular supply of the skin. Tims, one of the best remedies of the surgeon is to save surface sloughing, and fever, by Liberal incision of the integument, in order to facilitate the early escape of deeper sloughs. In these incisions he recog- ' In a patient shot through the distended bladder, recovery followed without any sloughing. (Vati Buren. New York Medical Journal, May, 1865.) Subcutaneous injections of fresh healthy uriue made experimentally by Keyes in man, were followed by no irritation or trouble whatever. (Van Burcii and Keyes, Diseases of the Uenito-urinary Organs, p. 144. New York, 1874.) HECTIC FEVER. 129 nizes a soft-solid condition of the subcutaneous layer, the meshes of which seem distended with fluid exudation of varying consistence, with softer portions of evidently dead tissue resembling wet tow and bathed in pus, and sometimes softened and dead muscular substance. Hectic Fever. As most frequently encountered in connection with the waste and conse- quent vital exhaustion from pus production attending lesions beyond repair, Hectic Fever is properly treated of as a symptom of destructive inflammation. It is a persistent, teasing, low form of continued fever, characterized by morning remission and nocturnal exacerbation ; manifesting a pretty con- stant and regular succession of chill, fever, and sweating, in the course of every twenty-four hours ; and characterized by progressive emaciation, with a tendency to a fatal termination unless its cause be removed. The immediate or exciting cause of hectic, like that of the other surgical fevers, is, as far as we know, the absorption into the blood of some of the fever-producing products of inflammation, by small quantities — instalments, as it were — day by day, never sufficient to raise the temperature of the blood high enough to produce immediately fatal results, but keeping up a steady persistent drain upon the system in the way of combustion of the tissues. As to its remoter causes, hectic is neither an essential nor yet an eruptive fever; it is ^ universally regarded as symptomatic, and, as already suggested, symptomatic of some lesion of the organism, generally attended by suppura- tion, with which the reparative powers are unable to cope. Chronic diseases of the larger joints, and compound fractures with ineffectual drainage, are common examples of the surgical lesions which cause hectic. It may exist where there is no actual suppuration, but such instances are rare. The occurrence of hectic in phthisis is regarded as an indication that soft- ening of tubercular deposit has taken place. A cold abscess may have been growing for many months without any evidence of fever ; but if its contents be suddenly discharged, and the air has access to its cavity, a chill almost invariably occurs within a day or two, followed by fever and sweating ; and the daily repetition of these phenomena marks the inauguration of hectic. If the vomica of the lungs, under exceptionally favorable circumstances, should heal, or if the walls of the abscess, instead of sloughing piecemeal, should unexpectedly granulate and adhere, the first evidence of this happy occurrence in either case would be cessation of the hectic fever. A case has been already mentioned in which the amputation of a thigh for chronic joint disease was followed by immediate and marked improvement ; this was due to the cure of hectic by removal of its cause. One of the very common occasions of secondary amputation in hospital practice is irremediable injury of a limb, most frequently through the consequences of compound fracture, for the purpose of preventing death by hectic fever. The fatal result is brought about surely and steadily by the waste of vital resources through combustion of tissue material to keep up the fever heat. Patients with hectic often consume a good deal of nourishment, but it seems to do them but little good ; emaciation goes on in spite of the beef and the porter and the cod-liver oil. The eyes of the patient become more deeply set, the ears more transparent, and the outlines of the skeleton more dis- tinctly visible. So in the dogs who were the subjects of Weber's fever experiments ; the animals in a state of fever who were fed to the extent of their capacity, lost weight more rapidly than those without fever who were simply deprived of all food and dying of inanition. The slow progress of vol. i. — 9 130 INFLAMMATION. hectic fever towards its usually fatal termination, is explained by the fact that the temperature of the blood is not sustained at a high figure ; it rarely exceeds 103.5° Fahr., and falls two or three degrees in the morning under the influence of the nocturnal perspiration— sometimes even below the normal standard. Before midday, the chilly period, which may be very slight, comes on, and is followed inevitably during the remainder of the day by fever, and during the night by sweating, often profuse. Sometimes there is a double movement, with chilliness in the afternoon as well as in the morning. The best diagnostic signs of hectic from typhoid or malarial fevers, are the regularity of the night-sweats in hectic, and the fact that the pulse retains its frequency during the apyrexia, even in the morning when the temperature is down to the natural degree. This depression of temperature in the morn- ing bears a certain relation to the profuseness of the sweating during the night, and is associated with feelings of weakness and depression. The worst signs in hectic are the intensification of its symptoms ; increas- ing frequency of pulse ; higher fever in the evening, with greater depression towards morning ; more exhausting sweats at night, with the occurrence of diarrhoea, and aphtha? in the mouth. The sweats and diarrhoea are called colliquative in consequence of the rapid emaciation and exhaustion by which they are accompanied. Chronic Inflammation. Of all the various forms which the inflammatory process is liable to assume, the most common is that known as chronic inflammation, in which the condi- tion tends to persist indefinitely, for the main reason that the object for which the increased nutritive effort has been undertaken has proved to be unattain- able. The dominant idea, which will explain most of the phenomena pecu- liar to this condition, is the non-fulfilment of a jnirjiose. In chronic inflammation, all the cardinal symptoms may be present, but in a limited degree, the causes on which they depend being very much dimin- ished in their intensity; fain is comparatively slight — it may be entirely absent, or intermittent, or possibly represented by itching ; heat is generally recognizable, but is not a prominent symptom ; redness is represented by a dull tint, sometimes livid, in consequence of passive hyperemia from stretch- ing of the vessels by previous over-distension and existing diminished activity of the circulation ; swelling, the most important of the four, takes the form of induration, because the exudation has had time to become organized into tissue : hence the hard embankment around an indolent ulcer, and the almost cartilaginous hardness surrounding an old sinus — a fistula in ano, for example. In the latter affection, which affords perhaps the best, because the most familiar, surgical illustration of chronic inflammation, an abscess has been prevented from healing by too much motion in its immediate neighborhood. Its walls have shrunken, but have failed to unite, through lack of sufficiently prolonged quiet contact; a limited amount of inflammatory exudation is still furnished, a portion of which goes to build up the sheathing of cartilaginous hardness outside of the cylindrical tube which remains, and the rest of which furnishes the scanty supply of serous pus yielded by the internal walls of the sinus. These Avails are lined by what remains of the granulating surface of the origi nal abscess. The granulations are now scanty in number and irregular in size ; most of tbe surface is red and smooth, and, if closely examined, will be found, to the naked eye, to resemble mucous membrane. In fact, this close resemblance of the internal surface of an old sinus to a membrane, led to the impression, so long prevalent, that there was an especial membrane \ CHRONIC INFLAMMATION. 131 whose office it was to secrete pus. The name pyogenic, or " pus-begetting," which was applied to this supposed membrane, is still in use in this sense ; but the means of closer scrutiny now at our command have demonstrated clearly that no such membrane actually exists. The surface to which the name was applied is simply granulation tissue, in a passive condition of sus- pended development, awaiting its opportunity of final growth into tissue of cicatrix. This is confirmed by what follows when such a sinus is laid open by the knife. Under these circumstances, the stimulus of injury starts the construc- tive effort anew ; the chronic inflammation is replaced by a renewed afflux of blood ; a fresh exudation of better quality is furnished ; and the old surface of granulation tissue sprouts afresh in the effort at cicatrization. The condition known as induration is one of the characteristic features of chronic inflammation. It is very familiar to us as a consequence of certain in- flammations of internal organs, as in consolidation of the lungs, and cirrhosis of the liver ; and it occurs constantly in surgical affections, notably around joints long diseased. Especially does induration take place where constructive, inflammation has been prevented from attaining its object in the healing of a breach of continuity. The nutritive material, brought for the purpose of aiding repair, remains unused in the form of new tissue growth, more or less organized, which collects around the capillary vessels furnishing the exuda- tion. It is new tissue formation intended for repair, but diverted from its object. This increase in the numerical elements of the connective substance imme- diately surrounding the capillary vessels, constitutes, in the term first em- ployed by Virchow, hyperplasia — a redundant tissue formation by elements which have been turned aside from their purpose. The use of this term serves to distinguish an increase in bulk caused by inflammatory induration, from hypertrophy, which is a purposive overgrowth of an organ generally provoked by its increased use ; the habitually increased functional activity soliciting constantly a larger supply of nutritive material. It is proper to notice that the new tissue growth which constitutes inflam- matory induration, is less perfectly organized than the more normal growth of cicatricial tissue ; hence induration may be removed by absorption, by atrophy, or by retrogressive changes, such as fatty degeneration. Thus, systematic pressure will cause the rapid disappearance of the embankment of induration surrounding a chronic ulcer of the leg. It is well known that all new formations are less enduring in quality of organization than the original tissues of the body. Thus cicatrices are notoriously liable to injury by pressure, as in a leg stump after an ampu- tation ; and under the influence of exhausting diseases they may even re- ulcerate, as^ in scurvy. But the substance of inflammatory induration ranks- still lower in the scale of textural vitality ; and this lack of quality is con- stantly taken advantage of by the surgeon in treating the consequences of inflammation. In laying open old sinuses, the dense gristly character of the induration surrounding them may present itself as a discouraging feature as regards immediate cure ; but, if the operation be thoroughly~accomplished r the suspicious hardness of the " lardaceous tissue," as the French have called it, rnelts away with surprising promptness, and a soft bed of healthy granu- lation tissue succeeds. In a mucous membrane, the induration, which is as characteristic of its chronic inflammations as suppuration is of their acute stage, is effected by exudative infiltration into the meshes of the submucous connective tissue. In serous membranes, similar thickening from induration occurs, but is less common. 132 INFLAMMATION. Catarrhal Inflammations. The group of inflammations called catarrhal, constitutes a variety presenting certain well-marked features. They occur in mucous membranes only, and, as the term catarrh implies, are characterized by increased discharge, as a cardinal symptom. Rarely acute, except when excited directly by trau- matism, poisonous contact, or the influence of chilling, the catarrhal inflam- mations belong, therefore, to the chronic class, and, with the exceptions just noted, are chronic from the first, both as regards mildness of symptoms and tendency to indefinite continuance. Some of the causes of chronic catarrh are exposure to habitual contact of irritating substances, as, in the case of the air-passages, to dust, to very cold or very warm air, or to sudden alterations of temperature ; in the case of the urinary passages, to concentrated or exceptionally irritating urine ; in the female passages, to acrid uterine discharges, aided by obstruction to circula- tion from the varying volume of the uterus. Certain constitutional and meteorological causes contribute strongly to the production of chronic catarrhal inflammation, e.g., the peculiar irritability of membranes that belongs to the gouty diathesis ; the relaxed condition and slowness to take on a healthy state after injury that occurs so constantly in the scrofulous ; and sudden or frequent changes of temperature. The discharge in catarrh consists of an increase in the normal secretion of the part by the addition of more or less inflammatory exudation. It con- tains also an increased number of cellular elements, besides the occasional mucous corpuscles and exfoliating epithelium usually present, in the shape of leucocytes and young epithelium. When the proportion of leucocytes is large, the discharge puts on the aspect of pus. Under these circumstances the grade of the inflammation more nearly approaches the acute form ; exfoliation of epithelium is more complete ; and the exudation from the sub-epithelial surfaces partakes more of the character of true inflammatory effusion. This exudation tends also to infiltrate the sub-epithelial connective layer surrounding the capillaries, with leucocytes, and thickening of the membrane follows as a consequence of their germination and development. As to the changes which take place in the epithelium lining the follicles of an inflamed mucous membrane, histologists are not fully agreed. These little mucous glands often enlarge and become more prominent. As in follicular pharyngitis, their secretion fails to lubricate the gullet, and there are dryness and pain ; or, as in urethritis, a little submucous abscess may form ; or there may be ulceration from obstruction of the follicular outlet ; but the latter is rare except in tuberculosis or epithelioma, or where there is coexisting disease of periosteum of bone, as in syphilitic ozsena. The nature of the discharge in chronic catarrh is liable, therefore, to vary with the grade of the inflammation, the constitution of the individual, and the locality in which it is developed, as well as with the nature of its excit- ing cause. In regard to the latter, it is of the first importance to form a correct opinion. This is to be done by careful and thorough inspection of the affected surface, as far as possible, and by close scrutiny of the discharge as to its physical character, and especially its anatomical elements. It is not rare for u chronic discharge of the ear to be kept up by the presence of a foreign body; and this is also occasionally true of nasal catarrh. The odor of the discharge in the ozsena or scrofulous nasal catarrh of early life, is so peculiar as to be diagnostic ; its vulgar name in France is taken from that of the bedbug. The odor exhaled by the nasal secretions of syphilis, even where no dead bone is present, is often very characteristic. As already INFLAMMATION IN THE SCROFULOUS. 133 mentioned, the chemical decomposition of pus, in catarrh of the bladder, by the reaction of the ammonia of the retained urine, produces a gelatinous mass that usually passes for mucus, and its resemblance to the nasal mucus in an ordinary cold undoubtedly suggested this popular name for cystitis. In conclusion, the general significance of chronic catarrhal inflammation is explained when we recognize that some constantly acting cause is produc- ing an injurious effect upon an exposed mucous membrane; and the theory of its cure is mainly based upon the removal of this cause. Inflammation in the Scrofulous. The scrofulous catarrh of early life has just been mentioned as presenting peculiar characteristics. In truth, all the manifestations of inflammation in persons of the scrofulous diathesis present features so marked and character- istic, and differing in so many particulars from their ordinary aspect, that it is proper to study inflammation in the scrofulous as presenting one of the most important varieties of the process. This constitutional diathesis has been always recognized, and its signs are so well known that it is useless to dwell on them. !Nor is it necessary here to discuss the facts which seem to justify a belief in the infective properties of tubercle, and to differentiate it from scrofula as its sole source of origin. It certainly finds a more congenial soil in the scrofulous. The influence of the latter diathesis upon the series of vascular and textural changes following injury, principally concerns us, and, after stating categorically the several modes in which this influence is manifested, we shall endeavor to reach the safest basis for treatment of inflammation in the scrofulous. It is in early life that the characteristics of scrofula are most apparent. They are seen in the tendency to enlargement of the lymphatic glands, and in the proclivity to certain forms of skin eruption, and to disease of the joints and bones. The effort required for growth and development at this period of life, seems to overtax the defective vital powers of those who inherit or acquire the diathesis. The lack of vital power manifests itself primarily in the quality of the blood, and consequently in the want of vigor and effectiveness in the nutritive machinery, and in the defective quality of the tissues and organs just indicated, but especially in the vascular tissue. There is apparently less want of power in growth, than in development ; and this is shown mainly in this lack of textural quality. A scrofulous child grows finely for several years, and then, without any adequate cause, is overtaken by meningitis, or by disease of the vertebne. The same peculiarity in textural development is manifest in the repair of injuries in the scrofulous. In the process of con- structive inflammation, cell production and germination are prompt and pro- fuse, but the subsequent development of the cells into healthy tissue for complete and perfect repair is liable to fail. Thus a sprained ankle which, in a growing girl of healthy constitution, would get well certainly in two or three weeks, in a scrofulous child may fail entirely to recover, and may become the starting point of chronic disease of the joint. It is defect in vital quality and power in the vascular tissue that ex- plains such results as this, which are not uncommon in the scrofulous. Capil- lary vessels are not formed rapidly enough in the organizing granulation tissue to furnish a sufficient supply of blood ; hence its constituent cells cease to develop ; they linger in an overgrown but unnatural attitude, constituting the material that gives its name and its fusiform shape to that form of white swelling known as gelatiniform degeneration. The want of an adequate blood-supply leads to other changes in the growing cells : they undergo fatty 184 INFLAMMATION. degeneration, and become transformed into a yellowish material with the appearance and consistence of soft cheese. This material has heretofore been regarded as tubercle ; but it is now rendered exceedingly probable that it is, in the majority of cases, nothing more than a result of degeneration of the constructive materials contributed for a reparative purpose in the normal course of the inflammatory effort, but not sufficiently supplied with blood to secure their development into tissue. The real nature of the true tubercular deposit is not yet certainly deter- mined ; but there seems to be evidence that it is generated more readily and with greater frequency in the scrofulous, although by no means necessarily, or invariably ; and that, when thus generated, it tends to produce more rapid and mischievous results. Histology teaches at present, mainly on the autho- rity of Rindneisch, that in the inflammatory process in the scrofulous, the exu- dation cells are unusually large ; that the white blood corpuscles, after escaping through the walls of the capillaries, take on ampler proportions than in healthy subjects. It is asserted that, in consequence of their size, their ab- sorption by the lymphatics is rendered more difficult, as they cannot enter these vessels ; and that this circumstance explains the slow disappearance of inflammatory induration in the scrofulous. Whether this be true or not, it has become sufficiently apparent why constructive inflammation is more slow and imperfect in its results in the individuals of this diathesis; and, also, that their tissues possess less power to resist destruction and waste in the way of suppuration ; and that inflammation in them has a greater tendency, under all circumstances, to take on the chronic character. In consequence of the difficulty and delay that attend tissue formation, it is not easy to bring a suppurating surface to the point of cicatrization. The granulations are usually pale, flabby, and scanty ; and they bear gently stimu- lating applications with advantage. Hence the benefit derived from the injec- tion of alcohol in the dermic abscesses of children. Hence, also, as regards the whole organism, with its equivalent defective qualities, comes the benefit derived from the purer air of the country, the more concentrated forms of food such as cod-liver oil and malt, and the drugs which increase the quan- tity of the nutritious constituents of the blood, such as iron and the hypo- phosphites. Inflammation in the Syphilitic. The permanent change impressed upon the blood, and consequently upon the whole organism, by the presence in it of the peculiar virus or poison of syphilis, is justly regarded as equivalent to a diathesis. Although the pro- cess of repair of injuries is usually effected in a normal manner in the syphi- litic, yet some uncertainty is always present as to the possible occurrence of irregular symptoms due to the presence of the poison in the system. A higher law, so to speak, seems to prevail in certain systemic diseases, which confers a paramount power upon the directly nutritive function as regards its con- structive manifestations. A patient suffering from cancer, is more liable, in some phases of the disease, to fracture of bone. This accident has occurred from simply changing the position of a patient in bed; and yet union of the fracture lias followed in the usual time. Most of the manifestations of syphilis are inflammatory in their character. There is a tendency to local hypereemia or congestion, and also to exudation, provoked by the irritating quality of the poison present in the blood, and, also, to cell germination, and, in a vague, purposeless ^'ay, to the formation of fibroid tissue. These manifestations have the peculiarity of occurring in TERMINATIONS OF INFLAMMATION. 135 limited areas or spots, as in the papular or so-called tubercular eruptions of syphilis. Nodes, and the characteristic gummatous tumors which appear late in the disease, are results of the same tendency to new growth of a peculiar inflammatory character. In the latter, there is evidence of inability to sus- tain constructive action, as shown in a tendency to central softening and sub- sequent absorption, after which a depressed cicatrix is left; or, to suppuration and ulceration — the latter often extending in such a way as to show that the poisoned blood has produced in the tissues a defective vitality; a weakness,, and an inability to resist progressive destruction. The most interesting feature of the syphilitic inflammations is that in most instances they are promptly controlled by certain drugs — mercury and iodine — which possess a remarkable power as antidotes to the poison upon the pre- sence of which in the organism the disease depends. Terminations of Inflammation. The object and end of the local disturbance of nutrition which we call in- flammation, is the repair of injury, or the removal from the organism of locally injurious influences. In the accomplishment of this end, and, indeed, when it fails in its accomplishment, there are certain incidents liable to occur during the process, which surgical writers have added to the simple facts of its result in success or failure, and described, technically, as terminations of inflammation. Thus, besides simple subsidence and disappearance of symp- toms (resolution), and absolute failure (gangrene), pus formation and ulceration have both been added to the category of "terminations ;" and, by some, indu- ration and chronic inflammation are also included. According to our present view of the subject, there are but three ways in which the inflammatory process may be correctly said to terminate : — (1) By resolution, in which all the inflammatory symptoms, which may have been provoked, gradually lose their intensity and disappear; the affected parts resuming, as far as possible, their normal condition. This termination takes place, as a rule, where the injury has not been severe in its character, and the progress of the inflammation proportionally mild, that is, confined to its constructive phase. (2) By formation of new tissue. In the repair of injury, the production of a new growth of tissue is the main resource by which this object is attained by inflammation. In the simplest form of union, by primary adhesion, as well as in a breach of continuity attended by loss of substance, where a mass of granulations is organized into a cicatrix, formation of new tissue is the all-important feature, as well as the final result, of the inflammatory process. It is for this purpose that inflamed parts tend to revert, at once, to their em- bryonic state as the first stage of organization and development. The forma- tion of new tissue, therefore, is properly recognized as a termination of in- flammation. (3) By gangrene, or local death. This termination conveys the idea that an inflammatory effort to repair an injury has failed in its purpose, and that the injured part has died. The local death results from the ineffectual working of the nutritive machinery in the constructive attempt: ineffectual, because the injury has involved the capillaries and the connective tissue surrounding them to such an extent as to impede their functions and to render the injury irreparable by the resources of the organism ; or because obstacles have arisen at a later period wdiich have thwarted the reparative effort, and left the injured parts to die. 136 INFLAMMATION. There are points which may be profitably noticed in connection with each of these terminations of inflammation. Resolution. — In resolution, the exudation which nas caused the swelling undergoes absorption by the agency of the lymphatics. Its more serous por- tions are absorbed directly and rapidly. The same is true of the leucocytes and wandering cells, which are said to find their way readily into the lym- phatics, but the process may be somewhat slower. Rindfleisch's opinion has already been noticed, that the exudation cells in scrofulous inflammations are often exceptions to this method of absorption, in consequence of their larger size. Under some circumstances the exudative products, when partially de- veloped, undergo liquefaction, or degeneration, and subsequent absorption. Although in the process of resolution inflamed parts are said to return to their normal condition, this is not absolutely true under all circumstances. The changes impressed upon the vessels and nerves by the excessive nutritive effort, leave traces of their effects in what is called "weakness" of the parts. The evidence of this weakness is recognizable in certain modifications of sen- sibility, e.g., increased liability to pain ; a deeper discoloration of the surface under circumstances which invite it, as in a warm bath, through passive con- gestion of the capillaries which have been overstretched ; and proneness to take on inflammatory action without sufficient cause. Tissue Production. — The occurrence of tissue production as a final purpose or termination of inflammation, which is recognized by all recent authorities, is a culminating proof of the original reparative intention of the process. Whether in union by primary adhesion, in the process of healing under a scab, in subcutaneous consolidation, in the secondary adhesion of granulations, or in the accomplishment of cicatrization after protracted suppuration, tissue production is, in all, the medium by which the final purpose of repairing in- juries is achieved. In primary union, the increased nutritive effort may be scarcely recogniz- able by the presence of any of the symptoms of inflammation, and its result may be a barely perceptible linear cicatrix, and yet this result has been brought about by tissue production. Newly developed capillary loops are passing across the chasm through a delicate layer of granulation tissue, just organized. All the earlier phenomena of the inflammatory process : increased rapidity of capillary circulation, dilatation — afflux, in short — and exudation, have this end in view. This becomes apparent if we study these phenomena in the variations they present in inflammation as seen in the several original tissues of the body, varieties due to the different ways in which their nutritive blood- supply is accomplished, mainly as regards the size and peculiar arrangement of capillary vessels. Thus, the process as it occurs in bone explains the rea- son of its exceeding slowness, and, at the same time, illustrates the unerring tendency to reversion to the embryonic condition in order to reach the result of tissue production. The Haversian canals of the bony tissue enlarge by absorption of their walls, in order that sufficient vascular distension may take place under the influence of the afflux, to secure exudation. Stimulated by the exudation, as soon as it has taken place, the adjacent cells begin to germinate, and thus absorption of bone goes on until it becomes replaced by embryonic or granulation tissue, in which, in due time, the earthy salts are deposited, and the formation of callus accomplished. In case of an obstacle to its accomplishment, the conversion of bone into embryonic tissue goes on in a purposeless way, a collection of pus takes place, or the process lapses into a chronic stage, constituting caries, or chronic osteitis. In a similar manner, but more rapidly, the peculiar substance of muscle, tendon, or even of nerve, TERMINATIONS OF INFLAMMATION. 137 is reproduced by the process of constructive inflammation. Surgical expe- rience furnishes evidence, in restoration of function, of the fact of reproduc- tion ; but of the mechanism by which it is brought about in the more com- plex tissues, the nerves for example, we are not yet fully informed. The most common example of tissue production, for obvious reasons, takes the form of connective tissue ; and this occurs primarily, replacing the more complex tissues, as in the case of bone, muscle, and nerve substance, until more perfect reproduction, requiring additional time, can be elaborated. When this latter result is not attainable, parts are permanently replaced by connective tissue, as in most instances in which muscular fibres have been cut across in a wound, and in fibrous anchylosis of a joint. Where obstacles exist by which reparative tissue production is hindered, the nutritive materials furnished for new growth are wasted, as pus ; the main end or purpose of the constructive inflammation being held in abeyance, awaiting, as it would seem, a more favorable opportunity. But suppuration, occurring under the circumstances just described, or, in fact, under any circumstances, is in no sense a termination of inflammation ; it is simply an incident — in many cases an accident — of the process, as we have shown alread} 7 . In the same sense ulceration is incidental to the sup- purative process, and not correctly called a termination of inflammation. It is an incident analogous to the absorption of the walls of the vascular canals in bone, acting solely in furtherance of the general process. When inflammation, having been acute, subsides into a subacute or chronic stage, it is obviously not proper to speak of it as having terminated in chronic inflammation. The inflammation, in fact, has not terminated ; it has merely lapsed into another phase, in which, in most instances, it is awaiting the final achievement of a purpose which has been obstructed and delayed" In this view it is also obvious that the accumulation of nutritive material in the form of induration cannot be admitted as a termination of inflammation. The hyperplastic formation is simply nutritive material diverted from its original purpose. Gangrene, as a termination of inflammation, depends essentially upon the amount and nature of the injury, and especially upon the degree in which the capillary and larger nutrient vessels are unfitted for carrying on the local circulation. When the vitality of the vessels is seriously impaired, stasis and thrombosis may occur, and the capillaries may be prevented from carry- ing on their functions as they do under circumstances of less grave injury ; consequently, local death becomes imminent. If actual death takes place in a limited area by this mechanism, the presence of the dead tissue, offering an additional obstacle to the local circulation, and additional provocation to afflux for its elimination, tends to favor the extension of the area of dying and dead tissues, and in this way spreading gangrene is explained. Thus the afflux of blood to repair injury becomes, by its obstructive influence upon the damaged vessels, in reality an additional cause of textural death ; and in this sense parts may be said to be killed by gangrene. This premature termina- tion of the reparative eftbrt in local death, as in gangrene from other causes than inflammation, is due, therefore, to an obviously material cause, namely, an inadequate blood-supply. The local action of poisons upon the tissues, especially upon the capillaries, may impair their vitality in a remarkable degree. This is illustrated by the well-known experiment of Ryneck, who injected the bloodvessels of a" frog with a solution of chromic acid, destroying their power of reacting: under ordinary stimuli. The singularly rapid serous exudation that follows in 138 INFLAMMATION. some cases the sting of a wasp or a hornet, or the bite of a venomous snake, is probably clue to this cause. The recognition of gangrene may be for the moment a matter of doubt ; within a day or two after a serious fracture of the leg, the coincidence of a livid color of the surface, from the ecchymosis of contusion, with large vesi- cations — a not unfrequent occurrence — is very suggestive of this condition. Similar bulla? containing bloody serum often form in erysipelas, and the black patches which they leave on drying have been mistaken for spots of commencing gangrene. But the sensibility elicited by the prick of a needle, and the absence of odor, will decide the question. It has been truly said that the earliest symptoms of gangrene are usually those of intense inflam- mation ; the swelling is hard, the pain burning and tensive, and the color livid. The pain then subsides, vesications make their appearance, and the parts put on a marbled purplish-yellow tint which afterwards becomes brown or grayish. Finally they become cold and insensible, and exhale a putrid odor. Treatment of Inflammation. The treatment of inflammation, an account of which will close this article, is necessarily derived, as far as it is logically consistent with inductive reasoning, from facts and considerations concerning the nature and causes of the process, such as those which have been somewhat imperfectly passed in review. But much that is most valuable in the practical management of inflammation, is derived from clinical observation and experience, and not from reasoning ; and it is, therefore, empirical. The mode of action of some of the remedial measures which have been found most effective in practice, cannot be satisfactorily explained, in consequence of our imperfect knowledge. In the practical treatment of inflammation, the surgeon is, therefore, com- pelled to adopt an attitude of intelligent empiricism. He follows the course which has seemed to be the best, without rejecting what he cannot explain, relying upon the steady growth of more accurate and precise knowledge to throw light upon the mofjius operandi of some of his best remedies. In the preceding pages much space has been given to the causes of inflam- mation, in the belief that their study offers the best illustration of its nature ; and it has been assumed that this course would lead at the same time to an intelligent comprehension of the rational principles of treatment. One fact has been rendered apparent by the study of inflammation from this point of view, namely, that it is the normal tendency of inflamed parts to return to a condition of health as soon as the causes which produced the inflammation have been removed. In all that belongs to this department of the subject, this important fact, which lies at the foundation of all treatment, is to be kept constantly in view. It is at once obvious that a large share of our ability to control the mani- festations of inflammation', comes from the knowledge by which we are enabled to foresee and avoid the action of causes, both predisposing and exciting, which clinical experience 1ms shown to be capable of provoking the inflam- matory condition. Thoughtful and intelligent prevention will, therefore, necessarily constitute an important share of the surgeon's duty in his rela- tions to inflammation, and it should receive our especial attention. The immunity from suppuration and the other manifestations of destructive in- flammation promised by thoroughly carrying out the antiseptic methods of treating wounds, which will be made the subject of a separate article, serves TREATMENT OF INFLAMMATION. 139 to illustrate the great and growing value of one of the forms of the preventive treatment of inflammation. Next in order, and second only to prevention in importance, is the detection and removal of the causes which have provoked inflammation and are keeping it up ; and here is a source of the great interest which attaches to the study of these causes. As examples of the importance of this indication for treat- ment, we may refer to the prompt improvement that follows the removal of a splinter which is keeping up a festering sore, of a foreign body in contact with the conjunctiva, of a stone from the bladder, of a nail from its inflamed matrix (as in onychia), or of a sequestrum of bone which has been keeping up the discharge from a sinus. Mr. Simon, who has so ably discussed this subject, remarks with great justice that " it is amongst the highest prob- lems of pathology to discover new groups of cases capable of being treated like the above by the simple removal of their respective causes. With the various dyscrasial inflammations, for instance, which are now treated exclu- sively from an empirical basis, and consequently often without success, how great an achievement it would be, if their immediate causes could be made as palpable as the mechanical causes just spoken of, and could, like them, be distinctly aimed at and destroyed 1 ." A third indication of paramount importance in the treatment of inflamma- tion, is to secure favorable conditions for the inception and progress of construc- tive inflammation, or repair. From this form of the inflammatory condition, which is absolutely necessary for the healing of wounds and injuries, every- thing is to be hoped. Its management requires all possible means for its pro- tection from interference, and for the promotion of its objective purpose — which is a termination by resolution, or cicatrization, coincident with healthy repair of the injury by which it has been provoked. Of these means the most important are : rest, as nearly perfect as possible, for the whole body, and especially for the injured part; quiescence for the mind, as far as it is attain- able; freedom from sources of external irritation — including protection of an external wound from the air; the best position for the injured part that can be secured — to promote relief from pain and equable local circulation; an equa- ble temperature and purity of air, with an adequate supply thereof. These and other means useful for the same end will be considered more at length hereafter. The proper temperature for an injured part is between 68° and 72° Fahren- heit. Frequent changes above or below these limits are incompatible with equability. For a healthy granulating wound, even a higher local tempera- ture is not undesirable. Embryonic development takes place normally, within the natural body, at blood heat. It may be inferred that cell germination and the development of granulation tissue, which are identical processes, would be favored by a similar temperature. In any event, sudden chilling of a gra* nulating surface should be scrupulously avoided. It has been known to pro- duce a fatal invasion of traumatic tetanus. 1 Addison tells us that in the arti- ficial incubation of the chick, the process is interrupted if the temperature falls below the normal standard of the female bird, which is higher than the human standard, namely 106° Fahr., and the vitality of the chick is endangered. This is not the place to enforce the necessity of an adequate supply of oxy- gen to secure the favorable progress of all processes involving unusual demands upon the powers of the organism, but the importance of\fhis condition for successful treatment of surgical injuries is constantly liable to be undervalued. • Agnew, ut supra. 140 INFLAMMATION. An ample air supply is a condition indispensable for health, and it is there- fore a duty incumbent upon those who have charge of the sick, to secure for them their still more urgent rights in this respect. The minimum supply for each patient in the ward of a hospital is two thousand cubic feet. The mor- tality in typhus fever has reached its lowest figure, even in the uncertain win- ter climate of this latitude, in patients treated under canvass, and in temporary wooden houses. The fourth and final indication for the treatment of inflammation includes all the means at our command for the mitigation and control of its manifesta- tions when excessive, or when threatening to become destructive ; and for their arrest when actually destructive. These comprise remedies competent to antagonize excessive manifestations, to repress their intensity, and to restrain them, if possible, within the limits of the constructive process. The means at our command for meeting the requirements of the third and fourth indications will be discussed under the following titles: rest and immobility >• position; cold; heat and moisture; compression; blood-letting ; drainage ; revulsion ; drugs ; diet and nursing. Prevention. — But foremost in order comes prevention. "We are to under- stand by the preventive treatment of inflammation, the employment of meas- ures which tend to favor the process of repair — that phase of the inflamma- tory process which we have called, after Samuels, constructive ; and, also, the means at our command to avert any excess, or to remedy any defect, of vascular action, which, besides defeating the reparative object of the process, would produce waste and destruction of tissue — constituting the phase of inflammation we have called destructive. The former is to be promoted ; the latter to be avoided, and, if possible, prevented. Happily, in the great majority of cases, both of these ends are to be attained by the same means. When we have secured complete primary adhesion in a recent wound, as a rule, all danger from inflammation is at an end. Keeping always in view the fact that inflammation is nothing more than an exaggerated, sometimes a perverted, effort on the part of the local nutri- tive apparatus to meet some emergency in which the integrity of the organ- ism is threatened, our first duty is to favor in every way the healthy per- formance of the all-important nutritive function. This is to be accomplished by providing pure air to breathe, plenty of sunlight, good food to eat, with proper attention to the conditions and surroundings by which the normal performance of all the functions is promoted. The constitutional peculiarities and acquired habits of life of an individual who has sustained a surgical injury should always be made the subject of careful inquiry; and the patient's habitual food and drink, and his hours of eating and of attending to the calls of nature, should be imitated as closely as circumstances will permit. He is to be regarded as a machine, and placed in all respects in the position, as to surroundings, in which the machinery will work to the best advantage. At the same time, the influence of the mind upon the healthy performance of the physical functions is to be kept in view; fear and anxiety are as far as possible to be dispelled ; and hope and confidence are to be in- spired. As Claude Bernard has shown, fear and apprehension of danger tend to depress the normal temperature of the body, which is kept up by the proper working of the nutritive machinery; whilst hope and happy antici- pations have ;i healthy stimulating effect. The next duty of the surgeon in preventing undue inflammation, is the avoidance, ;is far as circumstances will permit, of all possible causes of inter- ference with the process of normal repair, and especially of the causes liable TREATMENT OF INFLAMMATION. 141 to provoke unhealthy or excessive manifestations. The phenomena attending the reparative act, although forming a part of the process of inflammation, are to be recognized and favored ; not prevented. It is their excessive or perverted action which we have to guard against by our art. This subject will be more fully discussed hereafter. For the present, to avoid repetition, we may refer to the study of predisposing and exciting causes contained in the preceding pages, with the remark that the injurious action of certain amongst them is noticeably preventable. For example, if a patient is found to be under the influence of malaria, or if he is confined to a malarial locality, it would be eminently proper to place him under the prophylactic influence of quinine ; in other words, to make a few grains of quinine a part of his daily diet, If he be found to be syphilitic, according to the stage of the con- stitutional poisoning — whether active or passive — it would be a judicious course for the surgeon to avail himself of the tonic and blood-making prop- erties of iodine, or of minute doses of the bichloride of mercury. But of all the preventive measures within our reach for the purpose of avoiding unhealthy inflammation in the treatment of open wounds, the pre- cautions and means which constitute the antiseptic method of treating wounds have of late years grown into proportions of greatest magnitude. Judging from results alone, without attempting a decision as to the theory on which it is based, placing himself on the legitimate ground of intelligent empiricism, and following the plan which promises most benefit to his patient, the sur- feon of to-day is forced by the logic of facts to adopt the method of Lister, 'he cicatrization of open wounds without pus and without delay, as if they were subcutaneous, or healing under a scab — a result which can be com- manded with as much certainty as attends any human enterprise, if the details of the antiseptic method are scrupulously observed — constitutes one of these facts. Another is the greatly diminished frequency, if not the entire absence, of the infective forms of inflammation and fever in surgical cases treated by the antiseptic method when it has been conscientiously carried out from the inception of the case. But it is to be remarked that in the doubt- ing allegiance of many, and their consequently feeble adhesion to the new method, and the carelessness as to details that comes from want of full faith, from prejudgment of the question, greater attachment to old methods, or un- willingness to learn new and troublesome details, there are impediments which interfere with its adoption. This will be arrived at ultimately, it is not un- likely, as a consequence of the greater material success, in the aggregate, of those surgeons who practise the antiseptic method in all its details, and pos- sibly by improvement in those details. Meanwhile, antiseptics are gradually taking the place of antiphlogistics ; the latter cease to be thought of in^ pro- portion as the former grow in the confidence of the profession ; and the opinion is, on the whole, steadily gaining ground that antiseptics constitute the best preventive measures against unhealthy inflammation. Popular experience is not an unfair test of the value of local remedies in preventing inflammatory complications. When surgery was as yet unworthy to be called a science, the favorite applications to wounds were spirituous tinctures, balsamic substances, resins, and turpentines ; and they undoubtedly owed their popularity as vulneraries to their antiseptic qualities. One of them, with a reputation of several centuries, the "bamne du commandeur" praised by Ambrose Pare, known in England as "friar's balsam," in our country as " Turlington balsam," has a place in the IT. S. Pharmacopoeia as the compound tincture of benzoin. Many a fresh wound bound up with this vulnerary, which is still largely used in domestic practice, and afterwards left undisturbed through full confidence in its healing virtues, has got well without " inflammation getting into it." Basilicon ointment, ceratum resince, 142 INFLAMMATION. lias a popular reputation due to the same cause. Alcohol was a favorite dressing for wounds with Nelaton, and it has had enthusiastic advocates. It is claimed that it coagulates albuminoid substances and renders them impu- trescible, and at the same time " closes the smaller bloodvessels and arrests their power of absorption." It enjoys a large popularity in the form of Cologne water and its substitutes, and of " Pond's Extract." Spirit of cam- phor was the favorite lotion of the late Valentine Mott ; and the eau sedative of Raspail, consisting mainly of camphor and common salt dissolved in alcohol, is a universal panacea in France. Greasy applications exclude the air, and, when impregnated with an anti- septic balsam, form the bases of most ointments and salves used as dressings for wounds. The Peruvian ointment of the New York Hospital is one drachm of balsam of Peru to one ounce of simple cerate. Vaseline, which is antiseptic and entirely unalterable as regards rancidity, is gradually replacing other greasy applications. It is" noticeable as a feature of antiseptic dressings of all kinds, that they are associated with infrequency of wound dressing, mainly, it is to be pre- sumed, on account of lack of evidence as to the necessity for frequent inter- ference. • This circumstance alone, as conducing to quietude and equability of temperature, favors rapid and healthy healing ; and, other things being equal, that form of dressing which requires least frequent renewal is always to be preferred as a preventive of ill behavior of wounds through unhealthy inflammation. Addison quotes the case of a boy who fell into a caldron of boiling pitch. In removing his clothing, the sleeves adhered so closely that they were necessarily left on his arms. The boy ultimately recovered ; but the attendant expressed surprise that his arms had cicatrized more rapidly and perfectly than the other parts of the body which had enjoyed the benefit of his daily dressing. Apart from the question of antiseptics, there is abundant clinical evidence that the exclusion of air favors kindly healing and tends to avert suppuration in surface lesions of the body, such as abrasions, and especially burns. On a small scale, the popular use of court plaster is in point ; and the prompt application of an impermeable dressing of gum, with the addition of a little molasses to give it toughness, so long in use at the New York Hospital as a dressing for burns and scalds, has proved of great value. A mixture of col- lodion and castor oil is said to be employed in the same way at King's Col- lege Hospital, in London. Rest and Immobility. — The great advantages to an injured part of perfect rest and freedom from disturbance by movement of every kind, have already been enumerated in the remarks on motion as one of the mechanical exciting causes of inflammation. Their paramount importance in the treatment of inflammation, both preventive and curative, cannot be too strongly enforced, for tlie reason especially that it is being constantly undervalued, profession- ally rts well as popularly. The directions often given to a patient, in a per- functory way, 1<> keep an injured part quiet, should, in most cases be enforced by surgical appliances by which its motions are rendered impossible. A patient, however intelligent and docile, can rarely keep a part quiet unless its movements are physically restrained, or unless he is reminded to do so by the recurrence of pain on motion, and this always involves additional injury; in v'kw of this fact, the surgeon should not only advise, but enforce his advice. The lesson taught us by the ill behavior of trifling lesions of parts subjected 1m constant mobility, as, for example, the festering of an abrasion upon a knuckle, is entirely applicable to lesions of a graver character. TREATMENT OF INFLAMMATION. 143 Destructive inflammation is often provoked by inadvertent motion, as in the case of a laborer, or a mechanic, with a spreading inflammation of the forearm following a neglected hurt of the hand, which could have been cer- tainly prevented by timely precaution securing quietude and immobility. The average patient cannot understand that moving a wounded part can do it harm, as long as the motion does not give pain at the moment, It is as difficult for an open wound to granulate or cicatrize when continually sub- jected to motion, as for a rosebud to bloom whilst being carried in a button- hole. Similarly, a wrenched ligament after a sprain cannot promptly regain its integrity unless the part to which it belongs is rendered immovable ; nor can an inflamed eye get well whilst the organ is in constant use. Thus we must recognize it as an ultimate fact established by clinical experience, that too much motion is as certain to retard and pervert the process of repair, as it is to provoke and excite the destructive phases of the inflammatory process. The means at the command of the surgeon by which he can most readily enforce quietude and immobility of a part are, primarily, splints and band- ages, or strips of adhesive plaster. Even where confinement to bed might be thought sufficient, as in some forms of fracture, retentive appliances are generally indispensable. In the most firmly impacted fracture of the neck of the femur, it would be the best course to render the parts immovable. The so-called immovable apparatus, consisting of bandages hardened by gypsum, starch, dextrine, or the silicates, are easy of application, and useful for many lesions besides fracture. Billroth states that he has had a greater degree of success in the treatment of sprains since he adopted the use of the plaster of Paris bandage; and the value of the plaster jacket in disease of the vertebral processes and bodies has been demonstrated by Sayre. Carved wooden splints, and guttered splints of tin or wire, prepared felt, gutta-percha, or sole- leather, which can be moulded to the injured part, are available for lesions in the neighborhood of joints, where motion is especially to be guarded against. For smaller wounds, which are always liable, when neglected, to become sources of serious complication, strips of adhesive plaster, collodion, and even court-plaster, are of value. In wounds of the face where quick union is espe- cially desired, to prevent scars, the latter form of plaster, when free from coloring matter, is very useful ; also between minute sutures in plastic opera- tions on the face, collodion being applied over the ends of the strips, but not upon the wound itself. For securing rest by the relief of pain and consequent restlessness, which is often a source of additional injury after dressing a recent wound ; for every form of nervous excitability accompanying surgical lesions; and above all for traumatic delirium, which is an expression of the most intense form of nervous excitement — always excepting hysteria — opium in some form, as the typical anodyne, is invaluable. This drug is of such great importance as an adjuvant in the treatment of inflammation, through the possession of these qualities, that it has acquired a reputation as one of its indispensable remedies. This reputation is due, in the first place, to its power in controlling the symptom of pain, and in the next place, to its influence over muscular irritability and the prevention of twitching, spasm, and consequent injurious mobility at the seat of inflammation. By this latter quality its well-earned reputation in the treatment of peritonitis has been attained ; it not only arrests, for the time, the peristaltic squirming of the intestines, but slows the action of the diaphragm, thus favoring the adhesive results of inflammation, and averting fatal suppuration. Opium is in this manner eminently useful as a preventive of the destructive manifestations of the inflammatory process. Hence after dressing a surgical case, and having placed the injured part in the 144 INFLAMMATION. best position, the next step in treatment is to administer an anodyne, or to leave directions for its administration in case of pain or restlessness. As is the case with every favorite remedy, the power conferred by an ano- dyne of relieving mental distress, in most cases, as well as physical pain, is liable to be abused. An opiate should not be administered unless a distinct indication exists, for its use. In most cases it interferes with the functions of the stomach and intestines, and in conjunction with confinement to the horizontal position, so often indispensable after a surgical injury, its employ- ment begets a necessity for laxative medicine, and thus interferes with the important blood-making function, and increases the tendency to constitutional disturbance and fever. Moreover, the administration of an anodyne, espe- cially if its effect has been pleasant, often creates a desire on the part of the patient for its repetition when, perhaps, a sufficient indication is wanting. Thus, however much he may be tempted to exercise his power, the surgeon should be on his guard against the possibility of abusing it ; he has in trust what has been justly called one of the greatest gifts of God to man, and should be careful to bestow it wisely. Position. — The position of a part which has been the seat of an injury or a surgical operation, especially when seated in a limb, should always be con- sidered in reference to the avoidance of pain at the time, and of provocation to subsequent inflammation. In this regard there are several points to be noted: (1) a position should be selected which favors the venous or return circulation, so as to avoid the danger of passive hyperemia ; (2) muscular relaxation is to be secured — as far as possible — in order to guard against the involuntary spasmodic action liable to be provoked by muscular tension ; (3) if there is a wound, the position should be managed so as to favor the ready escape of all possible discharges ; and (4) the position should be, as far as pos- sible, agreeable to the patient's feelings. It is hardly necessary to add that undue manipulation or change of position is to be avoided, and where this is absolutely required, in a case of serious lesion involving much pain, as in a compound fracture, it is often the wiser plan to bring the patient carefully under the influence of an anesthetic before handling the part. The muscular relaxation secured by the anaesthetic, pre- vents spasmodic contractions which do harm by disturbing the relations of the fragments, and by possibly causing bleeding. And, moreover, when an anaesthetic acts kindly and without causing undue excitement or subsequent vomiting, it is a matter of clinical observation that there is less disposition to excessive vascular reaction after it has been employed. As after the admin- istration of opium, there seems to be less tendency to undue inflammatory ex- citement than where the same amount of violence has been inflicted upon a perfectly conscious and sensitive patient. Those who have had the experience of undressing and opening a recently closed wound in order to secure a bleed- ing artery, without the aid of chloroform or ether, can bear witness to the greater frequency of positive febrile reaction after such a double strain upon the power of endurance. Cold. — As a cause of inflammation, exposure to intense cold may literally freeze exposed parts, such as the nose, ears, or toes ; but if the temperature he very gradually elevated, and the suspended capillary circulation be restored, as by gentle friction with snow or ice-water, the parts may be brought back to a uormal or to a very slightly weakened condition. But if the temperature of I lie frozen parts be suddenly raised, as by entering a hot room or approach- ing a stove, they are liable to become intensely congested, livid, and possibly gangrenous ; or to remain in a condition of chronic inflammation, with a lia- TREATMENT OF INFLAMMATION. 145 bility to itcliing, vesication, and ulceration, as in chilblain. Tissues which have been frozen offer an analogy to tissues which have been poisoned, in respect of their weakened vitality and their tendency to take on a low degree of in- flammation readily and from slight causes. But this weakened condition may, under favorable circumstances, be recovered from entirely. Cold, in its effects upon the system at large, is distinctly tonic and "bracing," when it is not too severe or too much prolonged. In the latter case it acts as a powerful sedative to all the functions of life, producing an intense desire to sleep, and finally death, in stupor, by the arrest of function of the cells which generate nerve force, as in fatal collapse from shock of injury. Locally applied, cold — -judiciously regulated as to its degree and mode ot application — is regarded as a valuable means of diminishing the force of the circulation, and thereby of antagonizing a tendency to excessive vascular ex- citement in the earlier phases of inflammatory action. It acts not only as a local sedative, but, also, as an astringent. Cold is usually applied by covering the part with a cloth wrung out of iced water, or saturated with an evaporating lotion. The latter form of applica- tion was habitually employed before ice came into general use. As these applications tend to become soon dried by the heat of the body, if a part is to be kept steadily at a lower temperature, they must be renewed at short intervals. This demands attentive nursing, for frequent change of tempera- ture in a part, certainly in the early stage of inflammation, is harmful. These modes of applying cold are well replaced by systematic irrigation. If a vessel of iced-water be suspended above the part to be irrigated, and some strands of lamp wick be placed with one end at the bottom of the vessel and the other hanging over its side, the cold water can be made to drop steadily and continuously upon the cloth that covers the part. But a sheet of impermeable material must be placed beneath the part, so as to convey away the overflow, or the bedclothes will become saturated, and the patient's body possibly chilled. Cold with moisture, inopportunely brought to bear upon the organism, is a fertile cause of harm in many ways. A greater degree of cold, as a local ap- plication, may be secured when desirable by means of a caoutchouc bag, or bladder, filled with crushed ice and moulded to the part. Cold, applied locally, has always been regarded favorably and employed largely in the treatment of inflammation, and it certainly possesses power, and a certain degree of value ; but in practice its use is limited, because, as is evident, it involves trouble and care, and it is also undoubtedly capable of doing harm, if not employed with good judgment. In the first place, it is not well suited for open wounds ; for granulations, as we have seen, are aided in their germination, growth, and development, by a warm temperature. Where a wound has been closed with a view to primary adhesion, dry dress- ing suits better, in connection with the gentle and equable pressure by which this mode of union is promoted. Neither positive cold, nor the alternations of temperature incident to its employment as a dressing, are favorable to the process of adhesive inflammation. It is a mode of dressing very commonly employed, and often in a somewhat perfunctory way, but it may be questioned if the application of cold as a preventive of excessive vascular action to a wound just closed is the wisest course to pursue. Prevention is an excellent measure, but here it might possibly prove officious, as excessive action may not occur, and more really useful measures may be excluded by its use. Ab- solute quietude for the part — a stump after an amputation, for example — and an equable temperature, with gentle uniform pressure accompanied by anti- septic precautions, will more certainly second iSTature's efforts to bring about prompt union without complication, which is the result desired. Cold applications may, under some circumstances, prove positively injurious. vol. i. — 10 146 INFLAMMATION. The use of an ice bag, by producing excessive vascular contraction, has caused gangrene of the edges of a wound. It is to be observed, also, that after a cold application has been removed from a part, more or less vascular reaction always follows, in the way of afflux and increase of heat, Although the fact has not often been noticed, it is hard to believe that parts frozen by ether-spray , or freezing mixtures, to produce anaesthesia, are not more or less impaired in their vitality. On the other hand, the use of an ice-cap to the shaved head has a positive value in the cerebro-meningitis which so often complicates wounds of this region. Esmarch especially praises cold in injuries of joints as preventing and controlling intense vascular excitement. The use of crushed ice in a bladder, which can be moulded to the part, is a favorite remedy for inflamed hemor- rhoids in the early stage. In the excessive temperature of the body in fever, the cold bath and the cold pack are remedies of undoubted power in dimin- ishing the danger of fatal injury to vital organs from the overheated blood. Heat and Moisture. — Dry heat is well known for its efficiency in calming pain; and heat, with moisture, in the form of a poultice, constitutes, perhaps, the local remedy sanctioned by most general use for the relief of the pain and tensive heat of a local inflammation. Its soothing and relaxing effect upon the inflamed part is the reverse of the astringent, although sedative, action of cold. The latter finds the indication for its use in the very earliest evi- dences of excess in vascular action that succeed an injury, and here it con- stringes the capillaries of the inflaming part, and promotes a disposition to return to a normal condition — in other words, to a termination by resolution. On the other hand, the influence of moist heat upon the tissues of an inflam- ing part is distinctly relaxing, and, therefore, tends rather to promote exuda- tion, if not suppuration. This tendency of a poultice or warm fomentation to favor suppuration, is an article of popular belief, but there is no absolute certainty of its truth. Habitually, in practice, cold applications are aban- doned as soon as resolution seems unattainable, and poultices are substituted, on the assumption that suppuration is the next best result to be hoped for. At this juncture compression may be possibly introduced, tentatively, as an alternative, if the influence of the poultice in causing suppuration is feared. After this, if the pain continue, the use of the poultice is justified. Where pain is a prominent symptom, it is an excellent plan to sprinkle the surface of a poultice with laudanum, or to anoint the inflamed part, when the skin is unbroken, with the ointment of stramonium or any other narco- tic. In acute and painful inflammations of the testicle, the tobacco poultice has long been in use at the New York Hospital ; it is very effective in epi- didymitis. It is a common practice in France and Germany, sanctioned by the authority of Velpeau and Billroth, to cover an inflamed surface with mercurial ointment before applying a poultice. This is based on the wide- spread belief, founded upon its singular efficiency in syphilitic inflammations, that this drug has a certain power in mitigating the intensityof the inflam- matory act, and in rendering exudations more readily absorbable. There is no positive evidence that mercury possesses this power except in syphilis. The materials which have been found to possess the best qualities as poul- tices, aii' freshly ground flaxseed and slippery elm bark. The consistence of a poultice and its emollient and unirritating character render it capable of being moulded in contact with the irregularities of surface of open and granulating wounds. The addition of vaseline, or of boracic acid, or of a weak solution of carbolic acid, will prevent fermentation in the poultice, and counteract putrefaction in the wound. The liberal application of the balsam TREATMENT OF INFLAMMATION. 147 of Peru, which is a good antiseptic, to the surface of a contused wound before applying a poultice, is a favorite practice. Poultices have been criticized as uncleanly, particularly by Listen, who strongly advocated "water dressing" as a substitute. In its most common form, water dressing consists of a cloth saturated with water or an} T medi- cated solution, and then covered in by oiled silk or some impermeable tissue to prevent evaporation and drying. Water dressing is a very useful applica- tion for inflamed surfaces. When the latter are irregular, absorbent cotton may be applied more accurately in contact with them, and then saturated with fluid, medicated or otherwise, and covered in. A solution of boracic acid or biborate of sodium is an excellent medication. A bandage is more conveniently applied over a water dressing than over a poultice. The latter, however, has by no means lost its place in either professional or popular confidence. It is to be remarked that poultices are often continued unwisely long after the indications for their use have ceased. Their prolonged employment begets an unhealthy relaxation of the tissues thus subjected to too much maceration, by which the cuticle of neighboring sound integument is liable to become water-soaked and detached. In opten wounds thus injudiciously treated, granulations tend to become exuberant, pale, and flabby, and cicatri- zation may be indefinitely deferred. Under these circumstances a change to dry dressing with moderate compression is often followed by benefit. A very useful and beneficial mode of applying heat and moisture is by means of the local warm bath. In renewing dressings of open wounds of the extremities, it is constantly indicated. A tin vessel of proper size and shape to receive the forearm when the elbow is flexed, in which it may be subjected to prolonged immersion without inconvenience or fatigue on the part of the patient, who occupies a sitting position, is of great value ; for ex- ample, after incision and a first dressing by compression or poultice in spread- ing inflammation extending up the forearm from an injured hand, a local bath of an hour or two before the surgeon's visit will add greatly to the pa- tient's comfort and very much facilitate the subsequent dressing. Granula- tions have been found to form rapidly and grow well in a part submerged in tepid water ; and for restoring an unhealthy wound or ulcer to a health}' condition, there is no better resource than a prolonged bath rendered antisep- tic by carbolic acid or some other substance possessing similar properties. A thorough application of eight per cent, solution of chloride of zinc, followed by a prolonged local warm bath, has proved very effective in the disinfection of foul and unhealthy parts. As to the use of the general warm bath, its advisability must be determined by the condition and circumstances of the patient. Compression. — Compression, if applied evenly, continuously, and not too forcibly, is a very valuable agent in the treatment of many of the phases of the inflammatory condition. It is capable of acting beneficially in several different ways according to the stage of the process. In acute inflammation, we have undoubtedly the power, by the use of systematic compression, of restraining the tendency to over-distension of the enlarging capillaries, and of limiting the amount of exudation ; and in its chronic form, a wider range for application of the remedy, in promoting absorption. But the use of this power may be attended by pain, and no inconsiderable degree of danger. Of this we have clinical evidence in the cases recorded in which the testicle has sloughed after the application of strips of adhesive plaster to control acute epididymi- tis; and we may assume that instances in which this misfortune has occurred have been left unrecorded. This mode of treatment of inflammations of the 148 INFLAMMATION. testicle by strapping, was at one time largely in vogue, but it lias fallen greatly into disuse. The bad consequences which so often follow tight bandaging belong, also, to the category of ill effects which injudicious com- pression may cause. It is in the later phases of inflammation, that compression may be em- ployed with the greatest advantage. To aid resolution by increased support to the walls of vessels which have been over-distended, and are now tending to recontract ; to favor the absorption of liquid and solid materials which * have accumulated in the peri-vascular connective tissue by exudation ; and in this way to prevent, under many circumstances, the formation of pus by ex- pediting a return of the parts to a normal condition, are the results which may be accomplished by judicious compression. To keep healthy granulat- ing surfaces in contact so. as to secure their adhesion; to support and gently press together the walls of abscesses after evacuation, in view of a similar result ; and to restrain serous exudation in parts weakened by inflammation, are additional illustrations of its utility. But it is in chronic inflammation, and in facilitating the absorption of its products in the way of induration and accumulated neoplastic formation, that the employment of compression is, perhaps, most useful. An example of the benefit to be derived from systematic compression is afforded by the treat- ment of an indolent ulcer by strapping — after the method known as Bayn- ton's, at one time in great repute — by which the surrounding embankment of induration is effaced by absorption, and its obstructed circulation restored. Another is seen in the shrinking of glandular swellings which have resulted from chronic inflammation. The mechanism of the cure in these cases is explained, in part, by the restored action of the lymphatics effected by the removal of the pressure caused by the obstructive new formation. It may be remarked that the power of iodine applied locally over glandular swellings, in promoting absorption, although highly sanctioned, is probably exagge- rated, and notably inferior to that exercised by skilfully applied pressure. The remarkable effect of this drug in dissipating the gummatous .swellings of syphilis has acquired for it more reputation than it deserves, as regards swellings of a different nature. Compression, as employed in the treatment of inflammation, may be effected by different methods, each of which has its advantages. The ordinary roller bandage of undressed cotton-cloth is very useful in skilful hands, and applicable, extemporaneously, under man}' circumstances. By availing him- self of the elasticity of cotton-wool, and placing two or more layers of ordi- nary cotton-batting upon the part to be compressed, the surgeon may apply a bandage tightly over the cotton without fear of pausing any irregular con- striction ; and lie will also secure by this device the additional advantage of keeping the part at an uniform temperature. These are points of decided value, for an even soft elastic pressure, with warmth unvarying in degree, are most useful conditions in the treatment of inflammation. This method of dressing, with cotton, constitutes the "appareil ouati" of Alphonse Guerin, who has employed it largely at the Hotel Dieu, at Paris, claiming for if, when applied over recently closed wounds, absolute antiseptic properties. It is well known that air is deprived of all dust, and, therefore, <0p6s (red) and 7tt-k6$ (livid), " livid redness," or from ipv9p6{ and *sM.a, "red skin." But an objection to the last etymology is that the Greek word Ttiixa does not mean skin. Erysipelas may be defined as an acute, specific, and contagious fever, tend- ing usually towards a typhoid type, and characterized locally by a peculiar inflammation of the skin or mucous membranes. It may attack the same person more than once. History of Erysipelas. Erysipelas has been known from the earliest periods of medical history. Hippocrates gives a very particular account of it. 1 He relates that during a certain cold spring, many cases of erysipelas occurred with sore throat and loss of speech, adding that they were malignant and fatal. In many also, as from an accident, and sometimes even from a small wound, and especially in old persons, or if the wound were neglected, a great inflammation took place, and the erysipelas spread all over. In most instances, the inflammation ended in abscesses, and the flesh, tendons, and bones sloughed. It is particu- larly noticed that the discharge was not like pus, but a sort of putrefaction, or, as it would now be described, a sanious and ichorous discharge. When the scalp was attacked, Ave are told, the hair was apt to fall, and even the bones of the skull to exfoliate ; and, it is added, bad as these symptoms were, they involved less danger than when the disease was determined inwardly. In some cases, it is said, the whole arm might drop off, and the bones of the thigh, leg, and foot be laid bare; but the most formidable cases were those which involved the pubes and the genital organs. This author briefly states the case of a man who had erysipelas of tlie foot and leg, with phlyctense, 1 Epidemics, Book III. VOL. L— 11 ( 161 ) 162 ERYSIPELAS. and who became delirious and died on the second day ; and he points out the exceptional gravity of the disease when it invades the head. Under the name of cancer, Celsus 1 describes a rodent ulcer around which the skin may grow red and painful, which condition, he adds, the Greeks called tpvainiias, adding that not only does it attack wounds, but it may also arise idiopathi- cally, and that it becomes very dangerous when it affects the neck and head. From the time of Galen, accuracy of description was sacrificed to elaborate speculations concerning the nature of the disease, which, it was agreed, arose ' from a bilious humor that tended to escape from the skin where it occasioned the local phenomena of erysipelas. Behind the veil of this myth is discernible the idea that the disease is not to be regarded as a local affection merely. In accordance with such belief, which was doubtless sustained by, if it did not originate in, the frequent occurrence of bilious vomiting at the commencement of an attack of erysipelas, emetics and cholagogue purgatives were enjoined as appropriate remedies, and they continue to be used, but upon more rational grounds, at the present day. On the other hand, a recognition of the frequent topical course as well as origin of erysipelas, is just as clearly indicated by the mode of treating it which pre- vailed among the later Greeks and the Romans, by means of astringent and refrigerant applications. Caution, however, was strongly enjoined b} r them lest a too active or too prolonged treatment of this description should induce gangrene ; and Galen, as well as his successors, directed that when cooling (narcotic) herbs, vinegar, potter's clay, preparations of lead, verdigris, sulphur, alum, and other sedative astringents failed, and the parts grew livid, the skin should be incised and warm fomentations and poultices applied to it. The resulting ulcer, if one occurred, was to be dressed with honey or rose-oil rendered stimulant or astringent by the addition of wax, rosin, myrrh, etc. Nightshade, henbane, lettuce, horned poppy, opium, cicuta, and mandragora are also mentioned as proper dressings during the inflammatory stage of the disease. A poultice of bread-crumb with rose-oil, saffron, and opium, was applied in anal erysipelas. The Arabians omitted from their method of treat- ing erysipelas the more repressive topical agents of the Galenical school, but retained the cataplasms and other lenitive applications; they administered gentle cholagogues and laxatives, and, while favoring venesection in sthenic cases, and especially in erysipelas of the head, warned against the tendency to exhaustion characteristic of the disease. In this, however, they only followed Paulus .zEgineta, who, after describing " erysipelas of the brain," advised de- pletion from the ranine veins, and cooling applications to the scalp. Causes of Erysipelas. General Causes. — Whatever may be the specific cause of erysipelas, there is little doubt that certain external conditions favor its production, or at least its propagation. But care should betaken to distinguish between those which are essential, and those which are casual and contingent. It would be a waste of time to inquire into the greater or less susceptibility to the disease of per- sons of opposite sexes or different ages. Apart from the inherent vigor of certain persons as compared with others, there is no real difference to be noted, [ndeed, as far as individuals are concerned, the chief distinction relating to their liability to erysipelas depends upon whether they present or not some lesion of the skin, and whether or not they have breamed an atmosphere charged with effluvia from a source capable of generating the disease. The 1 Lib. v. cap. xxvi. sect. 31. CAUSES OF ERYSIPELAS. 163 character of those sources will be pointed out presently. Meanwhile it may be stated that the exposure to such effluvia of any wound, great or small, in- cised, lacerated or punctured, recent or chronic, healthy or unhealthy, suppu- rating or not, may be sufficient to admit the virus of the disease. And equally is it true that any mucous membrane similarly exposed to receive that virus, may become the channel of its introduction into the system. These facts must always be taken into account while studying the general influences which seem to determine more or less the prevalence of the disease. Thus it is often said that the total number of cases of erysipelas, and their proportionate mor- tality, are greater during the winter and spring months, or from October to March inclusively, than during the summer and autumn, or from April to September inclusively. But to infer from this statement that cold weather was a cause, predisposing or exciting, of the disease, would be unwarrantable; since it is perfectly intelligible that, if the disease were propagated by a mate- rial poison, it would be more prevalent and fatal in close rooms during the winter, than in well-ventilated summer wards or apartments. In point of fact, however, the rule is not absolute, and it has happened that epidemics which began in the winter, have reached their height only during the following summer. One of the worst epidemics of erysipelas on record prevailed at Paris in the summer of 1861. It is often remarked that erysipelas is apt to prevail or increase during cold and damp weather, and when the wind is easterly, and it has been charged that the habit of ventilating certain hospital wards in London, and elsewhere in the north of Europe, by opening the windows widely while the wind blew from the east, was frequently the means of producing and extending the dis- ease. That being chilled sometimes develops erysipelas, seems certain; and some persons have attributed to cold a direct and independent power of pro- ducing it, on the strength of such cases as the following: — A man subject to articular rheumatism was exposed to cold and wet, and after a chill was attacked with fever, and articular pains in a limb which presently became swollen, red, and covered with phlyctena? ; after a time the skin broke and discharged a large amount of sanious liquid, and then, as the patient was growing convalescent, he was attacked with erysipelas of the face, which ran its usual course. 1 In this case, it is not certain that cold was the only morbid cause to which the patient was exposed. Of the case reported by Mr. Beale, 2 in which a child three weeks old was, without known cause, attacked with phlegmonous ery- sipelas of the left leg and thigh, which speedily proved fatal, it can only be said that the cause was unknown. Certainly, in many cases, erysipelas of the face follows exposure to cold, and especially to cold winds ; but how far cold may be regarded as an essential cause, is uncertain. In like manner cached!*: conditions seem to favor the development of the disease, but probably only by lessening resistance to the morbid poison on which the disease more directly depends. It would seem that Bright's disease in a special manner consti- tutes such a predisposition, as appears in the -following instance related by Mr. Fergusson: — 3 A woman of intemperate habits, who had albuminous urine, pricked her thumb ; the wound soon grew painful and erysipelatous, and the inflammation in a phlegmonous form spread rapidly to the whole limb, terminating fatally about the ninth day. The difficulty of accounting for attacks of erysipelas is aptly illustrated by the remark of Mr. Callender^ made as lately as 1878, 4 that they sometimes 1 Denoyer, Archives Generates de Medecine, Dec. 1878, p. 719. 2 Lancet, March, 1800, p. 293. 3 Medical Times and Gazette, Aug. 1868, p. 211. St. Bartholomew's Hospital Reports, vol. xiv. p. 185. 164 ERYSIPELAS. seem " to grow out of the irritation caused by some acrid secretion by error allowed to remain in a wound." The term " acrid secretion" is familiar but indefinite, and is hardly to be accepted as correct in regard to any liquid at the moment of its secretion. But although any such liquid may become acrid by putrefaction, it is well known that no such change is necessary to produce even traumatic erysipelas, and to that alone the above remark applies. Neverthe- less, the proofs of the origin of many cases of erysipelas in the emanations of decomposing organic matter are conclusive. Of this statement some illustra- tions may here be given. Dr. Begbie published several cases of erysipelas, one of which was traceable to the emanations of decomposing vegetable mat- ter. 1 It is of interest in this instance to remark that the family attacked was from the country, and newly arrived in Edinburgh, while the other in- mates of the infected house had long been resident there, and had doubtless become seasoned to its poisonous atmosphere. Several years ago an English writer used this language: "There is now no more doubt that erysipelas is originated by sewer gas than that typhoid fever is more often than not due to impure water." 2 In numerous instances the prevalence of the disease has been proved to be coincident with the presence of choked drains, drains communicating with town sewers, or drains which had become permeable to fecal gases or liquids either by the corrosive action of their contents or by the gnawing of rats, while the subsidence of such local epidemics has coincided with a reformation of the existing defects in venti- lation, sewerage, and water supply. As an example of these agencies, the case of the Somerset County (England) Lunatic Asylum may be cited. Be- tween December and the following May , thirty-two cases of erysipelas occurred, of which four proved fatal, and, on investigation, it was found that none of the soil pipes were ventilated ; one of them had a communication with the main sewer; most of them were of lead, and several of these were eaten and riddled with holes ; and the main drain had, on one occasion, been blocked entirely to the extent of three or four yards. According to the same authority, in a large London hospital, pyaemia and erysipelas had prevailed to a deplo- rable extent, and, on examination, its means of ventilation were found to be very defective ; but as soon as the defects were corrected and the pressure removed from the traps of the closets and lavatories, no fresh cases occurred. In another instance, an epidemic of the disease was distinctly traced to the stopping up of a ventilation-pipe by a careless workman. The Sanitary Reports of England contain numerous instances which prove, like those just cited, that outbreaks of erysipelas, as well as of hospital gan- grene and of fevers, are, with scarcely an exception, connected with serious defects of drainage or ventilation, or with a lack of any provision for isolat- ing infection, or with some of these defects combined. Thus, at the Radcliffe Infirmary, where twenty-six persons affected with various diseases or injuries had been attacked with erysipelas, and five of them had died of the super- induced affection, the origin of the outbreak was undoubtedly owing to the imperfect arrangement of the drains, added to crowding, uncleanliness, and bnperfecl ventilation. At the Royal Infirmary, Manchester, recurring out- breaks of traumatic erysipelas had taken place, which were traced to the ex- cessively foul drainage and to the overcrowding of the house with patients and attendants. The water-closets, baths, ward offices, and drains of the infirmary were placed within the building, and several of the closets were without direct communication with the outer air, so that sewer gas escaping from them necessarily passed into the corridors and wards. Under such con- ' Monthly Journal of Medical Science, Sept. 18. r )2, p. 243. 2 London Sanitary Record, June, 1879, pp. 357, 37'J. CONTAGION OF ERYSIPELAS. 165 ditions, wounds do not heal but are apt to bo attacked with erysipelas or phagedsena ; the natural processes of cicatrization, by which a firm barrier is established between the lesion and the system, are interfered with ; the germs of disease and the products of putrefactive change are absorbed ; and erysipe- las and septicaemia ensue. Besides the sources of infection now described, others may be mentioned, of which the following are examples. In Middlesex Hospital, London, it was observed that the only patients attacked with erysipelas in a certain ward were those who occupied two adjacent beds. After long searching in vain for the cause of this peculiarity, it was discovered that the pipe of a water- closet which ran behind the plaster of the wall at this place, was defective. It was repaired and no more cases of erysipelas occurred at the time. But ten } T ears later, the same beds became again unhealthy with erysipelas, and the same remedy put an end to the disease. A perfectly similar case occurred in a Berlin hospital. 1 Again, in the hospital at Rostock, it was found that those patients only who had recently undergone surgical operations were attacked with erysipelas. After various fruitless researches the pillows of the operating tables which by long use had become saturated with blood, fell under suspicion, and were replaced by new ones, after which no more cases of the disease occurred. The soiled pillows were then treated with hot water, and an extract procured, with which two rabbits were inoculated. One escaped unharmed ; but the other was attacked with severe inflammation of the skin and connective tissue, which spread extensively and was accom- panied with blisters, gangrene, and fever, from which, however, the animal finally recovered. Contagion. — The origin of erysipelas which has been described, and its re- lations to puerperal fever to be noticed further on, would of themselves render the contagiousness of the disease probable. But direct clinical proof is also abundant that erysipelas itself is communicable by contagion. The case is well known, which is reported by Campbell, 2 of a hospital ward in which the disease travelled from bed to bed in regular succession ; but the following illustrations of the same import should be impressed upon the mind of every physician and surgeon. During an epidemic of " putrid sore-throat," which prevailed in Dublin after an absence of more than twenty years, a lady was attacked with sore-throat and fever, and in the course of a few days erysipelas appeared upon her face. Her son, a robust youth of eighteen, who helped to nurse her, got "a whiff of sickening air from her bed- clothes," and immediately suffered from headache and fever. On the fourth day he complained of pain in the shoulder, followed by swelling under the pectoral muscles, which increased, and on the tenth day this region was covered with erysipelas which spread over the trunk. Bulla? formed, succeeded by gangrene ; similar lesions affected the scrotum; and death took place on the fifteenth day. 3 In 1852, a man arrived in Platte County, Missouri, suffering from erysipelas of the face. He was nursed by a farmer who himself fell ill just as his patient was beginning to improve. A second farmer who assisted in nursing both of the other persons, and slept in the same bed with them, was seized with the disease, and subsequently six other persons who helped to nurse the former patients were themselves attacked. Be- sides these, no other cases occurred in the neighborhood.* Trousseau relates several instances of the contagiousness of the disease. In a cer- tain house, the person first attacked died, as did the nurse who waited on him, while 1 Berliner klin. Wochenschrift, 1868. 2 Zuelzer, Ziemssen's Handbucli, Bd. ii. S. 416. 3 Graves, Clinical Medicine, p. 576. 4 New York Journal of Medicine, vol. x. p. 41. 166 ERYSIPELAS. several members of the family who came into contact with those first affected experi- enced serious illness. A lady contracted the disease from her son, a young physician who had caught it from erysipelatous patients in a hospital. A gentleman, whose frae- num prasputii had been divided, died from gangrenous erysipelas ; shortly afterwards his wife, who had attended him assiduously, fell a victim to erysipelas of the throat and face, and the lady's maid suffered a similar attack, from which, however, she recovered. A gentleman received a gunshot wound of the foot followed by gangrenous and fatal erysipelas ; his brother, who nursed him, was attacked with erysipelas of the scalp which ended in 'his death on the eighth day; his daughter, a child of three years, had a slight burn of the hand which became erysipelatous ; the family laundress was affected with phlegmonous erysipelas of the right hand ; the sick-nurse had erysipelas of the face and head ; and a sister of charity, charged with the duty of irrigating the wounded foot, had a phlegmonous abscess of the right arm followed by several in other parts of the body, which sloughed, and finally caused the woman's death. Meanwhile, however, she had returned to her convent, where a number of the sisters were similarly affected, and two of them died. A hospital physician of Bordeaux admitted a patient with ophthalmia, placing him near one affected with phlyctenoid erysipelas; the former took the disease, and the physician, who had a slight excoriation of the lip, was also attacked. He was attended by his father, who was likewise a physician, and who con- tracted the disease and communicated it to his sister-in-law who came to visit him. Dr. Mackay, a British naval surgeon, testifies strongly to the contagious nature of erysipelas as it was exemplified on board a man-of-war. The ship itself after thorough inspection was pronounced exceptionally pure, and the only source of the disease as an epidemic, seemed to be a case of " erythema," in a cachectic, syphilitic sailor ; for, from his attack, and from contact with him, the subsequent cases appeared to take their rise. In several instances, the characteristic throat affection existed. The case has elsewhere been quoted, but is appropriate here, of a physician who, having bled a person suffering under erysipelas following a burn, bled a man with the same lancet, the operation being followed by erysipelas and phlebitis, and also a woman who was attacked with puerperal fever. 1 These cases all belong to a period of about a quarter of a century ago, and at that time the reality of the contagiousness of erysipelas was recognized by clinical observers; long, indeed, before it was admitted by scientific men, whose vision is sometimes more acute for abstract propositions than for the plain facts of experience. Thus the great surgeon, Velpeau, taught that erysipelas was not a simple inflammation of the skin, but the product of a special poison absorbed from without ; and several other leading physicians and surgeons in France held the same opinion. In a memoir addressed to the Academy of Medicine of Paris, in 1865, Blin cites the case of a young man who, after nursing in Paris a friend ill with erysipelas, returned to his village, where for a long time no case of the disease had occurred. Within a fortnight he died of it; then a servant who had nursed him was attacked, but recovered; a friend from a neighboring commune, which was free from the disease, came to visit the patient, after which he was attacked, and his wife also a little later. Four other persons who visited the last mentioned, took the disease, and the physician who attended them, his daughter, and the religious sister who nursed them, were all attacked, the physician fatally. In the report on Blin's memoir, Gosselin adverted to a number of analogous examples, and others were referred to in the discussion to which it gave rise. Nevertheless, the contagiousness of erysipelas was not frankly admitted, 2 and the reporter, Gosselin, in a later article on the disease, appears to be not thoroughly convinced of its contagiousnes -. ; In confirmation of the results of clinical observation which have now been brought forward to prove the contagiousness of erysipelas, it may be added 1 American Medical Times, April, 1863, p. 198. 2 Bulletin de L'AcadSmie, t. xxx. p. DO!). 3 Nouveau Dictionnaire de Mudeciue, etc. t. xiv. p. 40. SPECIFIC CAUSE OF ERYSIPELAS. 167 that Mr. Goodhart has collected a number of cases from hospital practice, 1 which show that erysipelas may be communicated to persons suffering from diseases of the urinary passages, by means of an infected catheter, and that the affection thus induced may be attended with its usual constitutional symptoms, with an erysipelatous eruption on various parts of the skin, and with serious and often fatal inflammation of the bladder and kidneys. Specific Cause of Erysipelas. — Of late there has been an evident leaning towards the adoption of the theory that erysipelas is produced by a specific virus. At all times, under one or another form, this doctrine has existed, and indeed it afforded the only rational explanation of the familiar fact that in- fectious and contagious diseases reproduce themselves under uniform types. Leuwenhoeck discovered bacteria nearly two hundred years ago, but it has required this long period to develop the existing doctrine which asserts that every one of such diseases depends direct]}' upon a specific, organic form. The growth of this theory has been retarded by that of Zymosis, which, although purely fanciful in its conception, acquired such authority as to have its name applied in an official nomenclature to the group of idiopathic febrile diseases.. But even if it were true, which it is not, that one and the same bacterium is uniformly found in connection with the same disease, the manner in which it occasions the specific phenomena of that disease, would thereby become no clearer. It has been suggested that each specific form of bacterium secretes a specific virus, which, in its turn, produces the specific, morbid type. But this is evidently an attempt to explain ignotum per ignotius. The present state of knowledge and opinion upon the subject, as far as relates to the disease we are engaged in studying, is perhaps expressed by Orth, whose elaborate ex- periments led him to the following conclusions: 2 — 1. Epidemic traumatie erysipelas is caused by a poison in the blood as well as in the secretions of the affected part. 2. These secretions are capable of producing erysipelas by inoculation. 3. Bacteria are generated pari passu with the development of erysipelas. 4. Bacteria stand intimately related to the septic cause of erysipelas, for its characteris- tic symptoms may be produced by artificially propagated bacteria. 5. But bacteria are only an indirect cause of the disease, since they are not formed abundantly in the blood of infected animals, and because they may be removed, without entirely destroying the activity of the infecting liquid. 6. Bacteria appear to belong to the microspheres and the schizomycetes. 7. It is probable that in different forms of the disease different micro-organisms occur,. but thus far no proof of this proposition exists. In 1879, Tillmanns, of Leipzic, performed some experiments on this sub- ject. Of twenty-five attempts to convey erysipelas by direct inoculation to healthy rabbits, a positive result was obtained in only five. In all the suc- cessful cases, the inoculated liquid contained bacteria, and the addition to it of a two to four per cent, carbolic acid solution rendered a previously active in- oculating fluid quite inert. But the presence of bacteria, either in the secre- tions or in the tissues themselves, is not a constant feature in erysipelas. It is thus probable that not every case of erysipelas is brought about by the migration of bacteria as such, and that the advance of the disease is not in all cases connected with the presence of these micro-organisms. 3 According to Koch, the distinctive micro-organism of erysipelas i&"a bacillus. 4 1 Guv's Hospital Reports, 3d s., vol. xix. p. 357. 2 Archiv f. experiment. Pathol, u. Pharm., Bd. i. S. 81. 3 Edinburgh Medical Journal, vol. xxv. p. 666. 4 Etiology of Traumatic Infective Diseases, New Sydenham Society's edition, 1S80, p. 57- 168 ERYSIPELAS. Whether the hypothetical, specific contagium produces the symptoms of erysipelas by a direct and primary action upon the blood and nervous system ; or whether it acts, first of all, upon the tissue that receives it, and only second- arily affects more distant organs ; or, finally, whether it may and does, accord- ing to circumstances, act in both of these ways, is still an open question, and is very likely to remain unsolved. Very probably the erysipelatous poison may enter the system, either by a lesion of the integument or through the mucous membrane of the fauces and respiratory organs, precisely as the viruses of smallpox, measles, and scarlatina find admission. The rapidity with which it infects the blood and the type of the resulting fever, will depend upon several conditions, of which the most influential is probably the inherent ac- tivity of the poison itself, and the next is the power of resistance possessed by the patient. The latter again will depend in part upon the conditions that surround the patient, including fresh air, proper temperature and food, fatigue, cleanliness, etc. The Causes of Erysipelas as illustrated by the History of Epidemic Outbreaks of the Disease. The histories of epidemics of erysipelas remove any doubts of the septic and constitutional nature of the disease that may be suggested by a partial study of it in isolated medical and surgical cases. Even in the medical records of the latter part of the eighteenth century, it was pointed out that erysipelas began in the throat ; and, although in some cases it appears to have been con- founded with diphtheria, no doubt remains that an erysipelatous angina asso- ciated with erysipelas of the skin prevailed epidemically in Great Britain between 1777 and 1800, and subsequently in 1821, as well as occasionally even as late as 1832. 1 Daude, 2 in his narrative of the epidemics of erysipelas that prevailed on the continent of Europe, refers to one that occurred in France in 1750, in which the symptoms were "difficult deglutition, hoarseness, swelling of the neck, and the other symptoms of quinsy," as well as to other epidemics of the disease in which pneumonia or diarrhoea existed as a complication. In almost every instance, the sore throat preceded the cutaneous inflammation, but some examples of the reverse order were met with. Daude describes the disease as presenting the following categories: (1) Cases of erysipelas com- mencing in the skin and extending to internal parts, including the organs of deglutition and respiration, the vagina, and the rectum ; (2) Cases beginning in the throat or the lungs, and thence spreading to the skin of the face, etc. ; (3) Cases beginning in the throat or other internal part, and not involving the skin. In the United States, epidemic erysipelas does not appear to have been ob- served until 1843 (a fact which of itself would demonstrate its specific origin), and it continued to prevail until the end of 1847. Another circumstance which also shows that it originated in some special, atmospheric cause, is that it prevailed within definite although extensive limits, which may roughly be indicated by the terms west and northwest of the Apalachian mountain range, and extending from Lake Champlain in the northeast, through the States ot New York, Michigan, Indiana, Missouri, Mississippi and Louisiana, while it was almost unknown in southern New York, eastern Pennsylvania, and the other Atlantic States. Almost the only exception to this statement is the occurrence of an epidemic of the disease at Bridgeport, Conn., in 1847. 3 In 1 Nunnely on Erysipelas. 2 Traite de l'erysipelo tpideniique. 3 Bennett, JN.evv yprjs: Journal of Medicine, July, 1853, p. 9. HISTORIES OF EPIDEMICS OF ERYSIPELAS. 169 the western and southwestern States, the name usually given to the affection was " Black tongue," which recalled one of its usual local symptoms, and suggested the distinctive type of the fever. On studying this epidemic in relation to the general subject of erysipelas, we find in the succession of its phenomena abundant evidence of its constitutional nature, and hence of that of other forms of erysipelas. For while, in some cases, the attack was ush- ered in by the simultaneous appearance of the throat affection and the general febrile phenomena, in many others the constitutional pyrexial disorder, even in an intense degree, preceded the anginose symptoms by one or more days, and even the glands of the neck swelled out of all proportion to the inflamma- tion of the throat. The latter usually preceded the erysipelatous inflammation of the skin, which, according to some authorities, occurred in about one-sixth of the cases ; but sometimes the opposite course was pursued, and, as has also been observed in Europe, the inflammation of the skin was primary and was seen to invade the throat by extension through the mouth or nostrils. The condition of the throat was as various as that of the skin is in the several forms of cutaneous erysipelas. Sometimes the inflammation was superficial, the part of a bright red color, and neither the mucous membrane in general nor its glands were much swollen ; but in other cases the fauces and the tongue were greatly swollen and purplish ; and in others, again, dark or ash- colored sloughs formed upon the roof of the mouth and the soft palate. " The tongue was apt to be very much swollen, assuming a blackish-brown color, and deglutition was almost impossible," says Sutton, in his description of the Indiana epidemic of 1843. " In most cases an erysipelas would commence at the angle of the mouth or nose, and spread over the face and head. The inflam- mation of the throat sometimes passed down the trachea and bronchia, into the nostrils, frontal sinuses, or antrum maxillare, buf usually the throat became well while the erysipelas was spreading over the skin." To these particulars it may be added that the sloughs above mentioned were apt to be preceded by bulla? or phlyctenre filled with a serous and sometimes a bloody liquid. All who have described this affection note the great elongation and flaccidity of the uvula, and the sometimes enormous swelling of the lymphatic glands of the neck. In not a few cases, stated at one-twelfth of the whole, diffuse inflammation affected the connective tissue in the axilla, or below the pectoral muscles, sometimes extending underneath the great muscles of the back and over the entire trunk, or to two or more limbs, dissecting out the muscles, and often terminating in gangrene, with a discharge or the artificial removal of long shreds of dead connective tissue resembling wet tow, such as will pre- sently be described as occurring in phlegmonous erysipelas of traumatic ori- gin. In many of these cases, anginose symptoms with fever preceded for days, or even weeks, the diffused cellular inflammation referred to. Accord- ing to the reporters of certain epidemics, the discharged liquid was so acrid "that the hardest steel was directly penetrated by it as by nitric acid." 1 In the most favorable cases, when a cure resulted, adhesions were apt to form between the denuded muscles and the skin, greatly and permanently restrict- ing the movements of the part. In the American as well as in the European epidemics, the internal compli- cations formed a very important element of the disease, not only by increasing its gravity, but also by illustrating its nature as a blood disease. One of the first of its American historians, Sutton, describes as accompanying the ery- sipelas, a typhoid pneumonia, which sometimes was associated with swelling of the axillary glands ; and he suggests that it might be regarded as a " pul- monic erysipelas." Ten years later this account was fully confirmed by Ben- 1 Hall and Dexter, American Journal of tlie Medical Sciences, Jan. 1844. 170 ERYSIPELAS. nett, who particularly noted the predominance of the subcrepitant over the crepitant rale, and who also described the hurried and labored respiration of the attack. By this writer and by many others, the complication of the dis- ease with inflammation of the serous membranes is much dwelt upon, espe- cially with that of the pleura, peritoneum, and cerebral meninges. They also allude to the pain of a neuralgic character accompanying the first-named affection. In a fatal case, complicated with pleurisy, the softness of the exu- dation and the presence of bloody serum are noted. Peritonitis, both in the puerperal and the non-puerperal state, was recognized as the most formidable expression, or complication, of epidemic erysipelas. In the latter, the patient was seized with pain in the abdomen, vomiting, and diarrhoea, followed by great frequency of pulse and fatal collapse ; and after death the peritoneum was seen to be dusky and injected, while its cavity contained a dark serum which presented occasional flakes of lymph, and exhaled a loathsome smell. The viscera were also darkly congested and softened. In the post-puerperal state the attack invariably commenced within forty-eight hours after delivery, with the same symptoms as in the non-puerperal cases, and, with rare excep- tions, terminated fatally. Having furnished this general sketch of epidemic erysipelas, it may prove instructive as well as interesting to present some examples of the associa- tion of the internal and external manifestations of the disease, which may serve to illustrate the essential unity of its various types. To show the growth of knowledge upon the subject, they will be presented in a nearly chronologi- cal order. As late as 1836, the nature of erysipelas was imperfectly recog- nized, and a teacher as acute as Latham endeavored to explain its various phases by representing the " disease" as at one time implicating the vascular, and at another time the nervous system. This ontological idea must, with our present light, be regarded as metaphorical, and as expressing nothing more than the fact common to all acute febrile diseases due to blood poison- ing, that their phenomena may, according to the nature and dose of the mor- bid poison, be either sthenic or typhoid. 1 In 1852, Blake 2 described the prevalence of erysipelas of the throat in California, was attended in some cases with fetid suppuration of the nostrils, in others with inflam- mation of the palpebral conjunctiva, or with a discharge of pus from the ears. In 1855, Todd 3 referred to a form of erysipelas beginning in and confined to the pha- rynx, in which, on inspection, there was little swelling observed, but rather a dusky hue of the mucous membrane, and a remarkable loss of reflex excitability. Deglutition was very difficult, and food was very apt to pass into the larynx, excite strangling, and be rejected through the nostrils. In the same communication 4 he states that it was probably of this affection that Nicholas, Emperor of Russia, died, the disease having been erro- neously stylctl " paralysis of the lungs." In 1856, Gubler went so far as to maintain that erysipelas of the face was usually a propagation of the disease from the pharynx, although it might pursue the opposite course ; and Trousseau, in a clinical lecture, took for his text a case in which the ery- sipelas was at first confined to the fauces and submaxillary glands, and only on the fourth day issued from the nostrils, and invaded the face and scalp, while it declined in the throat. 8 In 1 857, Forget reported a case of erysipelas of the face in which the patient hecame convalescent on the eighth day; but directly afterwards a large abscess formed over each parotid gland, and one of them discharged through the auditory canal, while the accompanying symptoms were in a high degree typhoidal. In 1858, Mr. Bird 7 drew particular attention to the frequency with which idiopathic 1 Compare Latham's Works, vol. ii. p. 460. 2 American Journal of the Medical Sciences, October. 1852, p. 60. ' Medical Times and Gazette, July, !K">. r », p. 28. ' Ibid p. 27. 5 Lectures on Clinical Medicine, Now Sydenham Society's edition, vol. ii. p. 251. '' Bulletin de The>apeutique, t. liii. p. 534. J Ranking'* Abstract, 1859. HISTORIES OF EPIDEMICS OF ERYSIPELAS. 171 erysipelas made its first appearance, now on the face, and now in the throat, subse- quently spreading from the one to the other part. lie drew attention to the erysipelas of the throat which takes its origin in the wound of tracheotomy. Indeed, in not less than sixty per cent, of the cases of idiopathic erysipelas of the face observed by this surgeon, a ditfused inflammation of the fauces occurred as a precursor ; while in trau- matic cases this local manifestation was rarely present. He very rationally suggested the reason of this difference in the following question : " Is it that the miasm in being inhaled into the lungs makes a direct impression on the throat, while in its entrance into the circulation by means of a wound this mode of contact is avoided ?" In 1859 and I860, Dr. Todd again 1 noted the passage of erysipelas between the fauces and the face, in certain cases the nearly simultaneous affection of both localities, and the tendency of the disease to cause oedema of the larynx. He also related a case of surgical erysipelas of the thigh, which was in process of improvement when the patient was attacked with severe dyspnoea with bronchial rales, and died asphyxiated. On examination, the lungs were found greatly congested and cedematous, and the bronchia choked with mucus. In 1861, Dechambre, describing the epidemic at Paris in the spring and summer of that year, 2 illustrated on a large scale the tendency of the disease to occupy the mu- cous membranes as well as the skin. Affecting the face, it caused an enormous swelling of the subcutaneous tissues, with phlyctenre, abscesses, and tumefaction of the lymphatic glands. Often the neck grew so thick and hard that the veins were compressed, and the mucous membrane of the mouth and fauces acquired a dull, purple color; the tongue was dry and rough ; deglutition was very difficult ; and delirium, violent at first, grew more tranquil as it passed into coma vigil, or absolute stupor, often ceasing entirely twelve or twenty-four hours before death. In a certain case the inflammation began in the throat and extended through both Eustachian tubes, producing the characteristic pains of internal otitis ; then appeared in the ears and spread upon the neck and face, advancing from both sides and meeting at the median line. In another case, the erysipelas started from the fauces, passed through the nostrils, and diffused itself upon the face. In 1863, a writer 3 pointed out the distinctive marks of erysipelatous pharyngitis as follows : A crimson color, with cedematous swelling extending rapidly from the uvula and tonsils to the mouth, posterior fauces, and pharynx, causing so much swelling of the latter as to impede or prevent deglutition, and of the opening of the larynx as to hinder respiration and to alter the voice or occasion aphonia. In 1865, Dr. John Ashhurst, Jr., 4 published the case of a man who entered the hospital for a simple fracture of the metacarpal bones. A fortnight later he was about to quit the hospital, when he was attacked with acute febrile symptoms and consider- able swelling of the fauces, which were mottled with yellowish shreds. On the follow- ing day erysipelas appeared upon the face, the parotid and submaxillary glands were enlarged and indurated, and the patient, falling into a typhoid state, died on the ninth day. On examination, it was found that the erysipelas extended through the larynx and trachea into the bronchia, and at the lower part of the trachea was a small ulcer. The heart contained large fibrinous clots, but elsewhere the blood was exceedingly black, and of about the consistence of molasses. In the following instance, the progress of the disease was the reverse of that de- scribed in the last case. In 1864, Simon published 5 an account of a girl affected with erysipelas of the scalp, face, and neck ; she then became unable to open her mouth, swallowed with difficulty, and grew aphonic. On the tenth day she died comatose. On examination, the mouth was pale, but the fauces were of a deep purple color, the follicles enlarged, and the mucous membrane softened. The same dark hue prevailed throughout the air passages which were dry and free from exudation. The lungs were greatly engorged, as were also the membranes of the brain. In 1866 Dr. "W. J. Wilson 6 described a case which began as sore throat, with pain- 1 Clinical Lectures. 2 Gazette Hebdomadaire, Juillet, 1861. 3 American Medical Times, April, 1863. p. 196. 4 American Journal of the Medical Sciences, July, 1865, p. 103. 5 Bulletins et Memoires de la Societe Medicale des Hopitaux de Paris, 2e seVie t. i. p. 199. 6 American Journal of the Medical Sciences, July, 1866, p. 275. 172 ERYSIPELAS. ful deglutition, and swelling of one tonsil and of the neck externally. These symptoms, subsiding, were followed by laryngeal obstruction which required tracheotomy. The wound was attacked with erysipelas which spread over the skin, but the patient made a good recovery. Not to prolong unduly this enumeration, a case of more recent occurrence may be noticed. Strauss 1 relates the history of a man who, during convalescence from an attack of erysipelas of the face and scalp, was seized with pain and swelling in the right side of the throat, while the corresponding lung was dull on percussion, and gave a crepi- tant rale in the lower lobe. But there was neither chill, cough, nor expectoration. In four days death occurred ; the pharynx and right bronchia were congested, but con- tained no fibrinous mould or filaments, and the alveoli were crowded with leucocytes. With these examples before the reader, the hearing of the following remarks will be more apparent and intelligible. As long as erysipelas was regarded as merely an inflammation of the skin, the unity of the disease and its dependence upon a special poison were not readily recognized. Hence the artificial, although apparently practical, disjunction of medical and sur- gical erysipelas, which deluded learners, misled practitioners, and em- barrassed authors. Continued observation, however, showed that the disease sometimes arose idiopathically, and was sometimes of traumatic origin, and that in both cases it could, on the one hand, be traced to certain definite causes, such as putrefaction, and yet might fail to occur when such causes existed in great activity, or might prevail fatally where no similar conditions could be detected. From such facts the rational conclusion could only be that beneath all the immediate and apparent causes of the disease, lay certain essential conditions of its production. But the time was not yet ripe for a demonstration of this proposition. Later, it began to be assumed that iti all cases of erysipelas a positive lesion must exist to admit the poison, and, very frequently, minute inspection revealed, upon the skin, a pimple, a scratch, or a patch of herpes or eczema, which formed the starting-point of the erysipe- latous inflammation, and sometimes an analogous lesion of the mouth or throat. However necessary it may be, and probably is, that a lesion of the skin should exist before erysipelatous infection can take place through that channel, for the sound skin is an exhaling and not an absorbing organ, the reverse is true of the mucous membranes, which are all, in various degrees, absorbing surfaces. If, therefore, erysipelas is disseminated by a materies morbi, it is only in accordance with a general law that it should frequently make its first impression upon the mouth, throat, and nostrils, as the poisons of smallpox, scarlet fever and measles, usually do; for if the poi- son is inhaled, it necessarily comes first in contact with these parts, and in its most concentrated form. In traumatic or surgical erysipelas, the mode of entrance of the poison into the system hardly needs demonstration, for it is in wounds of all grades, from the most trifling abrasion to the most extensive removal of the integu- meul by accident or by the surgeon's knife, that the starting-point of the disease is to be sought. Its characteristic phenomena are, indeed, not always first manifested at that point, for, as is more particularly set forth elsewhere, remote lymphatic ganglia are quite frequently the first parts to become swollen and painful; and in other cases, a febrile movement of a seemingly idiopathic nature sets iii before the local phenomena, whether traumatic inflammation or glandular swelling, are developed. It is evident, then, that it is not erysipelas as ;m inflammation, which alone occasions redness over the lymphatic vessels and swelling of the corresponding glands, but that some- thing is absorbed 03' those vessels from an infected wound or mucous mem- ' Medical News, Feb. 1880, p. 93. CONNECTION OF EPIDEMIC EKYSIPELAS WITH PUERPERAL FEVER. 173 brane, viz., the specific poison of the disease. Later, the morbid process takes on that peculiar form of inflammation which is known as erysipelatous; but it is important to bear in mind that the local phenomena, and especially the primary ones, are not necessarily proportioned to the general symptoms. A severe, and even a fatal erysipelas may follow infection through a trifling wound in the skin, or a short exposure to an erysipelatous atmosphere, just as a confluent variola may result from a like exposure to the contagion of smallpox. The specific virulence of the poison is, indeed, one element of its power, but the gravity of its effects also depends in no small degree upon the greater or less susceptibilitj- and power of resistance of the patient. Connection of Epidemic Erysipelas with Puerperal Fever. The prevalence of erysipelas and puerperal fever at the same time, and in the same places, could hardly have failed to attract the attention of observant physicians at all times, yet the intimate relations between the two affections appear to be of comparatively recent discovery. Perhaps, even now, they are either quite unknown to many, or else their significance is misappre- hended. It is very desirable, if these diseases stand related to each other as cause and effect, or, again, as common effects of the same cause, that it should be universally known both for the sake of removing the causes which are common to both of them, and for guiding the treatment demanded by the analogy, if not identity, of their nature. The earliest opinion affirming a relationship between the two diseases, is ascribed to Pouteau, who in 1750 expressed his opinion that the puerperal fever which then prevailed in Paris was an erysipelas of the peritoneum. 1 From that time until the fourth decade of the present century, the subject does not appear to have attracted much attention ; but in 1842, Mr. Storrs, of Leeds, England, reported that having attended a case of gangrenous erysip- elas of the foot and leg, in which several abscesses formed, which he opened, he delivered several women in succession, all of whom were attacked with puerperal fever and died. 2 In the following year, Dr. 0. W. Holmes related the history of a local epidemic of puerperal fever, which had its origin in the autopsy of a case which appears to have been one of gangrenous erysip- elas of the leg. Several cases of erysipelas occurred in the house where this person died; the nurse who laid out the body of one of the puerperal patients died of sore throat and erysipelas of the skin; and another nurse met Avith a similar fate, without presenting, however, any sign of cutaneous erysipelas. 3 About the same time puerperal fever and erysipelas prevailed epidemically in Cincinnati, Ohio, and Dr. Minor of that city distinctly traced the propa- gation of each disease by the other, and from one patient to another In- direct communication, including the production of erysipelas in the infants of mothers who had been attacked by puerperal fever. 4 In Missouri, the same coincidence and transmission of the diseases were frequently remarked, by Dr. G-. W. Sickles among others. 5 In 1850, a narrative was furnished by Hill 6 which illustrates the subject further : — 1 Ranking's Half-yearly Abstract, 1859, p. 84. 2 Provincial Medical and Surgical Journal, April, 1842. 3 New England Quarterly Journal of Medicine and Surgery, April, 1S43. * Erysipelas and Childbed Fever, 1S47. 5 St. Louis Medical and Surgical Journal, vol. viii. p. 1. 6 Monthly Journal of Medical Science, March, 1850, p. 299. 174 ERYSIPELAS. A carpenter wounded his hand while making a coffin, and, on placing the corpse in it, some fluid from the body came in contact with the wound. He had a severe attack of erysipelas, which he communicated to his wife. Meanwhile, their daughter, seven months pregnant, who had come home to be confined, was seized with fever. The phy- sician, after visiting this woman, went to attend another in labor. The following day the carpenter's daughter gave birth to a dead child, and died of puerperal fever. The physician did not return to the other lying-in patient, who, however, suffered an attack of puerperal fever, but recovered. In the practice of the same physician, a girl suffer- ing from erysipelas of the face was attended by her mother then about to be confined. The child was born with erysipelas and died. The midwife immediately afterwards attended a healthy girl in labor, who also had a mild attack of puerperal fever, but her father, who waited on her assiduously, was affected with erysipelas of the throat of which he died on the ninth day. Four other persons who assisted in nursing some of these patients were attacked with erysipelas, but recovered. During a local outbreak of erysipelas in Platte County, Missouri, Dr. Rid- ley reports 1 that while attending cases of this disease, he acted as accoucheur to three ladies within the space of one week, all of whom were attacked with puerperal fever and died. These were the only cases in the locality. In 1852, an epidemic of malignant erysipelas occurred in New Castle, Pa. While attending one of the cases, Dr. Leasure delivered a healthy woman of her seventh child after a natural labor. She died on the fourth day of typhoid metro-peritonitis, and, after a like interval, her infant died of erysipe- las. A second case occurred under identical circumstances, with like results for both mother and child, and the nurse also suffered from erysipelas, and barely escaped with her life. A third puerperal case of the same physician presented a similar history, as did two other cases under the care of another practitioner who had also been treating erysipelas. Both physicians then abstained from attending any more lying-in women, and no further cases of puerperal fever occurred. Dr. Leasure concludes his narrative with these words : " My cases of childbed fever were neither more nor less than cases of malignant erysipelas, fatally modified by the condition of the patients, and the manner of introducing the morbid poison. 2 About the same time, Dr. Todd, in England, said of puerperal peritonitis, it is " a disease which I be- lieve is really of an erysipelatous nature.'" 3 Dr. Dutcher related several cases illustrative of this subject, of which the following is very significant: — 4 A physician while attending a case of phlegmonous erysipelas was called to a case of confinement. The patient died of puerperal fever. In the course of four weeks he attended seven cases of labor, and in every instance the mother died of puerperal fever, while the children perished with general cutaneous erysipelas. Finally, the physician was himself attacked with erysipelas of the hand, which nearly proved fatal. In Philadelphia the case is well remembered of a physician in extensive practice; who had ninety-five cases of puerperal fever in rapid succession, while none were occurring in the practice of the neighboring practitioners ; and of the children born in these cases no less than fifteen died of erysipelas. In 1857, Dr. Duncan, of York, Pa., related the case of a lady in whom an attack of puerperal fever occurred simultaneously with erysipelas of the face, while her infant suffered from erysipelas of the umbilicus. 8 In lH(i2, a memoir upon this subject was published in Paris by Pihan- Dul'cillay, 6 who clearly demonstrated the relations of the two diseases to 1 New York Journal of Medicine, vol. x. p. 41, 1853. 2 American Journal of the Medical Sciences, January, 1856, p. 45. 3 Medical Times and Gazette, July, 1855, p. 28. 4 American Journal of the Medical Sciences, January, 1856, p. 99. E North American Medico-Chirurgical Review, vol. i. ]>. 31. 6 L'Uirion Mediuale, and American Medical Times, vol. v. p. 60. CONNECTION OF EPIDEMIC ERYSIPELAS AVITII PUERPERAL FEVER. 175 one another by numerous examples, domestic and foreign. lie maintained that there were eases in which the same cause seemed to engender both diseases, which differed from one another only in their subordinate characters, but were identical in their nature ; as appears when, under the same general conditions, erysipelas ravages surgical wards, and puerperal fever lying-in hospitals or wards. If the conjunction were rare, it might be viewed as a simple coinci- dence, but its frequent repetition, if not uniform occurrence, and that not in one country alone, but in Europe and America alike, leaves no rational doubt that an intimate relationship exists between the two diseases. Of the two, the primary affection is sometimes erysipelas and sometimes puerperal fever, and each has the power of generating the other. A very striking illustra- tion of the less usual of these reciprocal influences is related by this author: — A fatal epidemic of puerperal fever occurred in the lying-in ward of a general hospi- tal. After a time, the remaining and incoming women who were about to be confined, were transferred to a remote ward, which, until then, had been used for patients with diseases of the skin, while the latter were moved into the late obstetrical ward, after it had been thoroughly cleansed. Thenceforth the puerperal fever ceased, but a grave epidemic of erysipelas broke out among the new tenants of the obstetrical ward, attack- ing them without regard to the nature of their cutaneous disease, their constitution, or their general health. An analogous illustration is furnished by Trousseau. 1 An epidemic of puerperal fever desolated the Maternity Hospital, and, when the authorities felt compelled to re- move the pregnant women to other hospitals to be confined, erysipelas there broke out in a severe form in a great many of the surgical services, among those who had wounds. It is worthy of remark that in certain epidemics of erysipelas, and notably in that of Paris in 1861, to which reference has just been made, a morbid change in the blood was manifested by certain prevalent disorders. Gangrene frequently occurred, which was apparently not produced by, or proportionate to, the tension of the erysipelatous skin ; and, in like manner, boils and car- buncles formed, which were not at all confined to the seats of erysipelas, and which, therefore, must have originated in a special condition of the blood. A further and still more curious fact in this relation, is that many persons suffered from such affections who had not erysipelas, although they frequently occupied the same house or lodging with those who were laboring under that disease. It is of especial interest, also, that during this epidemic not only did puerperal fever prevail, but that in not a few cases pus formed in the articulations and in the serous cavities of the trunk. 2 Retzius has given the history of puerperal fever as it occurred in the Lying- in Hospital of Stockholm. It began in 1858, and grew more severe in*18o9 and 1860, so that the hospital became crowded, and, " as a consequence," it is stated, " erysipelatous inflammations soon manifested themselves, although no analogous disease existed in the town, and nothing in the condition of the individual patients afforded any explanation of their being attacked." 3 The following instance illustrates the dependence of erysipelas and puerpe- ral fever upon the same essential cause : — Dr. Cox states that a physician having bled an erysipelatous patient, soon afterwards used the same lancet to bleed a man who had been hurt by a fall, and also a woman in labor. The man was attacked with phlebitis and the woman with puerperal fever. 4 To pass over a period during which the instructive nature of these and many analogous instances, seems to have been forgotten or neglected, only one 1 Lectures on Clinical Medicine, vol. ii. 2 Dechambre, Gazette Hebdomadaire, Juillet, 1861, p. 476. 8 Medical Times and Gazette, April, 18(32, p. 383. * American Medical Times, April, 1803, p. 198. 176 ERYSIPELAS. or two additional illustrations of the important truth they teach will be ad- duced. In 1877, Dr. Atthill 1 furnished the history of a local epidemic of erysipelas, which he summarized as follows : " Of ten (puerperal) patients admitted into a hospital, of which the sanitary condition had, previous to the admission of a case of erysipelas, been most excellent, nine were attacked with illness more or less severe, and one died ; the only one who escaped being a case of abortion." Dr. Thomas H. Buckler has stated 2 that " on three several occasions, during nine years, a single case of erysipelas admitted into the wards of the Balti- more City and County Almshouse Hospital, was the starting-point for the spread of its poison to all the medical and surgical wards to such a degree that the most trivial operations had to be avoided, and even the slightest scratch on the skin was likely to take on erysipelas, followed in some instances by phlebitis and pyaemia. At last the poison reached a lying-in ward, more remote than the others from the sources of infection, with invasion so fatal, that, after a time, for a woman to be delivered there was certain death." Morbid Anatomy of Erysipelas. The most prominent lesion of erysipelas is an exudative inflammation of the skin, which is usually seated in the thickness of the derm and in the sub- cutaneous connective tissue, but which is often confined to the layers of the skin immediately beneath the epidermis. The exudation is not merely sero- fibrinous ; it contains a large number of white corjmseles, which have mi- grated through the walls of the bloodvessels. In cases which tend towards resolution, they disintegrate and are reduced to minute granular particles, which are then absorbed. Drs. Moxon and Goodhart 3 found in the blood of several persons affected with traumatic erysipelas, an increase in the pro- portion of white corpuscles ; but in others this condition did not exist. Dr. W. jSTorton Whitney 4 states that in severe cases the proportion of the white corpuscles is increased ; to one in fifteen in one case, and to one in thirty in another, and generally in proportion to the rise in temperature. In severe cases the red corpuscles run together, their edges are ill-defined, and they look like streams of yellow fluid crossing the field of the microscope. They also become more rapidly crenated than in healthy blood, showing a marked ten- dency, in severe cases, and especially when the temperature is high, to adhere to one another in masses, and not in rolls. In a case of Kollman, of Leipsic, 5 in which repeated hemorrhages from the bowels took place, fatally exhaust- ing the patient, it is probable that such blood-changes existed in a high de- gree. To them also may be attributed the altered action of the heart, and the hsemic murmurs heard during life, and more immediately the fatty or granular change sometimes found in the cardiac muscles. In 1862, it was related by Pihan-Dufeillay, that enlargement of the sjrteen occurred during the then recent epidemic at the St. Louis Hospital (Paris); and in 1873, Friedreich stated that in ordinary facial erysipelas he seldom looked in vain lor enlargement of the spleen, adding that the organ fre- quently attained such a size as to project below the border of the ribs. He refers particularly to a case of floating spleen in which, during the progress of the erysipelatous attack, successive changes in the size of the organ could ' Obstetrical Journal of Great Britain, June, 1877. 2 Boston Medical ami Surgical Journal, October, 1880, p. '418. 3 Guy's Hospital Reports, :»1 s. vol. xx. p. 240. 4 Inaugural Thesis, University of Pennsylvania, 1881. 6 Archiv d. lloilkunde, Band xi., S. 398. SYMPTOMS OF ERYSIPELAS. 177 be accurately estimated. The tumor sometimes continued even for a fort- night after the subsidence of the febrile symptoms. This was particularly noticed in erysipelas of the scalp. 1 Even in cases presenting brain symptoms, whether active or passive, no cerebral lesions corresponding to them are found ; no exudation of lymph, and not even a large effusion of serum ; but the veins, both of the meninges and of the brain, are sometimes engorged with blood. In erysipelas of the throat and bronchia, the mucous membrane of these parts is apt to be darkly congested and coated with tenacious mucus ; occasionally ulcers are found upon it. They have also been met with in the intestinal canal. Larcher 2 met with them near the opening of the ductus communis into the duodenum, or on the opposite surface. The ulcers were about the size of a split pea, and did not penetrate the mucous coat. The analogy of these ulcers with those that have been found after burns of the skin, and also after scarlatina, is in- teresting. Malherbe 3 met with such ulcers in the jejunum and ileum; but they were not seated in the glands. In many, if not in most cases, the lymphatic vessels and (/lands are in- flamed, or at least structurally altered, and the veins may be the seat of a similar change. This may lead to coagulation of the blood in the veins (thrombosis), and the clots so formed may be carried into the vessels of the lungs, constituting embolism in those organs. Or the coagulation may obstruct an artery, and lead to gangrene of the parts beyond. Such accidents appear to be more frequent in persons of feeble constitution or impaired physical con- dition than in those of average health. The local lesions found in fatal cases of erysipelas consist of an infiltration of the connective tissue with a sero- purulent fluid, which renders the parts soft and pulpy, and dissects out, as it were, the muscles, bloodvessels, and nerves. The parotid gland may be quite disorganized by purulent infiltration in cases of facial erysipelas, and the periosteum of the ramus of the lower jaw may be separated from the bone. The small muscles are often reduced to a pulp, and the lymphatic glands are enlarged and suppurating. Similar destructive effects are observed in cases of phlegmonous erysipelas of the extremities. Symptoms or Erysipelas. Like other diseases in which the local phenomena are subordinate, although essentially due, to a vice of the system, the first symptoms of erysipelas depend upon the condition of the blood. The material cause of the disease, circulating through the system, occasions phenomena analogous to those which introduce other febrile affections. These phenomena include general discomfort, muscular aching, pain in the head, loss of appetite, a chill, and, above all, nausea, with a bitter taste in the mouth, and vomiting, which is often bilious. Sometimes, a convulsion is among the earliest phenomena of the affection. ^ The chill is apt to be prolonged and severe, and may often lie taken as an indication of the gravity of the subsequent attack. It is fol- lowed by fever proportioned in severity to the chill, and the temperature may rise in a few hours to 104° F., or even higher. If the patient is already suffering from fever, these phenomena may not be present, or the rise of tem- perature may be unnoticed. The pulse becomes frequent, and is usually full and strong, especially in cases which are rapidly developed and in previously 1 German Clinical Lectures, New Sydenham Society's edition, 2d series, p. 8. 2 Archives generates de Medecine, Dec. 1864, p. 689. 8 Ibid., Dec. 1865, p. 725. VOL. I. — 12 178 ERYSIPELAS. lieal thy persons. The fever, however, usually presents a daily morning remission. The tongue becomes rapidly covered with a yellowish, thick, and pasty coating. Even yet the place of entrance of the poison into the system may betray no sign of its passage, while the lymphatic ganglia through which it has passed grow tender, swollen, and it may be red. In other cases, however, but in a relatively small number, the ganglionic inflamma- tion appears later than the local evidences of erysipelas. It is important to observe that not only does the lymphatic tenderness and swelling, as a rule,\ precede the inflammation of the skin, but that it may even do so for several hours or even days. Indeed, an interval of three or even of six days has been observed between the two events. This familiar clinical fact disposes readily of the notion that erysipelas is merely a dermatitis, and that the constitutional symptoms are due to that inflammation and proportioned to its severity. They rather bear to the local affection a relation analogous to that between smallpox and inoculation, or between vaccinia and vacci- nation. In the part about to be invaded by erysipelas, a sense of tightness is first perceived, accompanied with itching and burning heat, and followed by a steady pain which grows worse at night and when the skin is touched. At the same time, or soon after the pain is felt, usually in from one to three daj*s after the occurrence of the initial symptoms, a blush appears upon the skin, and gradually deepens from a rose to a deep crimson color, or, in cases of a low type, to a still darker shade, while it extends in every direction around the point of origin; and in the same degree the skin swells, grows tense, smooth, and shining, and the redness and swelling, whether presenting a curved or an angular outline, are bounded by an abrupt elevation or ridge which can be both seen and felt as they tend to invade more and more of the sound skin. In persons of fair complexion, the contrast between the inflamed and the adjacent sound skin is very striking, and the former gives to the finger an impression of roughness which is due to the distended papillae of the derm, and to the minute vesicles which form upon its surface. The erysipelatous swelling is greatest where the subcutaneous connective tissue is most abundant, and, when it affects the face, the eyelids cannot be opened, the nostrils are obstructed, and even the jaws can be but slightly separated from one another. In no other disease, except smallpox, are the natural features so completely deformed. When a limb is involved, it is so heavy, stiff, and painful on motion, that it is instinctively kept at rest. The swollen part does not usually pit on pressure, but is tense and hard ; but in certain Bluggish forms of the disease the skin does not resist pressure, and has a boggy feel. Besides the face, the parts most liable to extreme swelling arc the genital organs in either sex. The tendency of the inflammation is to extend, not always steadily and uniformly, but by fits and starts, and each new exl ension is accompanied with an increase of the fever. Nor does it usually spread equally in all directions from the place of starting, but gene- rally tends from points on the extremities towards the trunk, and from the lace towards the scalp ; it may also pursue a linear path, or break out freshly at one or more remote points (Wandering Erysipelas). This is more common in surgical than in medical cases. In the latter, there is a very singular peculiarity relating to the point at which the inflammation com- mences. In the v;ist majority of eases, the eruption first appears at the root of the nose, and next in order upon the cheek or the car. In old persons, especially such as have varicose veins, it is apt to attack the legs, but with- out presenting, as a rule, very acute phenomena. It has been remarked that the chin is very rarely involved, even in eases of erysipelas in which the eruption occupies the rest of the face and the scalp. ^ SYMPTOMS OF ERYSIPELAS. 179 Iii surgical erysipelas, the local inflammation ordinarily and evidently begins at a wound, which always becomes dry, and of a dull color; but when the disease prevails in a hospital, some other part, and especially the face, may be the first to suiter. The general appearance of the eruption has already been described, but it may here be added that wherever it occurs, except upon the scalp, there may also be present true vesicles, phlyctense, or blebs, which are filled with a thin and milky serum in cases of moderate severity, but with a bloody or dark liquid in the typhoid form of the disease. This liquid sometimes escapes, and concretes into thin and dark brown crusts. In other cases, and probably from its excessive tension, the skin loses its vitality to a greater or less depth, and sloughs form, which may or may not involve the whole thickness of the integument. The blebs and the sloughs, in a greater degree, are apt to occur where the skin is delicate, as about the genital organs, and quite frequently on the eyelids. Blebs are not very uncommon upon the cheeks and even on the extremities. Such cases are not to be confounded with those of phlegmonous erysipelas, in which form there is less activity of the disease in the skin itself than underneath it. Xor are the limited abscesses which sometimes form beneath the skin, although tending to augment the fever, to be considered as constituting phlegmonous erysipelas. Meanwhile the general symptoms become severe in the same proportion as the local phenomena. The temperature may reach or even exceed 105° F., by the third day ; the pulse ranges from 100 to 120, and is only moderately full and strong, while the impulse of the heart and its first sound are rela- tively feeble ; the patient sutlers from headache, general distress, restlessness and sleeplessness, and is apt to be delirious, especially at night, and to be somnolent at other times. Irregular chills are experienced from time to time; the tongue is thickly coated; and, at the height of the attack, nausea, vomiting, and constipation, or diarrhoea, are not uncommon. At this period erysipelas manifests, even in cases of average severity, a tendency to assume the typhoid type, with a dry and brown tongue, tremulous movements, muttering delirium, and imperfect consciousness, while a small proportion of albumen may be detected in the urine. This tendency renders more intelligible the epidemic forms of the disease, in which from the beginning the same type prevails, clearly denoting the existence in the blood of a poison which primarily occasions the specific phenomena of erysipelas, and second- arily those which are everywhere characteristic of the typhoid state. The temperature has more than once been alluded to, but demands a more particular description. The rise to 104° F. may take place within a few hours after the initial chill. Most frequently this temperature continues with but slight morning remissions as long as the inflammation continues to extend, or the evening exacerbation may be attended with a temperature of 105.8°-106.7° F., or, though rarely, 107.6° F., while the morning remission falls a little below 104° F., and occasionally below 102.2° F. The maximum temperature is not usually reached at the end of the fever, but one or two days earlier. Defervescence then follows, and generally, in the course of twelve hours, or in a single night, the temperature falls to the normal point, or very nearly so. Sometimes, however, this rapid subsidence does not occur, espe- cially when the temperature has previously been very high, but one more exacerbation takes place in the evening, and the normal degree is not reached until the following night. Not unusually the defervescence is less rapid, and exhibits something of a remittent type, as in typhoid fever. This is most apt to occur when the inflammation of the skin subsides slowly, or still continues, but with diminished activity, to extend. Not infrequently, after an interval of from one to six days, and whether or not it has meanwhile become normal, 180 ERYSIPELAS. Fig. 8. Day of Day of 9S 99 100 101 102 103 104 105 Month Disease April 24. 1 ^ Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Morning. Evening. Chart showing variations of temperature in a mild case of facial erysipelas. April 25. 2 April 26. 3 April 27. 4 April 28. 5 April 29. 6 April 30. 7 May 1. 8 May 2. 9 May 3. 10 May 4. 11 May 5. 12 ft SYMPTOMS OF ERYSIPELAS. 181 the temperature takes a sudden and striking rise, which either accompa- nies or announces a new extension of the erysipelas. The relapse, however, does not generally last as long as the original fever, indeed for only one or two days usually, but it may recur several times, especially in the erratic forms of erysipelas ; nor does the fever finally subside until the eruption per- manently disappears. When such relapses succeed one another, the fever de- clines with each one more- and more, until with a very slight eruption it may become imperceptible. In fatal cases, death generally occurs with a high temperature (Wunderlieh). The exacerbations and remissions now referred to appear to be in some manner inherent in the disease, or, at least, their ex- citing causes elude observation ; but often the former can be traced to some imprudence in eating, some exposure to cold, or even to undue mental excite- ment. The accompanying diagram (Fig. 8) exhibits the changes of tempera- ture in a mild case of facial erysipelas following lupus of long standing. As the fever subsides, the hardness and tension grow less, and the skin pits more or less under pressure ; the elevated ridge which abruptly bounded the inflammation, subsides, the redness becoming less vivid, and shading off gradu- ally into the color of the sound skin. As the tissues shrink more and more towards their normal dimensions, the over-stretched epidermis becomes loos- ened, and is apt to be detached in large flakes, leaving the inflamed skin with a new cuticle, and with more or less of a red color, which it retains in some degree for many weeks. When repeated renewals of erysipelas occur in the same part, they may induce a thickening of the skin, and in the lower ex- tremities are apt to occasion also a permanently bluish tint and an cedematous condition of the limbs. The tendency of erysipelas in its simple form to recur again and again, and not only in attacks directly succeeding one another, but after an interval of months or years, presents one of the strongest contrasts between it and the eruptive fevers, with which in other respects its analogies are very close indeed. It is true, however, that the nature of most of these recurrent cases is open to question, and that not a few of them seem to have been instances of erythema rather than of erysipelas, or, as they have been called by Daude, eiysipeloids. Further remarks upon this point will be found in the section on Diagnosis. The description which has now been given relates chiefly to erysipelas as it is observed in and confined to the skin ; but when the inflammation ex- tends to subjacent parts, the phenomena are different, and depend partly upon the nature and partly upon the extent of the process. In general, its extent is determined by its nature; that is to say, the more sthenic the in- flammation, the more apt it is to be limited in extent ; the more asthenic, the greater is the tendency of the inflammation to extend indefinitely. In the former case, the system is capable of establishing barriers of lymph, which circumscribe the inflammatory process ; in the latter, this goes on unresisted, and may spread far and wide beneath the skin. Yet the very intensity of the local inflammation may destroy the vitality of the skin in a limited area, as has already been stated in regard to the eyelids and the organs of genera- tion. In these cases, and generally at the height of the attack, spots of a darker red appear on the erysipelatous skin, which gradually grow livid and black, and ultimately separate as eschars. Or suppuration may occur be- neath the skin, in consequence of the imperfect supply of blood in the part, as not uncommonly happens in erysipelas following wounds of the scalp. The abscesses referred to may be conjectured to take their rise in an inflam- mation and obstruction of the lymphatics leading from the primary seat of the erysipelas ; they are seldom large, and do not materially aftect the course 182 ERYSIPELAS. and issue of the primary affection. To them, rather than to the next form to be noticed, should the term " phlegmonous erysipelas " be properly applied. Phlegmonous Erysipelas. — The affection usually described as phlegmonous erysipelas is an erysipelas which originates most frequently in wounds that involve both the skin and the subcutaneous connective tissue, and which tends to diffuse itself in the latter and on the former, without being limited by the formation of an inflammatory abscess. It issues in suppuration or gangrene, or both at once, and according to its degree and type is attended with inflammatory or typhoid phenomena. The onset of the attack gene- rally presents in a high degree the premonitory symptoms which have been already described, and the part about to be affected feels tense and heavy. When the eruption appears, the skin is not of a uniform redness, but often darker streaks are visible along the lymphatic vessels, and the corresponding glands are enlarged and tender. The skin is very greatly sAvollen, hot and hard to the touch, and very painful. By degrees the tension and hardness diminish, and give place to a boggy softness, with abatement of the pain. Meanwhile, underneath the skin the congestion has been followed by an exu- dation of pus and a softening of the connective tissue, as well as of the cutis. Sooner or later the skin becomes eroded, or is opened by incision, and gives issue to a large quantity of thin and fetid pus, of a gray or brownish color, and mixed with shreds of dead connective tissue that have been aptly com- pared to "strings of wet tow," to "the membranes of a young foetus," to " wads of wet chamois leather," etc. The destructive process is much more active in the subcutaneous connective tissue than in the skin itself ; whence it often happens that the latter is to a great extent undermined, and between it and the muscles, and among the latter, vast cavities are formed. A case is related in which the whole integument of the abdomen thus became detached from the muscles, without, however, destroying the vitality of any portion of the skin (G. B. Wood); but more frequently the loosened skin mortifies, and vast ulcers result, which are difficult to heal, and often lead to permanent contraction of the denuded parts. The general symptoms are apt to be severe, and include high fever and delirium ; and when suppuration sets in, there is usually a chill, followed by increased fever, and often by depression, prostration, hectic sweats, diarrhoea, wasting of the tissue, and, in a word, by all the phenomena of pya?mia, including, in some cases, metastatic ab- scesses. The examples of arthritis complicating erysipelas are probably of this nature. Dr. John Ashhurst, Jr., has related 1 the case of a man who, without apparent cause, was attacked with erysipelas of the right lower extremity, accompanied with great swelling of the knee-joint. Although the general symptoms suhsided, the joint re- nin ined enlarged for several weeks, and then gradually became smaller. Some weeks later the left knee began to swell, and subsequently an opening formed, through which pus was discharged to the amount of a pint at first, the discharge, however, not ceasing until the patient's death, which was hastened by bed-sores. After death, it was found that both knee-joints were distended with pus, that the cartilages had nearly disap- peared, and that the ends of the thigh-bones were eroded. It may be objected that in this case the arthritis was the primary, the ery- sipelas the secondary, affection, and, indeed, this objection has been made to analogous cases (Gosselin); but the suppuration of the joints observed in pu- erperal lever, and the close relation of the latter disease to erysipelas, renHer probable the direct dependence on the latter of certain cases of arthritis. 1 American Journal of the Medical Sciences, July, 1865, p. 103. SYMPTOMS OF ERYSIPELAS. 183 According to Gosselin, an erysipelatous inflammation of the joints may either terminate by resolution without impairing the movements of the limb, or by suppuration, and in the latter case with all the possible consequences of such an arthritis from other causes. (Edematous Erysipelas. — There is a degree, or variety, of phlegmonous erysipelas which has been described as the (Edematous; it differs from the for- mer in presenting far less active symptoms, and congestive rather than inflam- matory. The color of the skin is not a bright, but a pale or dull, brownish red ; the swelling is smooth and shining, and pits but slightly and momenta- rily on pressure. When incised or punctured, bloody serum flows out. It occupies the same seats as idiopathic erysipelas in general, and does not fre- quently accompany the traumatic form. Gangrenous Erysipelas. — Of gangrenous erysipelas it maybe remarked, in addition to what has been said above, that it is oftenest met with among the old and feeble, or persons exhausted by intemperance or disease, and in the cachetic infants of scrofulous or syphilitic parents. It is rarely primary, but usually arises in the course of some other affection. The color of the skin is a dusky red, which does not disappear under pressure ; its heat is not great, nor is the pain, and the swelling is doughy and circumscribed. Phlyc- tenre form upon the inflamed skin, and discharge a thin and offensive serum, and such parts are apt to slough, especially where the skin is delicate. In this Avay considerable portions of the scrotum have been lost, and cases are recorded in which this covering was entirely destroyed and the testicles ex- posed, but which, nevertheless, ended in recovery. In other cases, attended with high fever and other grave symptoms, and, according to Gosselin, be- tween the fifth and the tenth day, or even later, there appear upon the ery- sipelatous surface, and sometimes quite at its limit, one or several dark spots, which are moist, insensible, and cold, and from which the cuticle presently separates with or without the previous formation of phlyctenre. At the same time the fever becomes more intense, the tongue grows dry, the strength fails, and gradually the patient sinks, and almost invariably dies. Of these different degrees or forms of gangrene affecting the skin, one appears to de- pend upon the relative intensity of the inflammation as compared with the resisting power of the tissue involved, while the other seems to be more es- pecially associated with that typhoid condition which everywhere implies an impaired vitality of the tissues. Howard Marsh 1 describes an erysipelatous inflammation of the scrotum and penis, which also involves the surrounding parts. It may arise either as a primary affection, and is met with as such chiefly in persons above middle age, whose health is reduced in many instances by advanced kidney-disease, or may depend upon some local condition in which the original mischief was deep-seated abscess of the perineum. It was described by Liston as "inflam- matory oedema," and that surgeon declared that in Edinburgh he had had no less than six cases under his care during a very wet and unhealthy season. Mr. Holmes has particularly pointed out that the retention of urine which is apt to occur should be regarded as the effect, and not the cause, of the ery- sipelatous swelling of the scrotum. Hence the importance of determining, if possible, whether an urethral obstruction existed before the erysipelas, and also the actual condition of the canal. If a catheter can be passed readily, it is evident that the urethra is not strictured, and that, consequently, there is no need of retaining in it an instrument, which would only aggravate the 1 Medical Times and Gazette, September 30, 1865, p. 363. 184 ERYSIPELAS. renal and vesical disease which is generally present. In regard to the treat- ment of the swelling itself, it may be mentioned, in passing, that it has been usual to make free incisions into the distended parts. In 1791, Dr. Percival, of Manchester, England, described a peculiar affec- tion of the vulva in a girl five years old ; and in 1815, Mr. Kinder Wood related the history of twelve similar cases that had occurred in his own prac- tice. Like erysipelas, it usually had prodromes of two or three days' dura- tion, when the difficulty of passing water drew attention to the genitals of the little patients. It was then found that the labia first became swollen, and afterwards inflamed, blistered and ulcerated, while the inflammation ex- tended to the thighs. There was no spontaneous tendency to gangrene. 1 The reporter of the cases discusses the question whether this disease was erysipe- latous, and deeides in the negative ; but the analogies of the affection with erysipelas render some notice of it in this place appropriate. Erysipelas of the Face and Scalp. — Of the local and external varieties of the disease, erysipelas of the face, and that of the scalp, demand a few special remarks. The former affection is by far the most common form of the disease unconnected with surgical affections. Preceded by the general phenomena already described, the eruption usually makes its appearance upon the bridge of the nose, in which case it almost always spreads symmetrically to either side, involving by turns the eyelids, the nose, the forehead, the ears, the cheeks, and the upper lip, but usually stopping at the junction of the skin of the forehead with the hairy scalp. It does not often descend beyond the middle of the neck. Sometimes it begins on one side of the nose, and, indeed, Mr. Bird 2 affirms that its starting point is most frequently the right side of the face. Not uncommonly it first affects one ear. Each of these cases is adduced in favor of the doctrine that the idiopathic disease always takes its rise from a direct infection ; and in these instances it is held that the first impression of the poison is upon the nasal and pharyngeal mem- branes, whence its effects extend through the lachrymal canal to the face, or through the Eustachian tube to the ear. As the inflammation spreads over the face, the skin is at first of a scarlet, and then of a crimson or almost pur- plish color, and its surface is tense and shining. The ears especially are dark red. The swollen eyelids close the eyes, and obliterate entirely the depres- sions of the orbits, while from between them tears flow abundantly; the tumid nose and lips complete the disfigurement, and no trace of the natural ex- pression of the face is left. The deformity is exaggerated when the scalp is involved as well as the face, and no* only is the pain singularly increased by the unyielding nature of this integument, but cerebral symptoms of excite- ment or stupor are often present. The swelling of the ears renders hear- ing dull, and the obstruction of the nostrils compels the patient to breathe through the mouth. Very commonly phlyctense form upon the cheeks, and their escaping contents are apt to irritate the skin. Erichsen 3 lays much str*ess on the fact that the erysipelas which is so apt to follow injuries of the scalp, seldom arises unless the tendon of the occipito- frontalis muscle is divided. In that case, the products of inflammation accumulate between the pericranium and the bone, causing a cellulitis with profuse suppuration, the pus from which undergoes putrefaction and sets up erysipelas. This surgeon denies that a wound of the seal}), or the use of sutures in treating it, has any special tendency to induce erysipelas, which 1 Medico-Chirurgical Transactions, vol. vii. p. 84. 2 Ranking'a Abstract, No. xxix. 1859, p. 85. 3 Lancet, January, 1S78, p. 115. SYMPTOMS OF ERYSIPELAS. 185 he attributes exclusively to the retention and putrefaction of the exudations beneath the integument. Hence he condemns all dressings which tend to retain the discharges within such wounds. It is of importance to note that in this as in all other forms of traumatic erysipelas, the general precede the local symptoms. After a chill, followed by fever, the wound becomes dry and painful, and begins to be surrounded by an erysipelatous blush. In erysipelas of the face, as in other forms of erysipelas, the general symp- toms vary with the existing type, from sthenic to adynamic, but as this form more frequently than others affects persons previously in good health, its type is, on the whole, sthenic, and its issue favorable. The extension of the inflam- mation to the scalp is doubly inauspicious, for it not only denotes an inability to prevent the spread of the disease, but directly aggravates it by giving rise to derangements of the brain functions. Although delirium is apt to occur in erysipelas of the face, it is much more marked in that of the scalp, when it is usually low and muttering, though occasionally maniacal. In all forms of erysipelas, however, provided that the temperature is high, there is more or less tendency to delirium. At night it is of common occur- rence, even when the eruption is confined to the face. It does not arise from inflammation of the brain or its meninges, for after death, in cases presenting this symptom even in an aggravated degree, no inflammatory exudation has ever been found within the cranium, and not even venous congestion uni- formly. The delirium and coma preceding the fatal issue of the disease must therefore be attributed either to congestion of the brain or to an altered condition of the blood, or to both of these causes together. Many years ago (1860), Todd combated the prevalent idea that the cerebral symptoms of erysipelas were produced by a lesion of the brain, and explained them by the circulation of noxious blood through that organ. On the whole, we may fairly conclude that congestion has a share in producing the brain symptoms, because they are more frequent in erysipelas of the scalp than in that of any other part ; but that the blood lesion shares in their production is denoted by the occurrence of coma in the puerperal and other forms of epidemic erysipelas, in connection with gangrene and evidences of blood-poisoning. Many writers have attached importance to the gastric derangements in this form of erysipelas, and have described vomiting, and especially bilious vomiting, as quite characteristic of it. The sjmiptom does indeed often occur, but perhaps is quite as often wanting. There is less reason for sup- posing that it is occasioned by any special disorder of the stomach or liver, than for regarding it as a sympathetic phenomenon due either to the altered quantity or to the quality of the blood circulating in the brain. The duration of erysipelas of the face, especially when idiopathic, may be stated at from one to two weeks ; but this may be greatly exceeded when the disease involves the scalp, or becomes phlegmonous. This form of the disease is perhaps less liable than others to relapses. Besides the sequelas common to all the forms, there is one that is indeed rare and seems peculiar to erysip- elas of the face. It is blindness, due to an atrophic degeneration of the optic papilla, which sometimes affects only one eye, and sometimes both eyes. The impairment of sight when it occurs only in one eye, begins towards the close of the attack, or when the swelling of the eyelids has subsided suffi- ciently to permit them to be raised. When both eyes have been involved, the impairment of sight appears^ not to have been noticed before the com- plete subsidence of the erysipelas, and, after varying in degree, to have left a permanent defect of vision, sometimes, however, in regard only to certain colors. 1 1 Parinaud, Archives Generales de M^decine, Juin, 1S79, p. 64 1 . 186 ERYSIPELAS. A quite unusual seat of the eruption presented itself in a case of Steiner's. 1 In a child two years of age, without known cause, the disease attacked simultaneously both thighs, and then extended to the feet. • After it declined there a relapse occurred, the eruption appeared upon the trunk, and the child died. Bilious Erysipelas. — The bilious phenomena above alluded to have such a predominance in certain instances, that to cases presenting them has been applied the title bilious erysipelas. The cases now alluded to occur in localities and at seasons in which a malarial influence prevails, and they are marked by bilious eructation and vomiting, bitterness of the mouth, a. yellow tongue, epigastric uneasiness and tenderness, great thirst, sometimes constipation, or, again, bilious diarrhoea, scanty and yellow urine, and yellow- ness of the skin or conjunctivae. Metastatic Erysipelas. — Erysipelas is said to be metastatic, when it dis- appears abruptly from one place to reappear as suddenly in some other part. Thus it may pass from the face to the external genital organs, from the ear to the limbs, from the skin to some internal part, etc. This trans- lation is sometimes produced by cold air, or by the application of cold or astringent lotions. Such phenomena illustrate the doctrine that erysipelas is not a local inflammation, but a disease involving the whole system, just as analogous metastases show a similar nature in gout and rheumatism. The change of seat, moreover, does not always take place abruptly; an internal organ may be attacked after the complete resolution of the original inflam- mation, presenting, in fact, the characters of a relapse in which the seat of the secondary is quite different in its character from that of the primary affection. For example: — A young and healthy man experienced an attack of erysipelas of the face and scalp, which ran the usual, and a favorable course, even to desquamation. After six days of apparent convalescence, the patient was attacked with pain in the right side of the chest, cough, fever, sore throat, redness of the fauces, and crepitant rales at the base of the right lung. Death occurred in four days, when the pharynx was found of a bright red color which ceased abruptly at the oesophagus, but extended into the larynx, trachea, and right bronchus, even to its smallest subdivisions, though it did not affect the left. The alveoli of the right lung were distended with leucocytes, but there were no bronchial casts, nor did any hepatization exist. The nature of the exudation was characteristic of erysipelatous, but not of " croupous" or fibrinous inflammation. The disease, in this case, appears to have made two separate and independent attacks ; but whether the poison that occasioned the second was the same that produced the first, and afterwards remained quiescent in the system, or whether the relapse was due to a fresh infection, may remain in doubt, the former view, however, seeming to be the more probable. Erysipelas of New-born Infants. — Erysipelas in new-born children, at least in its epidemic form, is, as was long ago observed, almost entirely confined to lying-in hospitals. It was doubted by Underwood whether it ever affected those who were more than a month old, but, unless those cases alone are regarded which originate in section of the umbilical cord, this opinion is too exclusive. The disease sometimes prevails among children of one or two years, confined iii hospitals. On the other hand, it is known to have occurred during infra-uterine life, as in Bromfield's 2 case, in which the child was born with erysipelas of the face and legs, and in which, although sloughs existed on the latter at birth, recovery followed. In nearly all cases of this form, ' Prager Vierteljahrsohrift, IM. lxxxix. Anal. S. 67. 2 Medical Communications, vol. ii. p. 22. SYMPTOMS OF ERYSIPELAS. 187 the erysipelas is distinctly traumatic, and takes its starting-point from the divided umbilical cord ; but it as distinctly coincides with epidemics of puerperal fever, and must be attributed to the same essential cause as that affection. Trousseau, at an early period of his career, pointed out this rela- tionship between the two diseases, and in 1855, Lorain stated that under the same conditions infants also perished with peritonitis, abscesses, septicemia, and gangrene of the limbs, and that in the greater number of sueh eases the mothers had died of puerperal fever. Isunneley followed Underwood in noting the extremely sudden onset and rapid development of the inflamma- tion, and Trousseau insisted upon the same point, and also upon the almost •inevitable fatality of the disease within the first two or three weeks after birth. 1 It generally begins to show itself at the pubes, extending rapidly upward on the abdomen, and downward upon the thighs and genitals, which grow exceedingly red, swollen, hard, and cedematous, and then purplish ; phlyctenas form, and the skin is attacked with gangrene. The infant at the same time falls into a state of prostration, yet has scarcely any fever at first; but as the inflammation spreads and grows more intense, fever comes on with pain, and there is great restlessness, sleeplessness, and debility, with vomiting and diarrhoea, which rapidly exhaust the strength and bring on a fatal issue from the fifth to the seventh day. This termination is sometimes due to gangrene of the erysipelatous parts, and sometimes to the formation of abscesses, although, according to Trousseau, the latter occurrence is, on the whole, a favorable sign. Erysipelatous Peritonitis. — This form of erysipelas was first described in 1828, by Abercrombie, 2 who alludes to its symptoms as being sometimes slight and insidious, though sometimes very severe, but as chiefly distin- guished by the rapidity with which they run their course, and by a re- markable sinking of the vital powers, which occurs from an early period, and often prevents the adoption of any active treatment. In one of the cases related by this author, an erysipelas of the leg abruptly subsided, the patient was seized with symptoms of peritonitis, and died in a little more than twenty-four hours from the time of the attack. In another case, the primary attack was an erysipelas of the throat, but during convalescence the patient was suddenly seized with violent pains in the abdomen, followed by collapse and death in about forty-eight hours from the commencement. In the Merchants' Hospital (a charitable institution for the education of girls), and while an epidemic of erysipelas of the throat prevailed in Edin- burgh, a number of the inmates were attacked with the disease in a similar form ; but, after a week, one of the girls who seemed to be entering on con- valescence, was suddenly seized with symptoms of peritonitis, including vomiting, diarrhoea, pain, and collapse, of which in a few hours she died. A second fatal case occurred with nearly identical symptoms ; and in both of them inspection after death revealed the lesions of peritonitis, including an exudation which was puriform rather than fibrinous. Abercrombie makes the^ following commentary: "This affection differs from the usual forms of peritonitis; and, without speculating further upon the nature of it, we may add that its alliance to erysipelas appears to be an obvious and remarkable character of the disease." 1 Lectures on Clinical Medicine, New Sydenham Society's edition, vol. ii. p. 271. 2 Pathological and Practical Researches, etc., p. 181. ■ 188 ERYSIPELAS. Diagnosis of Erysipelas. The direct or positive diagnosis of erysipelas may frequently be made before the actual appearance of the eruption upon the skin or adjacent mucous membrane. It rests primarily upon the swelling, redness, and tenderness of the lymphatic glands connected with the part about to be attacked. Those of the neck usually present such appearances in erysipelas of the face or thmat ; those of the axilla or the groin, in erysipelas of the upper or lower extremities. "When the inflammation itself appears, it may be recognized by the uniform pink or rose color of the skin, which in the throat assumes a dusk}' hue ; by the rapid swelling of the integument, accompanied w^ith a burning heat of the part; and especially by the abrupt ridge that divides the inflamed from the unaffected skin, the rapid encroachment upon the latter of the inflammation, and the equally rapid rise of the temperature. These signs distinguish erysipelas from lymphangeitis or avgeioleucitis, in which the swelling is less, and the redness, instead of being uniform, follows the trunks of the lymphatics, and is therefore streaked, and also presents limited and indurated swellings, and is not abruptly bounded by the sound skin. It does not follow, however, that the two affections may not coexist in the same case. Erythema, such as is at all likely to be confounded with erysipelas, is a much more superficial inflammation of the skin, and its edges are not abrupt and elevated as in the other disease. "When it occurs, as it often does, upon tt'deinatous or dropsical parts, this sign is distinctive, especially as the affec- tion is not attended with the febrile movement which accompanies erysipelas. When it is traumatic, it is more apt to arise from abrasions, from friction, etc., than from a division of the tissues. Yet it is not uncommon around certain more deeply seated lesions, such as old ulcers, especially of the legs. Volkmann has directed attention to the difficulty of distinguishing from phlegmonous erysipelas, a diffused inflammation of the connective tissue which results from severe injuries, and which presents an irregular and often dull red- ness and an cedematous swelling of the skin. lie notes as distinctive marks of this affection, a slow development of fever, with a relatively rapid appearance of bluish-red or dusky, venous congestion, a doughy state of the swelling, and a peculiar sanious or gangrenous aspect of the original wound, while the gene- ral condition of the patient does not present any grave disorder. It is to these contrasts, in a particular case, that Erichsen probably alludes when he speaks of the difficulty of distinguishing between abscess of the scalp and erysipelas. 1 But while in both there may be fluctuation, it is in abscess always limited by the attachments of the occipito-frontalis muscle to the occipital ridge and the zygoma, while in front the pus will be apt to gravitate towards the eyes, and form a puffy swelling of the eyelids. But in diffused erysipelas of the seal}), the ears are always involved, and become red, swollen, and covered with blebs. Prognosis or Erysipelas. The prognosis of erysipelas varies, according to the character of the attack, from almost absolute safety to as absolute fatality. The former estimate rd'.is to the idiopathic, sporadic disease, the latter to the epidemic puerperal form. Between these two extremes lie the large number of cases of surgical erysipelas in which the mortality fluctuates indefinitely, and chiefly with the dominant type of the disease, 1 Lancet, January, 1878, p. 115. PROGNOSIS OF ERYSIPELAS. 189 First, in regard to medical erysipelas occurring primarily and confined to the skin, the prognosis is generally favorable. One of the greatest of French clinicians, Chomel, declared that he had never seen a fatal case of primary erysipelas of the face ; and Trousseau, whose immense experience gives his statement great weight in such a matter, stated that of the large number of cases of this affection which he had seen, not more than three had proved fatal. During a period of four years he met with but one death in fifty- seven hospital cases, and in it the hairy scalp was involved. Indeed, he was disposed to regard this most ordinary form of the disease as benignant in its character, and even less fatal than bronchitis ; and he charged that where recoveries had taken place after the use of bleeding or purging, or the em- ployment of emetics, blisters, or cauterizations, they had occurred not in con- sequence of the treatment, but in spite of it. 1 Our own experience coincides perfectly with this, for we have never yet met with a fatal case of primary, idiopathic erysipelas of the face in hospital or in private practice, where the disease was submitted to a palliative or a supporting treatment. But Ave have seen it fatal under the use of evacuant, sedative, and so-called alterative measures. If, however, we take all the accessible reports of the mortality from idio- pathic erysipelas of the skin, which have emanated from hospitals, especially in Europe, a different result is obtained. For instance, in the Parisian hos- pitals, in 1862, there occurred 759 cases of various forms of non-traumatic erysipelas. Of these, nearly 17 per cent, terminated fatally, while in the fol- lowing year the mortality was only 8.5 per cent. In still stronger contrast with the usual mortality of the disease, as it is seen in this country, the fur- ther statement may be made that during the two periods just mentioned, in Paris, the mortality of surgical erysipelas was, for the former, nearly 78 per cent., and for the latter nearly 77 per cent. In this country no such lament- able results have ever been observed, not even during our civil war. It has been stated elsewhere that erysipelas occurring within the first month of life, is nearly always fatal ; but once this period is passed, the issue of the disease depends upon the same general conditions as in the case of older persons, and especially upon the original vigor of the patient, and the appropriateness of the hygienic and medicinal treatment. It is proper to state once more, what has been already mentioned, that the decline of an attack of erysipelas of the skin is always to be expected when the inflamed area shades off gradually into the sound skin ; while, as long as it is abrupt, a further extension may be looked for. But even after the com- plete subsidence of the inflammation, a relapse may take place, and in some persons the attack recurs repeatedly, even after long intervals. It appears that this tendency has been exaggerated by confounding together erythema and erysipelas. However this may be, the liability of erysipelas to relapse is most apt to be exhibited in hospitals and other places where a number of cases of the disease have been brought together. In his account of one hos- pital epidemic, Miller states 2 that out of twenty cases, six suffered relapse, four of them once, one of them twice, and one five times ; and that on almost every occasion the fresh attack could be traced to infection by a newly ad- mitted patient. According to Gosselin, 3 the secondary eruption usually oc- cupies the same seat as the primary, extends more rapidly than it, runs its course in a shorter time, and always ends in cure. Erysipelas commencing distinctly in the fauces, or invading them by exten- • Clinical Medicine, vol. ii. p. 263. 2 Edinburgh Medical Journal, vol. xxv. p. 1095. 3 Dictionnaire de Medecine et de Chirurgie Pratiques, t. xiv. p. 25. 190 ERYSIPELAS. sion from the face, or extending to the air passages or to the brain, from the throat or from the scalp, always involves danger. Phlegmonous and gangren- ous erysipelas are dangerous in proportion to their extent, and to their tend- ency to spread without limit. Suppuration in the form of ahscesses involves no special danger. As a common exciting cause of traumatic erysipelas is alcoholic intemperance, so does this habit also render the issue of the disease less favorable ; it tends to favor the extension of the inflammation, and to increase the risk of suppuration and gangrene, as well as to bring about that typhoid state of the system which constitutes one of the greatest dangers of erysipelas. Erratic erysipelas is not severe in itself at any one time, but by its recurrence and its duration for many weeks, or even months, may gradually exhaust the patient's strength. In the epidemic form of erysipelas, and in those local outbreaks of the dis- ease w T hich sometimes assume an equally low type, the danger of death is great in proportion to the degree in which the typhoid state is exhibited, due regard being had to the original soundness and vigor of the patient. When the disease is confined to the throat, or when it also attacks the skin, the dis- ease is seldom fatal, unless it acquire a phlegmonous character in the former situation. This is especially true of cases in private practice. The most fatal form of erysipelas is that which attacks internal organs, and especially the lungs and peritoneum. In both cases the hope of recovery is very small ; but in puerperal peritonitis of erysipelatous origin the mortality is almost ab- solute, and the rapidity of the fatal course is often as appalling as its issue is inevitable. In general terms, the conditions that increase the danger of erysipelas are such as involve debility, including infancy, old age, and complication by pre- viously existing or concomitant diseases, such as phthisis, Bright's disease, diphtheria, or the eruptive and typhous fevers. Moreover, death has occurred by hemorrhage from the bowels in a case which was otherwise benign, and in which no lesion could be found to account for the accident. 1 Finally, blindness has been known to result from erysipelas of the face, as in the case of Despagnet. 2 , Prophylaxis of Erysipelas. The measures which it is advisable to adopt for the prevention of erysipe- las may readily be inferred from the description of the causes heretofore given. They may all be included in the following rules : — I. The utmost purity of the air should be preserved in all apartments habitually used by day, or for sleeping, and especially in hospital wards and other places occupied by the sick. II. All patients suffering from erysipelas should be isolated, and nothing that has been used by or for them, and, least of all, surgical instruments, should be em ployed for non-crysipclatous patients. On the same principle, in climates and seasons which make it possible to treat the wounded in tents or in tem- porary wooden hospitals, such as were used during our civil war, the danger of erysipelas is reduced to a minimum by doing so. III. On no account should a puerperal patient be confined in a house in- fected with erysipelas, nor be attended by any physician who has recently had charge of an erysipelatous case. IV. A surgical ward should never be in close proximity to a lying-in w T ard, » Archiv der Heilkunde, Bd. xi. S. 398. 2 Kooiioil d' Ophthalmologic, Paris, 1880. TREATMENT OF ERYSIPELAS. 191 nor even in the same building, and the attendants in one should hold no com- munication with those of the other. V. During general or local epidemics of erysipelas, all cutting operations should be, if possible, avoided, it being remembered that the danger of the erysipelatous infection of wounds is in direct proportion to their extent. VI. For the reason just mentioned, it is held by some surgeons that subcu- taneous incisions should, under such circumstances, be preferred, and that the surface of recent wounds should be protected by a nitrate of silver film. Treatment of Erysipelas. The most ancient treatment of erysipelas, as described by Hippocrates, consisted in the application of cold water, provided that no ulceration of the skin existed. 1 According to Paul of ^"Egina, 2 if the patient's strength per- mit, blood-letting and cholagogue medicines should be employed, with the topical use of ointments overlaid with cooling lotions. This writer also re- commends emollient poultices made from various mucilaginous plants, with the addition of anodynes, and, at a later stage of the disease, cooling or astrin- gent applications, some of the former containing vinegar, and some of the latter saturnine solutions, potter's clay, and various astringents, including copperas and alum. He also refers to the necessity of incising the skin when mortification threatens (a recommendation made also by Galen and his suc- cessors), and speaks of the virtues of hot or salt water in chronic states of the affection. It is worthy of remark that he and nearly all medical authors from the most ancient times, dissuade from depletion in this disease, although some Arabian authors are exceptions to this statement. Another point upon which there is a general agreement, is the administration of certain purga- tives supposed to be cholagogue. Whether this practice rested on the fact , that epidemic erysipelas was apt to be attended with jaundice, or upon the authority of Galen, who enjoined it upon grounds that now seem quite futile, it is unnecessary to inquire. Beyond a doubt, the practice itself is good at the commencement of an attack, especially when it is associated with the use of emetics, which the ancients do not appear to have employed in this disease. Celsus 3 gives the same qualified advice respecting venesection, and directs the use of cooling and astringent applications, especially ceruse and solanum (dulcamara ?), or chalk. He adds that whatever topical remedies are used, should be applied cold, and kept covered to prevent their getting dry. But he is by no means prejudiced in favor of this refrigerant method, for he enjoins, if its effects should not be favorable, that stimulants and astringents infused in wine should be substituted for it, and, if the part should still re- main indurated, that anodyne ointments and cataplasms should be applied. The history of erysipelas illustrates the general truth in therapeutics, that modes of treatment, and especially of acute febrile affections, should be de- termined by their type, rather than by their essential nature. In a large number of cases, it is so far local and superficial that its treatment may be confided to protectives and palliatives ; in many more, an active antiphlo- gistic method will be tolerated, even if not really indicated ; but in a still more numerous class, and especially during epidemics, whether nosocomial' or more widely spread, and whether idiopathic and primary or puerperal or traumatic, a general treatment at once stimulant, supporting, and tonic, is the only one from which favorable results can be expected. In this disease, as in 1 Works, Sydenham Society's edition, vol. ii. p. 741. 8 Sydenham Society's edition, vol. ii. p. 66. 3 Lib. v. cap. xsvi. sect. 33. 192 ERYSIPELAS. all that tend to assume a typhoid type, the sagacity of a physician is dis- played less in the general plan of treatment he pursues, than in the modifica- tions by which he adapts it to the peculiarities of individual cases. He will keep constantly in mind that he is not treating an abstract disease with ab- stract remedies, but human beings, whose health or life may depend upon his use of agents that may be mischievous or salutary, according to the manner in which they are employed. In no disease more than in erysipelas, have greater errors been committed by overlooking its natural history. Internal medicines, the most diverse in their nature and the most opposite in their effects, have, at different times, or by different physicians, been equally vaunted as cures for this disease. At one time depletion, at another stimulants, now sedatives, and now tonics, have been in vogue, while external applications, as opposite to one another as oil or mucilage, on the one hand, and mercury, iron, and nitrate of silver, on the other, have alike enjoyed a temporary or local favor. One acquainted with the history of therapeutics must regard the claims constantly and con- fidently put forward in favor of successive remedies, as exhibiting a very in- sufficient acquaintance either with this particular disease or with the laws which should govern the search after truth. The instructed pathologist and therapeutist knows that the majority of the cases of acute disease tend, under favorable circumstances, to recovery, and therefore require only a palliative and expectant treatment ; and he also knows that under exceptional circum- stances, as during certain epidemics, death is the necessary end of most of the cases. Only on the middle ground between these two extremes is it that the physician is of much avail to determine the issue ; at either extreme his influence is limited to smoothing the way to death, or rendering easier and more pleasant a return to health. To abstain from interference when it is needless, is as high a duty as to interfere when it is necessary, and rightly to judge how far the intervention should proceed. It may be laid down as the law of non-epidemic erysipelas in general, when it occurs in a previously healthy person, and is not complicated with septicaemia in traumatic cases, that it tends spontaneously to recovery ; and that in simple, or so-called idio- pathic cases, such a result may be looked for within a week. Even if it be possible to shorten this duration by the use of certain medicines, the gain is a gain of time rather than of life over death. Such is the verdict of experience, and no ingenuity of scientific pleading can set it aside. " When," said Trousseau, " a patient suffering from erysip- elas is placed under my care, my rule is to abstain from every kind of treat- ment," and he adds that such had been his plan for twenty-eight years, and that, thanks to it, he could not remember losing more than three persons from erysipelas during that period. He insisted on the importance of keeping patients in bed, both "in the acute stage and during convalescence, to prevent their catching cold and suffering relapse; he prescribed acidulated drinks, laxatives if the bowels were confined, and purgatives if the vomiting were violent. But Ik- insisted also on the necessity of giving food, in spite of fever and even of delirium, and of avoiding whatever would debilitate^ such as low diet, depletion, purgation, or the use of sedatives. In a like spirit with Trousseau, that very accomplished English physician, Latham, said "erysip- elas is a disease that may be treated, but not cured;" 1 and Gosselin, the eminent French surgeon, declares that "erysipelas can be arrested by no treatment whatever." 2 In ordinary cases, then, of erysipelas, that is to say, in cases of average 1 Works, New Sydenham Society's edition, vol. ii. p. 461. 8 Nouveau Dictioimaire, t. xiv. p. 30. TREATMENT OF ERYSIPELAS. 193 severity, and whether of the medical or the surgical form, it is imperative that the patient should, as tar as possible, be isolated; that he should have no more attendants than are absolutely necessary ; that his chamber should be well ventilated, but without exposing him to draughts of air or to dampness ; that perfect cleanliness should be maintained about the wound, if there be one ; and that when the bed- and body-clothing are washed, they should be thoroughly scalded before being handled. The inflamed part should be placed in as comfortable a position as possible, and the face, when affected, should not be exposed to a strong light; the skin should be kept dusted with lycopodium, or finely powdered starch, or wheat or rye flour, and covered with carded cotton; and in cases attended with much burning and tension, a smaller or larger proportion of oxide of zinc should be mixed with the flour, or the part may be kept anointed with vaseline, a far better protective than glycerine which has been much used for this purpose. Vaseline is also greatly superior to ointments, for unlike them it is not apt to become rancid, and it may serve as an excipient for oxide of zinc or lead, or any anodyne extract which may seem appropriate. The white of egg alone, or mixed with finely powdered alum, may also be used. Mucilages should never be employed. The mucilage of slippery elm, and still more of flaxseed, and poultices made of these substances, have to answer for a great deal of discom- fort during their application, and the production of a vesicular or pustular eruption which is unsightly, painful, and sometimes difficult to heal. At a time when every inflammation and fever was recognized as an almost infallible indication for blood-letting, it was naturally and extensively employed in the treatment of erysipelas, and its use was justified by names of unques- tionable authority. Even the candid and clear-sighted Sydenham advised copious depletion. But the weight of judgment is on the opposite side. According to one, it is of "fatal tendency;" others "always found it hurt- fid," or " rarely admissible," or " destructive." " It makes bad worse," said Heberden ; " it renders the disease more obstinate and severe," said Desault ; and Willan declared that " in the low forms it is manifestly improper, and in the phlegmonous not always necessary." According to Copland, " large depletions should be employed with much circumspection, for however high the temperature, or hard and bounding the pulse, there is always a dispo- sition to asthenic vascular action and a deficiency of vital power;" and Bally is of opinion that " it tends to aggravate the symptoms, bring on and intensifjr delirium, and prolong the attack." Yet, even half a century ago, there were found eminent surgeons to say, like Sir W. Lawrence, that, "as this affection resembles other inflammations, it must be treated upon the same principles. Venesection, local bleeding, purging, and low diet are the first measures, to which saline and diaphoretic medicines may be afterwards added. Vigorous treatment in the beginning will often cut the attack short." It is true that he qualified the rigor of this method by stating numerous exceptional cases in which it would be mis- chievous, and especially those of patients weakened by old age or previous disease, and he recognized its inappropriateness after the first stage of the attack. Since his time, depletion having gone out of fashion, even in the treatment of sthenic, inflammatory diseases, it has naturally come to be regarded as pernicious in those which, like erysipelas, tend so readily to a typhoid state. The judgments against depletion in this disease are therefore quoted, not because at the present time any one would probably be tempted to adopt it as a mode of treatment, but to serve as an argument in favor of the opposite method which is advocated in this article. The objections are measurably applicable to local as well as to general depletion. Indeed in the former, if less injury is risked by the loss of blood, much more danger is vol. i. — 13 194 ERYSIPELAS. incurred, through the wounds made by leeching or cupping, of infecting the system anew with the erysipelatous poison, and of creating a starting-point for suppuration or gangrene. Such objections are still weightier against punctures and scarifications employed to relieve the congestion of the skin in simple erysipelas, inasmuch as they form wounds which, besides this special risk, answer their purpose as depleting agents very imperfectly indeed. The use of incisions in the treatment of phlegmonous erysipelas has special objects which will be considered hereafter. The most ancient treatment of erysipelas included, as has already been stated, the application of cold water and other lotions to the affected part, but the dangers of the method, recognized even then, are more generally acknowl- edged now. We cannot therefore commend the practice of Luecke, who, fol- lowing the example of Hebra and others, advises the application of ice to the erysipelatous scalp, and declares that he did not lose a single patient out of a , large number treated by him in this manner. 1 Whether the same result would not have been reached by him, as it has been by others, with a purely negative topical treatment, may well be questioned. Indeed, it may be re- marked here, once for all, that apart from the surgical treatment of phlegmo- nous erysipelas, local applications have not the slightest influence upon the course or issue of the disease beyond that which they exert as protectives and palliatives. This influence should not be undervalued, but it ought not to be mistaken for a radical and curative action. As palliatives, then, may be employed a variety of astringent and stimulant applications , all of which protect the inflamed part from the irritating action of the air, and either repress the vascular action in it or overcome the stagna- tion of the blood by quickening its circulation. Of the former description are lime-water liniment, alum curd, fresh or sour cream, solutions of the salts of lead and zinc, or of the chloride or the sulphate of iron, or some of these salts, and especially the oxide of zinc, in powder. In France, a popular preju- dice regards all watery applications as injurious. The acetate of zinc has been prescribed internally, upon theoretical grounds, and without advantage. The carbonate of lead has been applied, mixed with linseed oil, as a paint ; but if any lesion of the skin exists, it is apt to be poisonous. Flexile collodion has also been used to protect and constringe the affected skin, but is more painful than useful in all cases of erysipelas that really call for active treat- ment. Solutions of gutta percha and also of salicylate of sodium have been employed for the same purpose, and with analogous results. Mechanical com- pression of the affected part lias been made by bandages, especially in surgi- cal erysipelas of the limbs. Velpcau, who was one of the first to make use of it, limited its application to cases in which the inflammation did not extend deeply beneath the skin, and perhaps, like the astringents already noticed, it tended to retard or limit the inflammation. But the impossibility of antici- pating the future course of any such affection, and the great danger of the ] »arts swelling beneath their bandages so as to produce, as actually happened in several cases, not only excessive pain, but ulceration and gangrene, suffice to condemn this method which, in reality, was the product of crude theory and not of clinical experience. Another method of local treatment consists in the application of stimulants to the inflamed part. One of the first used .of these was a blister, the extent of which was limited only by that of the erysipelas. Cases are on record in which it was made to envelop an entire limb ; and although, as usually hap- pens to medicinal agents, its novelty brought it some applause, and not a little false credit, its condemnation was not slow to follow, for the demon- 1 Neftel, Medical Record, vol. iv. p. 79. TREATMENT OF ERYSIPELAS. 195 stration of its good and evil results was not difficult. Subsequently, blisters were applied around limbs affected with erysipelas, not upon the inflamed portion, but upon the sound skin at a little distance from the latter, and were believed to prevent the extension of the disease in that direction ; but expe- rience has shown that this belief was delusive, and that erysipelas pays no respect to any such barriers in its path. Almost identical with fly-blisters in its mode of operation in this disease is a strong solution of nitrate of silver, for which a claim was long ago made, and more recently renewed by its proposer, Du. Iligginbottom, that it absolutely arrested the progress of the disease. The total loss of faith in this vaunted remedy, which was not only painful but inefficacious, is another fact among the many which prove that erysipelas is as little to be cured as smallpox by remedies applied to the skin. Of agents belonging to this class, iodine is one of the best. It has, of course, an array of ' " cures" in its favor ; but it is certainly a valuable palliative of the pain and swelling in some cases of erysipelas, especially of the face. The compound solution, or the compound tincture, should be painted on the inflamed part. It is unnecessary to discuss the value of the actual cautery, or the moxa, which have been vaunted by certain surgeons in this disease ; they are as cruel as they are useless. As a substitutive and protective agent, the liniment of turpentine, or Kentish's ointment, is a very convenient palliative of the local symptoms in cases of superficial erysipelas, and has long been used for that purpose. More recently (1869), Luecke 1 conceived that it had a specific power of destroying the hypothetical virus of erysipelas. Another medicine whose mode of action was conceived to be similar, is hyposulphite of sodium, and its curative powers were attested by several physicians and surgeons of established reputation. But as the success of the medicine was said to be just as great whether it was employed internally or topically, we may fairly conclude that its virtues were more apparent than real, an inference which is quite confirmed by the complete neglect into which it has fallen since its first introduction, about 1860. A like estimate which has been made of iodide of calcium, probably calls for a similar criticism. Among the topical applica- tions used in this disease, camphor may be mentioned, which is anodyne, and when used in alcoholic solution and allowed to evaporate, is also somewhat cooling. At one time mercurial ointment was held by some authorities to be almost certain to arrest the inflammation and extension of erysipelas ; but such effects were soon found to be uncertain, if not unreal, while the frequent occurrence of salivation after the mercurial inunction led to its general dis- use. That it cures cases of the disease which would not get well spontane- ously, cannot be admitted. Finally, it may be mentioned" that bromine has been used in watery solution, as a lotion. As far as it is useful in superficial erysipelas, it may be supposed to act as a local stimulant and anodyne. In phlegmonous erysipelas, when an opening exists, and especially when slough- ing of the cellular tissue takes place, a solution of bromine may be used as a stimulant and disinfectant. Surgical Treatment. — The surgical treatment proper of erysipelas, relates mainly to the management of those cases of the phlegmonous form of the disease in which openings must be made through the skin, to give exit to dead connective tissue and the liquid products of inflammation; but it also relates to that of the wound which is the starting-point of the attack. But often the inflammation forms bullae, or abscesses, which are of limited extent, and do not require any other treatment than would be appropriate in the ab- sence of erysipelas, viz., the evacuation of the blebs and abscesses, and their 1 Bulletin de Therapentique, t. lxxvi. p. 422. 196 ERYSIPELAS. dressing with wet compresses or poultices, or with dry astringent powders, or with salves. The same applications are suitable when superficial sloughs occur. As such sloughs often form upon parts the integument of which is delicate, as upon the eyelids, the ears, and the genital organs, if this accident appears to be due to the tension of the part more than to the deli- cacy of the skin, it is generally prudent to diminish the pressure by punc- tures or incisions that will give issue to the subjacent liquid. When phlegmonous inflammation of the coimective tissue takes place, it is the usual practice, if not always necessary, to make openings through which the products of inflammation can escape. This may sometimes be effected by jmnctures, or more thoroughly by free incisions (Copland Hutchison), at the most convenient, depending point of the swelling; but not unless the tension of the part, its painfulncss, the tendency of the suppuration to advance, or the threatening of gangrene, furnishes the indication for interference. Punctures were highly recommended more than half a century ago by Dobson, who employed them in all cases, in number from ten to fifty, and varying in depth from two to four-tenths of an inch, repeating them from two to four times in the twenty-four hours, and on the scalp, face, trunk, or extremities, as occasion required. He contended that not only were the in- teguments better preserved by making several small openings than by one large incision, but that the effused matter was quite as well evacuated. 1 It may be objected to this method that it involves a very unnecessary suffering in all forms of erysipelas, except the phlegmonous, since they spontaneously tend to recovery ; and at the time of its original proposal, it was said not to be adapted to the phlegmonous form. It was, however, a mild procedure in comparison with that of Lawrence, for which it was proposed as a substitute, and which consisted in " making incisions through the inflamed skin and the subjacent adipose and cellular textures," which were sometimes of appalling length. In one case, it is said, " an incision was made from the ham to the heel," and in another, involving the forearm, the cuts " extended nearly the length of the limb." The method by punctures, and that by short incisions, seem to be quite sufficient for all the exigencies of this disease. The former is said to be adapted to its early stages ; but, as already suggested, the neces- sity of the procedure is so far from apparent, that it would seem to be called for only in exceptional circumstances. In the brawny stage of the inflam- mation, it is recommended that " incisions from one to two inches long, and two or three inches apart, should be made over the inflamed surface, in the general direction of the subjacent muscular fibres " (Ashhurst), and on alter- nate lines, thus | | , " the greatest relief from tension being thus ob- tained with the least destruction of tissue." "At a later stage, when braw- niness has given place to bogginess, showing that sloughing of the subcuta- neous tissues has already occurred, free and deep incisions, three or four inches long, may be required, in order to prevent gangrene of the skin, and to afford exit for sloughs, the separation of which may be hastened by the forceps and scissors. Warm fomentations should be constantly applied, and antiseptics may be freely used, not only in the dressings, but injected among die (issues by syringing. When the suppuration is very profuse, the fomentation may be omitted, the part being simply covered with lint and charpie, tow, oakum, or carded cotton, and supported by the gentle pres- sure of a bandage"' (Ashliurst). When there is, as is most apt to be the case in traumatic erysipelas, even less tendency to circumscription of the disease, Medico-Chirurgical Review, Auguat, 182S, p. 383. TREATMENT OF ERYSIPELAS. 197 and from the first the part is soft as well as greatly swollen, and the type of the attack typhoidal, such incisions as have been described are imperatively necessary to lessen the danger of gangrene of the skin, and to furnish an outlet for the products of decomposition. "In the scalp, crucial incisions are the most effective, while in the scrotum a single free incision on either side of the raphe will usually be all that is neeesssary." When the eyelids are much swollen, it is prudent to incise them parallel to their folds, to prevent puru- lent collections. If the eyeball becomes very prominent, and there is rea- son to believe that pus is infiltrated behind it, a deep incision of the soft parts that line the floor of the orbit is called for, and a blunt probe or direc- tor should be introduced to the supposed seat of the pus, to guide the blade of a lancet or bistoury, held flatwise. Besides the use of carbolic acid as a dressing in the proper surgical cases above noticed, it has been employed in different manners. Thus it is stated by Zuelzer 1 that Kaczorowski applied to the inflamed surface a mixture of one part of carbolic acid and ten of oil of turpentine, which, after temporarily irritating the skin, subdued its inflammation in a marked degree ; that AVilde injected subeutaneously into the inflamed part a solution of sulpho-carbolate of sodium (1 : 12); and that Iluter employed a three per cent, solution of car- bolic acid in the same manner. Tillmanns's experiments led him to the conclu- sion that a carbolic acid solution (2 to 4 per cent.) rendered a previously active erysipelatous inoculating liquid quite inoperative, 2 and he has more recently recommended the hypodermic injection of a similar solution around the limits of the affected skin in the earliest stages of the inflammation. This mode of treatment is said to cause no pain, and to render the skin pale and wrinkled. 3 Tassi claims to have cured four cases of erysipelas by means of a saturated solution of the acid employed in the same manner. 4 Eothe attributes to the following lotion a mitigation of the inflammation in duration and severity : R. Acid, carbolic, gr. xv ; alcohol, tij,xv; ol. terebinthinse, f 3ss ; tr. iodinii, nixv; glj-cerinre, f3iss. M. "With this the part should be bathed every two hours, and kept covered with cotton-wool. Dr. S. J. Radclifte has reported the case of a very old and feeble woman, in whom erysipelas, beginning at a bunion on the foot, extended to the whole of the lower extremity, producing enormous swelling, and attacked the buttock where it occasioned an eschar. After the total failure of local protectives and of the internal use of iron and quinia, he applied a solution (1 : 16) of carbolic acid in olive oil, three times a day, covering the part, also, with cotton-wool. Relief was obtained almost immediately, the local phenomena rapidly declined, and the patient recovered. 5 Dr. A. G. Miller, of Edinburgh, while inclined to regard as useful the internal employment of sulpho-carbolate of sodium, and that of the carbolates of so- dium and quinia, refers to their irritant effects., and especially those of the latter preparations, upon the stomach and bladder. 6 The internal medication of erysipelas in ancient times consisted, as we have seen, chiefly in the use of purgatives, which were believed to be cholagogue, and which appeared to be indicated by the gastric derangement which is the usual accompaniment of the first stage of febrile affections in warm climates. In recent times, emetics have been more generally employed for a similar pur- pose, and perhaps, by the shock which they give the system, to break up 1 Ziemssen, loc. cit. 2 Edinburgh Medical Journal, vol. xxv. p. Gu7. 3 Philadelphia Medical Times, January, 1881, p. 201, 4 Bulletin de Therapeutique, t. c. p. 239. 6 Philadelphia Medical Times, vol. xi. p. 455. 6 Edinburgh Medical Journal, vol. xxv. p. 1095. 198 ERYSIPELAS. "the chain of morbid associations," to use the figurative hut not unmeaning phrase of another epoch. However this may he, the frequent occurrence of spontaneous vomiting was supposed to indicate a biliary derangement, and "a saburral condition" of the stomach, and this belief was confirmed by the accompanying thick coating upon the tongue. But now it is certain that vomiting is a frequent precursor of febrile attacks of very diverse nature, and that the degree and nature of the tongue's coating is immediately related to the general state of the system, and not at all to that of the stomach. Al- though the reasons given for an emetic treatment of erysipelas may have been groundless, the method itself may have been good, by as much as facts are generally better than opinions, and practice than theory. It may very well be that an emetic or an emeto-cathartic given in the forming stage of this as well as of many other febrile diseases, will tend to mitigate its severity and modify its course, partly by cleansing the alimentary canal of its putrescible contents, and partly by quickening all the eliminative secretions, and very possibly by expelling in this manner a portion of the morbid poison contained in the blood. It is a treatment which may be eligible without being elegant, and that it is the former, our experience, especially in hospitals, does not per- mit us to doubt. The most appropriate emetic is ipecacuanha, the most unsuitable, as a rule, is tartar emetic ; or, if the latter be used, it should be prescribed in small doses dissolved in a weak solution of Epsom salt or some analogous saline. The emetic treatment, it need hardly be added, is not so well adapted to surgical as it is to medical erysipelas. The use of alcoholic stimulants, in ordinary cases of the disease, is not only unnecessary but injurious, for they increase the fever, lessen the appetite for food, and impair the digestive function. It was part of a system of stimula- tion which Dr. Todd, of London, brought into vogue about 1860, to administer in this disease, at stated times and in small doses, so as not to excite nausea and intolerance, beef-tea and brandy. He even went so far as to say, " If I were restricted to one remedy in this disease, I should assuredly choose brandy." 1 And he repeated and elaborated this idea in his clinical lectures published four years later. Considering that he had to do with neither sur- gical (traumatic) nor puerperal erysipelas, it is certain that he went far beyond either his contemporaries or his successors, in his recommendation. Nothing can be more certain than that erysipelas, as such, stands in no need of alcoholic treatment ; but that the typhoid forms and states of the disease may and generally do call for it, as the same conditions do in all other febrile affections, is unquestionable. And not only for alcohol but for other stimulants, cardiac and nervous, of which oil of turpentine is by many ranked highest, as it is also in whatever form of fever a tendency to the typhoid state is most marked ; and next to it, or even higher but for its more transient operation, carbonate of ammonium may be placed. ]STot many years ago, the prevalent theory of erysipelas attributed its phe- nomena directly to the extravasation of the white corpuscles of the blood, and, as at that time quinia became endowed with a specific control over this migration, it was looked upon as the natural antidote of erysipelas. But as the theory could not be made to embrace all of the cases in which the utility of quinia had been demonstrated, another virtue was assigned to it, viz., that of destroying disease-germs; and, finally, this being found an inadequate explanation, the antipyretic virtues of quinia were invoked to account for its power in curing erysipelas. It was omitted, however, to show that in any true and real sense quinia did cure, i.e., arrest, this disease. It is claimed that the use of large doses of quinia in erysipelas was instituted, in this 1 Medical Times and Gazette, January, 1855, p. 29. TREATMENT OF ERYSIPELAS. 199 country at least, by Surgeon Satterlee, IT. S. A., as long ago as the Florida Indian war, in 1835. In 1836, Latham 1 claimed that in certain cases the patients must have died without quinia, and that it " cured them outright, without the fulfilment of any intermediate purpose whatever;" and he recalled the fact that at the beginning of the present century bark was regarded by all experienced physicians as a specific for erysipelas. Indeed it was pre- scribed by Ileberden, Hoffman, Fordyce, Pearson, Cooper, and many others, to control a tendency toward the typhoid state so charaeteristic of this disease. In 1857, Coale prescribed ten grain doses of quinia in pharyngeal erysipelas. 2 More recently, quinia has been employed for quite a different purpose, viz., in such doses as to produce a sedative impression. In 1874, Dr. F. Satterlee reeommended the administration, in the forming stage of the attack, of sulphate of quinia in doses of twenty-five or thirty grains, but if the disease was fully developed, lie directed a similar dose every night for three successive times. He claimed that in some cases a single one of the doses mentioned proved sufficient to abort the attack, while in other instances the temperature and pulse fell greatly, and the general symptoms either dis- appeared or improved, from twenty-four to forty-eight hours sufficing to abort the disease. 3 Binz and Liebermeister have also used this method with like results. It may be added to these statements, without attributing to it great weight, that, according to Rombla, hydrobromate of quinia, employed hypodermically, caused a rapid subsidence of the symptoms in a case of typhoid erysipelas. 4 It will be observed that equal success is claimed for quinia, whether it is given in small or tonic doses, or in massive, sedative, or so-called antipyretic doses. Theory apart, it must be believed that the former are most appropriate in the epidemic and typhoid forms of the disease, and the latter in the more sthenic cases, of which erysipelas of the face, as it ordinarily occurs, may be taken as the type. Tincture of chloride of iron was, at one time, regarded as almost a specific, at least in the idiopathic forms of erysipelas. In 1851, Mr. G. II. Bell, of Edinburgh, declared that for twenty-five years he had made use of it without having in a single instance tailed of success. In mild cases he prescribed fifteen drops, and in severe cases twenty-five drops, of the medicine every two hours, night and day, however high the fever and delirium, until the disease was completely removed. These conclusions were confirmed by C. Bell and others. In 1852, Begbie related several cases in which the exhibition of the medicine was quickly followed by a remission of all the symptoms. 5 Pirrie stated, that under its use, " the febrile condition seemed to be relieved, the frequency of the pulse reduced, the powers of the system generally to be upheld, and the stomach and bowels in no way irritated. Headache and sensorial disturbance diminished under its use." He prescribed 15 to 20 drops every two or three hours, until convalescence was fairly established. 6 In France it was used soon afterwards by Aran, Mathey, and others. Ac- cording to Mathey, by the third day after the medicine was commenced, often by the second, or even by the first day, the progress of the disease was checked. He, however, prescribed not more than thirty drops a day ; but Aran increased the dose to twice or three times as much, or even more than this, and obtained equally satisfactory results. He conceived that certain cases were not benefited by this treatment, especially those occurring in young 1 Op. eit., p. 401. 2 Boston Medical and Surgical Journal, February, 1857, p. 63. 8 New York Medical Journal, vol. xx. p. 579. 4 Compendium de Therapeutique, 1880, p. 83. 6 Monthly Journal of Medical Science, September, 1S52, p. 243. 6 Edinburgh Medical Journal, July, 1861. 200 ERYSIPELAS. and healthy persons of a sanguine temperament, and that it was most efficient when the patients were of a delicate, feeble, lymphatic constitution, or Lad been exhausted by previous disease, when the local inflammation was (edema- tous rather than phlegmonous, the pulse soft rather than tense, and the tem- perature not very high. It appeared to be most useful in the milder and more superficial forms of traumatic erysipelas, in the chronic and wandering forms, in a word, in all that involved debility of the system. It would seem, also, to have been successfully used as a prophylactic for persons about to be operated upon in surgical wards where erysipelas prevailed. 1 As late as 1880, the utility of tincture of chloride of iron in this disease was still recognized in Edinburgh, for it is stated by Miller that in the Royal Infirmary in that city the ordinary treatment of erysipelas consisted of a purge, milk diet, and the iron tincture, with a dressing of flour and cotton- wadding. Its effect on the milder cases was manifested in a few hours inva- riably. With these statements the experience of the writer substantially agrees, and while the measure of the medicine's utility is not always the same, it appears to him none the less prompt and decided, although most unequivo- cally so in the less sthenic forms of the disease. The impression he has re- ceived from his experience is that this preparation has a double mode of action ; that it acts by constringing the bloodvessels, and thereby limiting the inflam- matory process, and that while it tends to maintain the normal constitution of the blood, it also counteracts the noxious operation of the poison in the system. It is proper, however, to state that a less favorable judgment has been pro- nounced by some clinical observers. Long ago, Todd, prepossessed, no doubt, in favor of his own stimulant method, considered that the iron might be use- ful in otherwise benign cases, partly and chiefly because it excluded depress- ing treatment. "But," he added, " I would as soon think of trusting to it in the treatment of grave cases, as I would to the billionth of a grain of aconite, or of arnica, or sulphur, or any other homoeopathic absurdity ;" 2 but five years later he softened this contemptuous judgment by the advice not to trust to the medicine alone, " but merely to use it as an adjunct to the stimulant regi- men." 3 Nortel was not very happy in declaring that the medicine " ought to be entirely discarded from the treatment of erysipelas, for, like all the pre- parations of iron it increases the temperature, and is therefore injurious in febrile diseases." 4 The question is not whether iron raises the temperature, but whether this preparation of it tends to cure erysipelas. Estlander pro- nounced it to be of no real utility ; 5 and Dr. R. J. Lee concluded that cases treated with it were of longer duration than usual. 6 But the weight of tes- timony upon the subject is altogether against these objectors. It would be easy to enumerate many other medicines than the few which have been mentioned, and which have been set forth as possessing a really modifying and curative influence in this disease, but as a type of them may be given "the following conclusion respecting one of them, by a writer upon the subject: " It is difficult to decide which is the best treatment, but experi- ence seems to point to bicarbonate of soda, largely diluted with water, to be drunk warm." 7 Such conclusions indicate how great is the incompetency of some observers to judge of the operation of medicines. 1 Bulletin do The'rapeutique, t. liii. p. 12. 2 Medical Times and Gazette, July, 1855, p. 30. 3 Clinical Lectures, 18G0, p. 216. * Medical Record, vol. iv. p. 78. 6 Medical Times and Gazette, December, 1871, p. 71 G. 6 Practitioner, vol. viii. p. 158. 7 Braithwaite's Retrospect, Quarterly Epitome, 1880, p. 171. TREATMENT OF ERYSIPELAS. 201 In erysipelas of infants at birth no treatment is of much avail, but it necessa- rily must consist mainly of topical agents, such as have been enumerated for the disease as it occurs at a later age. Of these, oxide of zinc and mercurial ointments are most generally recommended. When erysipelas affects persons at the opposite extremity of life, the only modification of the ordinary treat- ment should consist in the tree hut judicious administration of alcoholic stimulants, and of the preparations of hark in tonic and stimulant doses. When the disease commences in the fauces, or extends into the tarnyx, these parts should he treated with astringents (nitrate of silver, chloride or sulphate of iron), which may be applied by means of a swab or brush, or, still better, by means of the steam atomizer, which is equally appropriate when the inflam- mation invades the bronchia. If the swelling of the mucous membrane of the larynx interferes with respiration, it should be scarified, and, if this pro- cedure fail to give relief, the operation of tracheotomy remains as a last re- source. It is possible that a large blister on the chest might be of service, but the evidence of its virtues is not conclusive. It is unnecessary in this article to discuss in detail the treatment of epi- demic erysipelas, or even of those typhoid states of the disease in its sporadic form which are occasionally met with. As in all similar cases, the treatment of the local affection must be subordinated to the type of the attack, that is to say to the treatment of the typhoid state. In carrying out this idea, the practitioner must not be misled by the delirium, etc., into believing that a meningitis exists, for no lesions representing that disease are ever found after death. The most efficient remedies are alcohol and opium, or, for the former, coffee may he substituted, and quinia in small and repeated doses should be given, while stimulating food is not omitted. As in other typhoid affec- tions, serpentaria, ammonia, camphor, musk, etc., may be useful. In this form of the disease, good nursing is of primary importance, and includes not only the h} T gienic measures that have been pointed out, but the watchful and judicious administration of stimulants, tonics, and food, as they may be re- quired by the varying condition of the patient. PYEMIA AND ALLIED CONDITIONS. BY FRANCIS DEL AFIELD, M.D., ADJUNCT PROFESSOR OF PATHOLOGY AND PRACTICAL MEDICINE IN THE COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL DEPARTMENT OF COLUMBIA COLLEGE, NEW YORK. Nomenclature. It has long been known that a certain number of patients, who have re- ceived wounds by accident, or by the hands of the surgeon, may sutler from general constitutional symptoms of greater or less severity. To designate the condition of these patients, the terms pyaemia, septicaemia, septico-pyaemia, ichorrhaemia, inflammatory fever, surgical fever, traumatic fever, suppurative fever, purulent infection, etc., have been used. These terms, however, are used in different ways by different authors. At first the tendency was to group all these conditions together. Since 1848, however, pyaemia and septi- caemia have been distinguished as different conditions. At the present time many different views prevail. Billroth defines septicaemia to be "a constitutional, generally acute disease, which is due to the absorption of various putrid substances into the blood, and," he adds, " it is thought that these act as ferments in the blood, and spoil it so that it cannot fulfil its physiological functions." Pyaemia is "a disease which we suppose to be due to the absorption of pus or its constituents into the blood." Hueter says " septicemic fever is produced by the entrance of products of putrefaction into the blood. It is possible that the products of putrefaction are of different kinds, and that consequently there are different varieties of septicaemia." He defines pyaemia as follows: "Pyemic fevers are developed by the introduction into the blood of the components of pus, either the serum or the pus globules. The pus may enter directly into the blood- vessels or lymphatics, or it may first form parts of thrombi in the veins, and then enter the circulation, carried in the fragments detached from these thrombi." He distinguishes simple pyaemia from metastatic pyaemia, and he also admits of a combination of pyaemia and septicemia, which he calls sep- ticopyemia. Burdon Sanderson says: "What I mean by septicemia is a constitutional disorder of limited duration, produced by the entrance into the blood stream of a certain quantity of septic material. It must, there- fore, be regarded, not so much as a disease as a complication, differing from pyaemia, not only in the fact that it has no necessary connection with any local process, either primary or secondary, but also in the important particu- lar that it has no development. Pyemia is a malignant process, which goes on and on to its fatal end ; but in the case of septicemia, inasmuch as the poison which produces it has no tendency to multiply in the organism, there is no reason why the morbid process should not come to an end of itself, un- less either the original dose is fatal, or a second infection takes place from the (203) 204 PYEMIA AND ALLIED CONDITIONS. same or another source." Mr. Savory, speaking in the debate on pyaemia at. the Clinical Society of London in 1874, classes septicaemia and pyaemia to- gether as but different degrees of effect of the same poison. The London Royal College of Physicians defines pyaemia to he " a febrile affection result- ing in the formation of abscesses in the viscera and other parts." Ordinary usage, at the present day, applies the term pyaemia to those cases in which infarctions, abscesses, and local inflammations are present; while the term septicaemia is employed to designate cases in which similar clinical symptoms exist, but in which no lesions are found. But, as Koch says, the names pyaemia and septicaemia no longer express what was originally meant by them. For pyaemia does not arise, as was for- merly supposed, from the entrance of pus into the bloodvessels, nor is septi- caemia a putrefaction of the living blood. These have only remained in use as general names for a number of symptoms, which most probably belong to a series of different diseases. In this article the word pyaemia will be used as a general term to designate the entire group of cases. Nature of Pyemia. There are three theories which have been held as to the nature of pyaemia : — I. That pus is absorbed, circulates in the blood, and acts as a poison; II. That a chemical poison is evolved from pus and the other matters which are found in wounds, and that the system is poisoned by this ; III. That microscopic organisms are introduced into and developed in the wound, find their way into the blood and tissues, and there multiply. I. The Theory of Pus Absorption. — The idea that pus can be absorbed and act as a blood poison, is a very old one, dating from the times of Ambroise Pare (1561) and Boerhaave (1720). Hunter, in 1784, modified the prevailing views by declaring that the pus was derived from the interior of inflamed veins, and found its way from thence into the circulating blood. The idea that the symptoms and lesions of pyaemia were due to the presence of pus in the blood, whether absorbed from wounds or from inflamed veins, continued to prevail, based partly upon clinical observation, partly upon the results of injections of pus into the veins of animals, until there appeared, in 1846 and in subsequent years, the studies of Virchow concerning thrombosis and embo- lism. He showed that the changes in the veins which had been regarded as due to phlebitis, Averc caused by the coagulation of the blood, and by sub- sequent degenerative changes in the thrombi thus formed ; that the infarc- tions and abscesses seen in the viscera were due to emboli which had become detached from the softened thrombi; that, as the white blood globules and pus globules were identical in appearance, they could not be distinguished; and that it was improbable that pus globules made their way into the blood. These researchej afforded a mechanical explanation of some of the lesions of pyaemia. But there was still a tendency to ascribe to the absorption of lauda- ble pus a certain number of the lesions and symptoms. Sedillot, Weber, Billroth, ami others, have held that laudable, fresh pus, was capable of being absorbed, and of producing a febrile movement. This opinion has, indeed, been controverted, but the doctrine of the absorption of laudable pus has hardly yet disappeared from pathology. II. Tin: Chemical Theory. — Gaspard (1822), one of the earliest investiga- tors of septicaemia, suggested that the poison might be one of the chemical products of putrefaction. This opinion was sustained during subsequent NATURE OF PYJSMIA. 205 years by other observers. The most thorough studies of the subject, how- ever, from this point of view, are those of Panum (1855 and 1874). His studies were careful and systematic, and were carried on during a number of years. His conclusions are essentially as follows: "It is demonstrated that there is in putrefying fluids a specific, chemical substance, soluble in water. This substance, if introduced into the blood, produces the peculiar symptoms which belong to what is usually called putrid or septic infection. This sub- stance possesses such infectious properties after being completely freed from all microscopic organisms." Attempts to isolate this infectious substance and find a definite chemical composition for it, have not been successful. Ililler (1876) also went over the ground very thoroughly, and arrived at the con- clusion that there were two putrid poisons: A chemical poison, producing symptoms in proportion to its dose ; and a septic ferment of great malignity, a malignity increased by successive inoculations. Besides these views of a chemical, putrid poison, it must not be forgotten that the introduction of a variety of substances into the circulation can produce fever. Blood, solutions of sulphate of ammonium, even distilled water, can act in this way. It must also be remembered that in simple fractures, where no air or germs contained in the air can approach the wound, there may be fever. In such cases it seems probable that the absorption of the tissues destroyed by the contusion may be the efficient cause. III. The Germ Theory. — This theory is founded on Pasteur's studies concern- ing putrefaction and fermentation. He has demonstrated, to almost universal satisfaction, that putrefaction and fermentation are due to the presence and growth of certain minute organisms; that unless these organisms are present, fermentation and putrefaction do not take place ; that these organisms are in suspension in the air, and that it is for this* reason that the access of air in- duces putrefaction. From these facts came the probability that the different infectious diseases might be due to analogous processes; to the introduction of microscopic organisms into the body, and to their multiplication there. Septicaemia and pyaemia have been especially studied from this point of view. Notwithstanding all the work that has been done, however, we are still far from positive results. Investigations have been carried on in two directions: (1) examinations of the blood and tissues in persons who have died of pyaemia and septicaemia ; and (2) the production and study of similar lesions in animals. (1) The Examination of the Blood and Tissues in Persons ivho have Died of Pyaemia and Septicaemia. — -This study is rendered singularly difficult by the minute size of the microscopic organisms, and all attempts to distinguish these bodies by means of staining or of chemical reagents have so far proved unsatisfactory. They are found of two principal shapes; little rods of various sizes, which may be single or joined in chains; and little globules which are collected in masses, or joined to form chains or dumb-bells, or scattered singly. The generic name for both is bacteria, but it has become customary to call the rods bacteria, and the little round bodies microco^-i, although other names have also been given to them. The larger rods and the clumps of micro- cocci can usually be made out, but the smallest rods and the scattered micro- cocci are always uncertain objects. It is also still undecided whether the micrococci and bacteria are the same organism in different stages of develop- ment; whether there are a variety of these organisms, one for each infectious disease ; whether any of them are altogether harmless. Observations differ also as to whether the rods or the micrococci, or either indifferently, are the active agents. Birch-IIirschfeld, examining the fluids from a number of wounds, found 206 PYAEMIA AND ALLIED CONDITIONS. that the pus from healthy wounds sometimes contained rod bacteria, some- times no organisms; but that when micrococci were present, the wounds were uniformly unhealthy. In the blood of pyemic patients, he found some- times nothing, sometimes micrococci in the plasma and in the white blood- globules. He also found that pus from pysemic patients was more infections than putrefying fluids, when injected in animals, and that such pus was less infectious after it had begun to putrefy. He believes that the micrococci rather than the rod bacteria produce pyaemia. On the other hand, Ranke has found micrococci regularly present in wounds treated antiseptically. Cheyne found that no rod bacteria were present in the discharges from wounds treated antiseptically, but that micrococci were often present. He regards the presence of bacteria as causing pyaemia, while micrococci, he believes, are harmless. The committee of the London Pathological Society found that organisms were sometimes present in the blood, sometimes absent. Rods were found most constantly, but besides these, ovoid bodies measuring from 3 (*■ to 8 /* [micro-millimetre = -njVa millimetre]; other larger granules, sometimes in clumps ; and dumb-bells. In the organs and tissues after death, the com- mittee found, in a large number of cases, micrococci ; especially in the thyroid gland, heart, lungs, 'liver, kidneys, suprarenal capsules, spleen, lymphatic glands, and blood clot. They were nearly always in bloodvessels and usually in capillaries. Bacteria were only found in two cases, both somewhat doubt- ful. Many other observers have also found micrococci in the tissues. The general results of the examinations of the human subject are that, in the wound, both rods and micrococci are found, but that it is doubtful whether one or the other, or both, are the harmful agents; in the blood, both rods and micrococci are sometimes found, rods most frequently ; in the tis- sues, micrococci are found frequently, rods but seldom. (2) The Experiments on Animals have consisted chiefly in inoculating animals with pus from pyemic patients; with putrefying fluids of different kinds, especially blood ; and with blood from other animals. The inoculation of pus from the wounds of pyemic patients is usually fatal to animals ; sometimes without any lesion, sometimes with metastatic inflam- mations (Birch-IIirsehfeld). The inoculation of putrefying blood or other fluids acts in three ways. Large doses destroy the life of the animal after a short time. Small doses produce no symptoms, or transitory ones ; or after some hours the animal becomes ill, emaciates, gradually loses strength, and dies. The putrefying fluids injected, always contained bacteria, and most observers hold that if the bacteria are re- moved, the remaining fluid is harmless. But Panum has shown that the fluid may be poisonous after the removal of the bacteria; and Ililler has shown that the bacteria, when isolated from the putrid fluid, may be harm- less. Davaine has shown that, in septicemic animals inoculated successively one from the other, the blood becomes constantly a more virulent poison. Burdon Sanderson has shown that, if a peritonitis be first artificially pro- duced by some chemical irritant, the fluid from such a peritonitis will by successive inoculation become more and more virulent, and will contain bac- teria. There has been considerable diversity of opinion as to the constancy of the presence of organisms in the blood of animals thus inoculated. Koch, in his experiments on mice, found in the blood of those killed by large injections of putrid blood, a lew rods of different sizes, and micrococci; but if the animals were inoculated with a very little septic fluid and developed septic symp- toms, then only the small rods were present in large numbers. Pasteur has endeavored to isolate the organisms peculiar to pyaemia by successive culti- SYMPTOMS AND LESIONS OF PYEMIA. 207 vations. He has arrived at the conclusions that there is a special rod-shaped form of bacteria, peculiar to pyaemia ; that this organism does not grow in contact with the air, but is killed by it (anaerobie) ; that micrococci are de- veloped from these rods, which are not affected by the air, and which can under favorable conditions grow into rods ; that there is another form of rod- bacteria which produces local suppuration. There seems good reason to believe, from all these different experiments, that putrefying fluids, when injected beneath the skin or into the veins of animals, produce serious symptoms, or death. These putrefying fluids in- variably contain bacteria. If the bacteria are removed by filtration, boiling, etc., the fluid is still poisonous (Panum). If the bacteria removed by filtra- tion are injected, they are also poisonous ; but if these bacteria are washed repeatedly, they may be innocuous (Hiller). On the other hand, successive cultivations of a particular kind of bacteria, in indifferent fluids, produces an organism which is constantly poisonous (Pasteur). These putrefying fluids seem to act in two ways: (1) as a direct and rapid poison ; (2) in small doses as a slower poison. In the animals killed by large doses, few or no bacteria are found in the blood, nor is their fresh blood poi- sonous to other animals. In the animals killed slowly, by small doses, bacteria are found in the blood, and the fresh blood is poisonous to other animals. It is still uncertain whether the symptoms and lesions produced in animals by such injections of putrefying fluids, are identical with the symptoms and lesions of pyaemia in man. Symptoms and Lesions of Pyaemia. It is impossible to describe the symptoms and lesions of pyaemia, as we can those of a definite disease. The best that can be done is to enumerate the different conditions which are commonly spoken of under the name of pyae- mia, and to describe the symptoms and lesions which belong to each con- dition. I. There are a certain number of cases of wounds and of injuries, which are characterized by the presence of a febrile movement, without any other symp- toms. The wound is healthy, the patient's general condition is good, the febrile movement is of moderate intensity, lasts a few days, then disappears, and the patient goes on to recovery. This symptom occurs in cases of wounds which are left open, in a certain number of cases in which the wounds are treated antiseptieally, and in simple fractures, especially fractures of the thigh (Volkmann). In these cases, there seems to be no infection from without ; no development of any organism ; no formation of a chemical poison. It seems probable that the febrile movement is due to the absorption of portions of tissue which are dead, but not putrefying. In such wounds and fractures, the injury is often sufficient to destroy the vitality of some portions of tissue. These portions do not putrefy, but undergo necrobiotic changes. The absorp- tion of such dead tissues in certain susceptible persons may be capable of pro- ducing a febrile movement. II. There are cases in, which in some part of the body a portion of tissue is not only dead, but undergoing putrefaction. While this process of putrefac- tion is going on, the patient suffers from rigors, a febrile movement, disturb- ance of the stomach and great prostration, and may even die. But if the putrefactive process is arrested in time, all these symptoms at once disappear, and the patient recovers. The most marked examples of such a condition 208 PYEMIA AND ALLIED CONDITIONS. are seen after childbirth. A woman, after a natural labor, is doing perfectly well, until on the fourth day she is seized with rigors, a febrile movement, and vomiting. The temperature runs up to 10-4°, there is great prostration, the woman looks very ill. She remains in this condition for 48 hours ; then, after repeated syringing, a small piece of putrid membrane is discharged from the uterus. Within half an hour the temperature has fallen to the normal, and the patient has no other bad symptoms. The cases may be even more serious than this; J. Matthews Duncan reports the following:— A. E. was delivered naturally of her second child on June 8. Flooding occurred after the birth of the child, and slight loss of blood continued for seven days. Then the lochia became fetid. On the eighth day, she had rigors, which were repeated daily. She was brought into the hospital on the tenth day, and was delirious that night. On the eleventh day, she complained of no pain, was pale, sick, frequently vomiting, with diarrhoea, the uterus tender, breath sweet, respiration 44, pulse 14G, temperature 104°, copious flow of stinking lochia. A piece of placenta was removed from the vagina. Under the influence of chloroform the hand was introduced into the uterus, and adherent placental masses were removed. The whole genital tract was then washed out with a solution of carbolic acid. That night the delirium ceased; the pulse was 100, the temperature 101°. After this, the recovery was uninterrupted. Similar symptoms are seen in some persons who have received wounds. A man, 19 years old, was shot in the popliteal space. On the same day the bullet was extracted, and the wound dressed antiseptically. The wound discharged so freely a sero-sanH years old, who had suffered for several years from disease of the knee, Bubmitted to resection of that joint. On the day after the operation, there was some fever. The wound was not dressed antiseptically, a thin sanious fluid exuded from it. There was no attempl al repair until the 7th day, when the superficial portions of the wound commenced to granulate. The lever continued, the patient emaciated, and on SYMPTOMS AND LESIONS OF PYJEMIAt 209 the 9th clay he became delirious. On the loth day, there were severe rigors. The fever and delirium continued, the patient gradually sank, and died on the 19th day after the operation. At the autopsy it was found that the edges of the wound were granulating, but that its cavity was filled with foul pus. There were no thrombi in the veins ; no lesions in the viscera. In such cases as these, it seems evident that the cause of the symptoms is the condition of the wound, and this condition in turn seems to be due to putrefaction. There appear to be only two probable explanations of the way in which the condition of the wound can produce constitutional symptoms : either some morbid material is absorbed from the wound, and poisons the system ; or the mere presence of such an unhealthy wound is sufficient. It seems that if it is a poison which is absorbed, this poison does not multiply after absorption, for the symptoms only continue while the wound remains unhealthy, and the severity of the symptoms is in proportion to the amount of putrefying tissue. If the patient dies, no lesions are found except the unhealthy wound, and perhaps thrombi in some of the veins. The indications for treatment seem to be evident, to remove the putrefying tissues ; or, if this cannot be done, to adopt such local treatment as will stop the putrefactive process. III. There are cases in which the original wound is very small, but in which some foreign substance appears to be introduced into the body through the wound, and to act as a poison. The most marked examples of such cases are some of the so-called dissecting wounds. It has long been known that the worst dissecting wounds are those received in examining a body in which decomposition has not commenced, and that the bodies of those dying with acute peritonitis are especially dangerous. It is also known that a small puncture or scratch is sufficient for the infection. The symptoms do not appear until several hours after the infliction of the wound. Then there are rigors, a febrile movement, and marked general prostration. There will be a little redness about the wound, and inflamed lymphatics extending up the arm. A general, unhealthy inflammation of the arm follows, the patient passes into a typhoid condition, and dies in from ten days to three weeks. Cases similar to these are observed, in which we are unable to discover the source of the infection : — A man, twenty-six years old, a porter by occupation, received a slight lacerated wound of the left forefinger nine days before his death. It was not known in exactly what way the injury had been received. Six days before death, the left hand, fore- arm and arm became swollen, as did also the axillary glands ; there were fever and marked prostration. The fever continued, the patient vomited constantly, passed into a typhoid condition, and died. At the autopsy there was found diffuse, unhealthy in- flammation of the connective tissue of the hand and arm, and of the axillary glands. There were red infarctions in the right lung, and in one of the kidneys. Similar cases are also seen after operations :— A child, seven years old, had the knee resected for the relief of a chronic inflamma- tion. The wound was dressed antiseptically, and there was no odor in the discharge at any time. The patient began to vomit on the day after the operation, and continued to do so. The temperature was never above 101° ; and fell to 96.2° before death. The leg became swollen ; the patient became cold, cyanotic, and pulseless, and died on the fifth day after the operation. There were no lesions except a slight swelling of the liver, spleen, and kidneys. 1 1 Report of the Committee of the London Pathological Society. Transactions, vol. xxx. 1879. VOL. I. — 14 210 PY.EMIA AND ALLIED CONDITIONS. In such cases as these, it seems evident that the cause of the general infec- tion does not reside in the wound, but is received into the body through the wound. It also seems probable that the poison thus taken into the system, is capable of multiplication after being absorbed ; for there is no proportion between the symptoms and the amount of poison which can have been ab- sorbed by the wound. There is only the single inoculation, but the S3nnp- toms continue, and become more marked. In most of these cases, the symp- toms do not immediately follow the inoculation, but there is a period of several hours which intervenes between the receipt of the injury and the de- velopment of the sj'mptoms. It seems probable, therefore, that the poison is an organism, capable of multiplying itself in the body. After death from such a cause, there are no characteristic lesions ; but there may be early decomposition, staining of the endocardium by the color- ing matter of the blood, a large soft spleen, and degeneration of the cells of the liver and kidneys. IY. There is a very large class of cases which it is difficult to classify. They are the ordinary hospital cases of compound fractures and surgical wounds. It is difficult to tell whether a poison derived from without and taken up by the wound, or a poison developed in the wound, or the forma- tion of thrombi in the veins, is to be looked upon as the efficient cause ; or whether different causes may combine in the same case. The symptoms are familiar to every surgeon. Within a few days, sometimes not until after two or three weeks, from the time the patient received the original injury, he develops a febrile movement, rigors, sweating, great prostration, rapid ema- ciation, vomiting, diarrhoea, delirium, and jaundice. The tongue becomes dry and brown, the breath has a peculiar sweetish odor, the pulse is rapid and feeble, and the patient dies exhausted. [The irregularity and absence of periodicity in the chills, and the great variations in temperature, which range over 10° or 11° F., may be looked upon as of diagnostic value.] After the death of these patients, there is a considerable variety in the post- mortem appearances : — (1) There are cases in which there are no recognizable lesions. (2) There are cases characterized by early decomposition ; post-mortem staining of the tissues; congestion of the lungs, stomach, intestines, and kid- neys ; extravasation of blood in the serous membranes ; swelling of the solitary and agminated glands in the small intestine ; swelling of the spleen ; degenera- tive changes in the cells of the liver and kidneys. (3) There are cases in which we find localized inflammations. The parts most frequently inflamed are the joints, the connective tissue around the joints, the pleurae, the pericardium, the peritoneum, the pia mater, and the connective 1 issue in different parts of the body. These local inflammations are of a puru- lent character, except in the serous membranes, where the principal inflam- matory product may be flbrine. (4) There are eases in which the veins in the neighborhood of the wound contain softened and puriform thrombi; there are no infarctions in the viscera, but in some eases local inflammations of the joints and serous mem- branes. (5) There arc cases in which the veins contain thrombi; there are infarc- tions and abscesses in the viscera; and local inflammations of the joints and serous membranes are also present, or may be absent. The thrombi are formed regularly in the veins in the neighborhood of the wound; sometimes, how- ever, they are found in veins at a distance from the wound; sometimes, although the infarctions and abscesses ;ire present, the thrombi cannot be dis- covered. The veins may be distended by the thrombi, or may only contain aaaJ /qjcwajoaaA AkcLfyca. TREATMENT OF PYAEMIA. 211 small coagula. The thrombi look like fibrine which has been coagulated some time, of a coarse, granular texture, whitish, reddish, or mottled ; or they are partly softened into a reddish, sticky fluid ; or they are softened into a yellowish, puriform fluid mixed with micrococci; or they putrefy with the growth of bacteria and the evolution of gases. Weigert has described small thrombi, adherent to the walls of the veins, composed of bacteria alone. There are usually inflammatory changes in the wall of the vein which con- tains the thrombus, especially if the thrombus degenerates and softens. Tortious of the softened thrombi may become detached, be carried into the circulation, and finally become lodged in some artery or .capillary. After becoming lodged in this way, such portions of thrombi may act only mechani- cally, by obstructing the circulation of the blood ; or may also act as local irritants, setting up a zone of inflammation about them. It is the softened, puriform, bacteritic thrombi from which such infectious emboli are derived. The mechanical emboli produce the so-called infarctions, especially in the lungs the spleen, and the kidneys. These infarctions are small, wedge-shaped por- tions of the affected viscus, usually situated near the surface, with the large end of the wedge outwards. They are of a dark red color, or decolorized at the centre, or white, or softened and broken down. The red infarctions are produced by a congestion of the bloodvessels, and an infiltration of blood into the tissue. This congestion and infiltration are due to a regurgitation of venous blood, and a change in the walls of the vessels (Cohnheim); or to a supply of blood from collateral vessels which is not carried off by the veins (Litten). The white infarctions are portions of tissue which are undergoing slow, necrotic changes as a result of their loss of blood supply (Litten). The infectious emboli produce abscesses of various sizes. Such abscesses are found most frequently in the lungs and liver, but they may also occur in the brain, heart, and other viscera. The abscesses are of irregular, globular shape, and may be situated in any part of a viscus. The portions of thrombi in the veins, which become detached, must of course pass into the right heart, and from thence into the lungs. It has always been a question how such fragments of thrombi can find their way into the aortic system of arteries, especially in those cases in which no infarctions or abscesses are found in the lungs. The ordinary explanation is that some of the portions of thrombi are small enough to pass through the vessels of the lungs, and so find their way into the left heart; and that in other cases secondary thrombi are formed in the lungs, from which fragments are de- tached and pass into the left heart. It is also possible that small agu'rt'Lra- tions of bacteria may find their way from the veins, through the lungs, into the left heart. It is the rule that abscesses in different parts of the body are found in those cases in which no thrombi can be demonstrated in the veins, and that infarc- tions in the lungs alone, are found in those cases in which thrombi can be demonstrated in the veins. Bacteria and micrococci are usually present in the wound, in the puriform thrombi, and in the abscesses. In the blood, during life, they seem to be sometimes present, sometimes absent. Treatment of Pyemia. There seems to be no question that the only successful plan of treating these cases of pyaemia is a preventive one. When the symptoms are once fairly developed, treatment is of no avail. It is indeed possible for patients to recover from the disease, but this seems to be due to their natural powers of resistance, rather than to any treatment. 212 PYAEMIA AND ALLIED CONDITIONS. [The editor feels bound to say that this view appears to him unduly fatal- istic. While cases of acute pyaemia terminate unfavorably under any mode of treatment, and while the resisting power of the patient is no doubt of prime importance in all cases which end in recovery, yet something may be done by treatment in subacute and chronic cases, to avert the fatal issue. The hygienic condition of the patient should, if possible, be improved, and great attention should be given to careful nursing and systematic feeding, very free stimulation should be employed — half an ounce or an ounce of brandy may be given every hour, or an equivalent quantity of wine — and the oil of turpentine and carbonate of ammonium may also be administered with advan- tage. But the most valuable single remedy is quinia, which may be given in large doses— from one to five grains every hour — and may be suitably com- bined with small quantities of digitalis and opium.] It is a just claim of modern surgery that these forms of pyaemia can be in great measure prevented, and the mortality after injuries and operations thus greatly diminished. The success attained in preventing these forms of pyaemia seems to depend on two causes: (1) The steady improvement which has been taking place in the methods of operating, in the general manage- ment of the patients, and in the hygiene of hospitals; and (2) The use of carbolic acid as a local application to wounds. The first cause has been a progressive one, and has been due to the efforts of many surgeons. Sir James Paget estimates that during his surgical prac- tice of 30 years, the mortality after surgical operations has diminished from 15 per cent, to less than 5 per cent., simply from these causes. The use of carbolic acid as a local application to wounds is almost entirely due to the teachings of Mr. Lister. This method of dressing, however, was adopted by Mr. Lister as a result of a certain theory concerning the causes of pyaemia. This theory is based on three hypotheses : (1) The local inflam- matory processes and the general febrile disturbances which follow wounds are due to putrefaction of the discharges of those wounds. (2) This putre- faction of the discharge is brought about by the growth of organisms. (3) These organisms gain access to the wounds from the air. The object of treat- ment, therefore, is to destroy any organisms already existing in a wound, and to prevent organisms from the air entering a wound during or after an opera- tion. To accomplish these results, Mr. Lister has devised a system of dressing based on the use of carbolic acid. This system, as described by Mr. MacCor- mac, is, when thoroughly carried out, practised as follows: — If an operation is to be performed, the adjacent surface must be shaved, and then thoroughly washed with a five per cent, solution of carbolic acid. The actual steps of the operation are conducted in a carbolized atmosphere, produced by a jet of steam mingled with a five per cent, solution of the acid. The sponges employed, the hands of the operator and those of his assistants, are thoroughly purified in a five per cent, solution, previous to the operation, and again and again during its progress. The in- struments arc kept ready in a three per cent, solution, which may also be used for washing the wound and the sponges. All bleeding points must be carefully secured either by torsion, carbolized gut, or carbolized silk, the ends of the ligatures being cut short. The sutures should be both deep and superficial; the former of wire, the latter of catgut. The entire surface of the wound should be brought into apposition. Drain- age tubes should be inserted, in order that bloody serum may escape externally. They should be removed as soon as their function is at an end. A sufficient number of tubes having been inserted, the projecting portions are cut off level with the surface, and a layer of protective silk applied to the wound. Over this are placed several layers of carbolized gauze, wrung as dry as possible out of a two and a half per cent, solution of carbolic acid, and fastened to the surface with a carbolized bandage. Over this is ap- plied an eight-fold layer of dry gauze, a piece of mackintosh being interposed between the last layers of the gauze. In all cases the first dressing is the most important. PROLONGED SUPPURATION. 213 Attempts to replace carbolic acid by any of the other germicides have not been successful. The success of this plan of treatment has been very great. Hospitals, espe- cially in Germany, which were previously mere pest-houses, now give good surgical statistics. Its disadvantages are the trouble, time, and expense in- volved in carrying out the full system of dressings, and the possibility of poisoning the patient by too much carbolic acid. For this reason, many sur- geons have discarded the complete Listerian system of dressing, and use car- bolic acid as a local application in various ways. Perhaps the question of antiseptic dressings may be best summed up in the words of Sir James Paget : — " I believe that, in its complete (Listerian) form, we can nearly neutralize the evil inflnences of unhealthy hospitals and other like sources of those infectious diseases from which arise the largest portions of mortalities after operations. "That it has not yet reduced the death-rate to a lower level than can be attained by good sanitary arrangements, good nursing, strict care and cleanliness, quietude, and simple dressing. " That recoveries after operations are quicker and more free from fever and other constitutional disturbances, when antiseptics are used, than when they are not used. " That in certain groups of cases, operations may be safely done with antiseptics which, without them, would be very hazardous." Prolonged Suppuration. There are cases of prolonged suppuration which are usually classed with pyfemia. There is first a wound, or a bruise, or an idiopathic, suppurative inflammation. This original focus of inflammation is of a purulent character, and shows no disposition to heal. After a time, successive abscesses are formed, without visible cause, in the connective tissue in different parts. These new abscesses all show the same disposition, to continue to suppurate and not to heal. The patient loses flesh and strength; there is a febrile movement; bronchitis or broncho-pneumonia may be developed, and the patient finally dies in a condition of extreme emaciation. After death, ab- scesses are found in different parte of the . body, but not in the viscera. In- farctions and thrombi do not belong to this condition. The lungs show the lesions of bronchitis and broncho-pneumonia. The liver, spleen, and kidneys are often waxy. A man, twenty years old, was admitted to the Roosevelt Hospital, February 18, 1880. Five months before his admission, his right testicle had become swollen and painful. This epididymitis had come on one month after sexual intercourse, but had not been preceded or accompanied by gonorrhoea. On February 15, he had begun to have pain, tenderness, and redness, along the femoral vessels on the left side, with nausea, vomit- ing, fever, and delirium, but no rigors. On February 18, the right epididymis was swollen and tender ; the lymphatic glands in the left groin were swollen and tender ; there was an erythematous blush over the anterior surface of the left thigh ; there was tenderness, but no induration, along the course of the left femoral vessels ; there was fever. By February 27, the lymphatic glands in the left groin had suppurated ; the abscess was opened, but it was found that the pus had burrowed down the anterior sur- face of the thigh. On March 24, an abscess in the right epididymis was opened. By April 4 an^ abscess had formed in the right inguinal region, and by April 23, one above the spine of the scapula. On April 29, an abscess had formed above the right clavicle, and on June 5 the patient died. At the autopsy, the abscesses were found as mentioned, but no thrombosis of any veins. There was purulent broncho-pneumonia, and commencing waxy infiltration of the liver, spleen, and kidneys. 214 PYEMIA AND ALLIED CONDITIONS. Spontaneous Pyaemia. Under this name we include a group of obscure cases, which resemble ordi- nary pyaemia in their symptoms and lesions, but are of obscure etiology. They do not begin with a wound, or bruise, or abscess. An individual, without known cause, will be seized with rigors followed by a febrile movement, and marked prostration. There may be vomiting, or diarrhoea, or cough. Sometimes ecchymoses or pustules appear in the skin. Usually headache and delirium are present. The patients die in a typhoid condition. At the autopsy, lesions are found like those of pyaemia : abscesses and infarctions in the lungs and kidneys ; suppurative inflammations of the joints and connective tissue. A girl, ten years old, after playing in the snow, was seized with rigors, followed by a febrile movement, and with pains all over the body. The fever continued ; she became delirious ; the pain was most intense in the right hip. She passed into a typhoid condi- tion and died on the ninth day. At the autopsy, the right pleural cavity was found half full of purulent serum, the left pleura coated with fibrine, and both lungs studded with hemorrhagic infarctions. The kidneys contained infarctions ; there was a small abscess under the scalp ; both hip-joints and one sterno-clavicular articulation con- tained pus. A man, forty-seven years old, of intemperate habits, was attacked twenty-six days before his death with headache, loss of appetite, and a general tenderness over the muscles ; but was not confined to bed. Eleven days before his death, rigors, a febrile movement, diarrhoea, and pain in the chest came on. He was noAv so ill that he was confined to bed. Eight days before death he became delirious, and continued so. After this the temperature was from 103°-107° F., the breathing from 42-48, the pulse from 112-120. There were no physical signs except a double aortic and a mitral systolic murmur. There were a few red spots in the skin, on the upper part of the abdomen. The patient passed into a typhoid condition, and died. An autopsy was made three hours after death. The brain was not examined. The heart showed the aortic and mitral valves to be thickened and insufficient, but not roughened ; the left ventricle was hypertrophied ; the heart cavities were empty. The larynx and pharynx were normal. The lower two-thirds of the trachea, and the larger bronchi, were congested; their mucous membrane was coated with a layer of tenacious muco-pus. The small bronchi were full of pus. The upper lobes of the lungs were inflated and dry, the lower lobes w r ere congested. The liver appeared normal. The spleen was large and soft. The stomach and intestines were normal. The kidneys were large ; in the cortex were numerous small white foci, surrounded by red zones. These white foci were formed of pus ; the glomeruli in the foci contained colonies of micrococci. The bladder was normal. [The reader may consult with advantage papers by Dr. Samuel Wilks, on " Pyaemia" and "Arterial pyaemia," in Guy's Hospital Reports, 3d s., vols. vii. and xv.] HYDROPHOBIA AND RABIES; GLANDERS; MALIGNANT PUSTULE. BY WILLIAM S. FORBES, M.D., DEMONSTRATOR OF ANATOMY IN THE JEFFERSON MEDICAL COLLEGE ; SENIOR SURGEON TO Till EPISCOPAL HOSPITAL, PHILADELPHIA. Hydrophobia and Rabies. Hydrophobia is a general malady which manifests itself chiefly through disturbances of the nervous system, of an intensely distressing character. The word hydrophobia (as^p water and $6/30$ fear) signifies dread of water, a name suggested by the inability to swallow liquids, which forms one of the most prominent and marked features of the disease as it exists in man. In consequence of the occasional absence of this striking symptom, and of its occasional presence in other diseases, the name has been objected to, and the word rabies, which is the term applied to the corresponding affection met with in the lower animals, has been sometimes substituted instead. It may be well, however, to retain the name hydrophobia at present, as it is the one by which the disease is most widely known. Cause of Hydrophobia. — The primary or exciting cause of hydrophobia may be said to be the inoculation of the body with a poison of a specific cha- racter, which is generated or at least contained in the salivary fluids or secre- tions from the buccal and faucial mucous membranes of an animal which is affected with rabies, the virus being introduced upon the animal's teeth, or possibly by its lips or tongue. It is not necessary that there should be an actual bite, but an abraded surface must exist, in order that inoculation shall be effected. Hydrophobia is apparently produced by the action of this spe- cific poison upon the respiratory centres of the nervous system, producing a morbid irritability of the medulla oblongata, and of the eighth pair of nerves of Willis's classification. Rabies originates in certain animals, such as the dog, the wolf, the fox, the skunk, the jackall, the cat, and the badger. The disease does not originate in man, and it is not sure that it can be communicated from one human being to another. But animals in whom the virus does not originate, are yet sus- ceptible to hydrophobia, and all are probably capable of transmitting it when under its influence. Magendie inoculated two dogs with the saliva of a man suffering from hydrophobia ; one of the dogs became mad and bit two others, one of which also became mad and died. The malady has been provoked in dogs by inoculating them with the saliva of rabid horses and asses, and cases have been reported of human beings having acquired hydrophobia from the bites of rabid horses and pigs. Rabbits and similar animals, as well as fowls, (215) 216 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. soon die from inoculation of this poison, without manifesting the ordinary symptoms of rabies. It is well known that many persons bitten by rabid animals do not con- tract hydrophobia, the morbid matter being no doubt wiped off as the teeth penetrate the clothes. Hence the wounds inflicted by rabid wolves are much more dangerous than those received from rabid dogs ; the difference being apparently due to the fact that wolves generally bite the exposed parts of the body, such as the face, neck, and hands, whereas dogs usually seize with their teeth those parts that are covered. Sir Thomas Watson writes that of 114 persons bitten by rabid wolves, 67 died of hydrophobia. Bouley gives the following summary of facts, collected from the report made to the Consulting Committee of Public Hygiene, France : — (1) In 49 departments wherein cases of rabies were reported by 108 communications, 320 persons were bitten by rabid animals. This figure is enormous, but must be re- garded nevertheless as far below the truth — for there are departments where the disease is common, from which no reports were obtained. (2) Out of 320 cases of persons bitten, the bites caused hydrophobia in 129, or a proportion of about forty per cent. (3) Out of 320 cases of persons bitten, the wounds were not followed by the disease in 123 known and specified cases. The established rate of exemption would, therefore, seem to be about 38 per cent. (4) Among the 320 bitten persons, 206 were males and 81 females, while in 33 cases the sex was not mentioned. With reference to the distribution of cases throughout the year, the author mentions the following facts : — During the three spring months, March, April, and May, 89 cases occurred ; during the summer months, June, July, and August, 74 cases ; during the autumn months, September, October, and November, 64 cases ; and during the winter months, Decem- ber, January, and February, 75 cases. This leads to the conclusion, that there is no great difference in the number of cases between the seasons ; that the danger from mad dogs in the winter season is about the same as in the heat of summer ; and that in the spring cases are most frequent, and in the autumn least frequent. The popular opinion, which regards winter as free from the curse of hydrophobia, and which indicates that the disease exists in summer more than at any other season, has no foundation in fact. This brings us to a conclusion of great importance, namely, that as far as sanitary measures, and the protection of the people are concerned, we should, at all times and in all seasons, be equally on our guard, and should take efficient measures of protection against dogs. Hydrophobia is not peculiar to any age — it prevails in all countries and in all climates. It is possible that idiosyncrasy may exert an important influence in preventing the effects of the poison. It is well known that this is true of other zymo- tic poisons. This influence of idiosyncrasy may be illustrated by the experience of Dr. I [ertnich, of Berlin, who inoculated fifty dogs with saliva taken from another dog affected with rabies, and not one in five was affected. Rabies in the Dog. — The disease as it affects the dog, has been well de- scribed by Mr. Youatt, and, as his description has become classical, I make the following extracts : — In the greater number of cases there are sullenness, fidgetiness, and continual shift- ing of posture. When I have had opportunity I have generally found these circum- stances in succession. For several successive hours perhaps he retreats to his basket or his bed. He shows no disposition to bite, and he answers the calls upon him laggardly. He is curled up, and his lace is buried between his paws and his breast. At length he begins to be ligdety. lie searches out new resting-places, but he very soon changes them for others. He takes again to his own bed ; but he is continually shifting his posture. He begins to gaze strangely about him as he lies on his bed. His counte- nance is clouded and Buspicious; he comes to one and another of the family, and he INCUBATION OF HYDROPHOBIA. 217 fixes on them a steadfast gaze, as if he would read their very thoughts. " I feel strangely ill," he seems to say : " have you anything to do with it? or you ? or you ?" Has not a dog mind enough for this ? If we have observed a rabid dog, at the commencement of the disease, we have seen this to the very life The disease manifests itself under two forms : the furious form, characterized by augmented activity of the sensorial and locomotive systems, a disposition to bite, and a continued peculiar bark. The animal becomes altered in habits and disposition ; has an inclination to lick or carry inedible substances ; is restless and snaps in the air, but is still obedient and attached. Soon there are loss of appetite and the presence of thirst, the mouth and tongue swollen ; the eyes red, dull, and half closed ; the skin of the forehead wrinkled ; the coat rough and staring ; the gait unsteady and staggering ; there is a periodic disposition to bite ; the animal in approaching is often quiet and friendly, and then snaps ; latterly, there is paralysis of the extremities ; the breathing and deglutition become affected by spasms; the external -surface is irritable, and the sen- sorial functions are increased in activity and perverted ; convulsions may occur. These symptoms are paroxysmal, they remit and intermit, and are often excited by sight, hearing, or touch. The sullen form is characterized by shyness and depression, in which there is no disposition to bite, and no fear of fluids. The dog appears to be un- usually quiet, is melancholy, and has depression of spirits ; although he has no fear of water, he does not drink ; he makes no attempt to bite, and seems haggard and suspi- cious, avoiding society and refusing food. The breathing is labored, and the bark is harsh, rough, and altered in tone ; the mouth is open' from the dropping of the jaw ; the tongue protrudes, and the saliva is constantly flowing. The breathing soon becomes more difficult and laborious ; there are tremors, and vomiting, and convulsions. Incubation op Hydrophobia. — The wound by which the poison is conveyed within the body generally seems to heal without any trouble, and the virus may lie concealed for a period of very variable duration, the length of which has been estimated as ranging from three days to seven years. Watson thinks that the virus may be inclosed in a nodule of lymph, or detained in tempo- rary union with some of the tissues, until some exciting cause sets it free upon its errand of destruction. Virchow compares the action of the poison to that of a ferment producing through the medium of the circulation its specific effect upon the nervous system. Trousseau says that the disease generally shows itself in man from one to three months after inoculation ; that cases are rare after three months ; and that the authenticity of cases reported as occurring after the' lapse of a year may well be disputed. [Fereol has, how- ever, reported an apparently authentic case in which the period of incubation was two and a half years.] Age influences the period of incubation, this being shorter in young people than in old. Fleming: tells us that from an estimate of ages from three to twenty years, and from twenty to seventy -two years, it has been found that for the first group there is a mean period of incubation of forty-four days, and for the second group of seventy-five days. Faber adopted the view that the contagious principle became encysted on its introduction into the body, and that it entered the blood subsequently under the influence of favorable conditions. Dr. Anthony Todd Thompson, 1 in speaking of rabies from the bite of a cat, says that the virus continues dormant in the part into which it is introduced by the bite of the animal, Until a certain condition of the system renders the nerves in the vicinity of the wound susceptible to the influence of the poison, and that this being communicated, a morbid action is begun in these nerves, and extended to those which preside over respiration, thus inducing the whole train of symptoms which constitute the disease. 1 Medioo-Chirurgical Transactions, vol. xiii. 1826. 218 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. Symptoms of Hydrophobia. — The symptoms vary with the peculiar idio- syncrasies of the person inoculated, and hence no detailed account of them can be given, which shall apply accurately or even approximately to each in- dividual case. Dr. f)olan says that there exist but two periods in this disease : (1) that of incubation, and (2) that of development, including all the phenomena between the first symptom and death ; but Virchow has divided the symptoms of the second period into several distinct stages. Symptoms of the First Stage. — In the first stage of the period of develop- ment, there are uneasiness and restlessness, with stiffness around the neck and throat, often nausea and vomiting, and cerebral symptoms, consisting of headache and mental excitement. These symptoms, however, are not of invariable occurrence, for the patient is sometimes suddenly seized witli dif- ficulty of swallowing liquids. Local symptoms are sometimes observed, but in other cases may be entirely wanting. Irritation of the scar and of the tis- sues in the vicinity of the wound, accompanied by darting pains of a rheu- matic character, is one of the most persistent symptoms. The cicatrix often becomes red and inflamed ; and if the wound is still open, it presents an un- healthy appearance, and the discharge becomes thin and ichorous. The mental and moral condition is at the same time changed, the patient being in some instances troubled and anxious about the wound, and very commonly becoming irritable and ill-tempered. Poland remarks that there often exists a characteristic anxiety, attended with pain in the prrecordia and a sense of weight and pressure on the chest. The sleep may be disturbed and broken ; the patient suddenly starting up in a frightful dream, and again sinking back in a state of mental depression and gloom. There is loss of appetite, no desire for swallowing, a feeling of clamminess in the mouth, with sighing and oppression, the patient breathing with unusually deep inspirations. There are attacks of chilliness, with a highly impressible state of the system ; there is a feeling of having taken cold ; the voice is rough ; there is a sensation of languor and lassitude, with great weakness and heaviness, and sometimes slight convulsive movements of the face and limbs ; there is a remarkable susceptibility to atmospheric im- pressions, the slightest contact of cold air being a source of great torture by producing a feeling of suffocation. The poison is now fairly at work, and in a few hours, generally from ten to twenty-four, explodes with frightful vio- lence. The period of latency is now past, the disease has reached its second stage ; the difficulty of swallowing and the dread of water fully establish the presence of hydrophobia. S'luvptoms of the Second Stage. — The second and specific stage usually follows the first, but sometimes occurs without any preliminary warning; it begins with stiffness and pain in the muscles of the jaw, throat, and base of the tongue. Hypersesthesia of the parts supplied by the eighth pair of cerebral nerves, i< now manifested by the convulsive spasms of the muscles of the throat, which cause every attempt at deglutition to be attended with pain and diffi- culty. Hence the great dread of food, and particularly of fluids. There is a distressing dryness of the mouth and throat, often accompanied by a sensa- tion .of extreme thirst which cannot he relieved. The secretions of the mouth ami pharynxare at first frothy, but soon become viscid, and cannot be ejected without great I rouble, a hawking and barking noise being often produced in the attempt. Tim violence with which the patient spits is a striking phe- nomenon. Before long the disease involves the muscles of the general sys- MORBID ANATOMY OF HYDROPHOBIA. 219 tern, through the medium of the spinal and cerebral nerves, giving rise to convulsions which may simulate those of tetanus or of epilepsy. In this stage of the disease the pulse is rapid and quick, reaching one hundred, and thirty, while the temperature rises to one hundred and two, and often to one hundred and live degrees Fahrenheit. There is frequent micturition ; the urine is at first limpid, but afterwards becomes red and sanguinolent, and Hows in small quantity. It contains renal epithelium and much albumen. It is usually acid in its reaction, and con- tains an abundance of earthy phosphates and carbonates. Heated in a tube and cleared of the albuminous precipitate, caustic potassa and the cupro- potassic fluid discover reactions which reveal the presence of sugar. This, according to some authorities, indicates congestion of the brain and spinal cord as well as of the kidneys. The patient's senses now become unnaturally acute; the surface of the body is excessively irritable ; the sight and sound of fluids aggravate the already exasperated condition ; and sometimes the slightest puff of air, or even the smell of particular substances, will induce a paroxysm. The mind is in a singular condition of fear and anxiety, and the patient experiences a dread of everything which is either seen or imagined, culminat- ing in a state of unutterable despair, or sometimes of furious anger. There is usually almost complete insomnia, and the patient is often unnaturally talkative. There ma}' be insane impulses and delusions, with sometimes, it is said, an inclination to bite. The features have a wild and anxious look ; the brows are firmly knit ; the eye is staring ; the angles of the mouth are drawn ; and the whole appearance is intensely haggard and ghastly. As the disease advances, both the frequency and the severity of the parox- ysms are augmented, and the mental state borders upon mania. After each paroxysm there is great prostration. The duration of this second stage varies from twenty-four to forty -eight hours ; seldom longer. Symptoms of the Third Stage. — -The third is the paralytic and last stage of the disease. It is marked by the occurrence of rapidly increasing depres- sion and exhaustion, with subsidence of the paroxysms ; the pulse is now small, quick, and often irregular ; the skin is covered with a clammy sweat, the eyes look dull and sunken, and the pupils are dilated. The patient rapidly emaciates; the mouth hangs open, allowing the saliva to escape, or if it flows backward into the throat, it causes a gurgling noise, and s;ives rise to a feeling of suffocation and choking. Death may take place from asphyxia during a convulsive paroxysm, or may result simply from exhaustion. All the symptoms have been known to abate, and the patient to sink into a state of repose and expire immediately on waking. The duration of hydro- phobia — that is, of its period of development — varies from three to six or seven days, or in some cases even longer. It has been fatal in sixteen hours, but death generally occurs on the third or fourth day. The foregoing description of the symptoms of hydrophobia is based upon the writings of Poland, Tanner, Fleming, Dolan, Virchow, and other authors who have had practical experience in the treatment of the disease. To use the language of Bigelow, " In fact one description is the copy of another." Morbid Anatomy of Hydrophobia. — Dr. Dolan writes that on the loth of May, 1877, Dr. Gowers exhibited before the Pathological Society of London a series of microscopic sections, illustrating the structural changes in the medulla oblongata and spinal cord in four cases of rabies. In all four cases the vessels of the gray matter were greatly distended, the distension being greater in the medulla near the gray nuclei, in the lowest part ot* the fourth 220 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. ventricle. In three of the cases, the larger veins in this position presented aggrega- tions of small cells within the perivascular lymphatic sheath Similar cells were scattered through the tissue, among the nerve elements, and in some places, chiefly in and near the hypoglossal nuclei, there were dense collections of these cells, constituting in fact miliary ahscesses. Similar smaller collections were seen among the fibres of origin of the hypoglossal and glossopharyngeal nerves. In the paroxysms of hydrophobia, the respiratory apparatus is wholly engaged, and in Dr. Gowers's cases the structural change was especially well marked in the region of the " respiratory centre," in the medulla; and in the case in which the change was most decided the diaphragm had been violently affected. [Changes in the medullary and spinal cord, analogous to those observed by Dr. Gowers, have also been noted by Clifford Allbutt, and by Cheadle. Bene- dikt, of Vienna, and Wassilief, of St. Petersburg, have found inflammatory changes in the brain, while Nepveu has noticed congestion of the nerve-struc- tures in the neighborhood of the wound, and inflammatory lesions in the salivary glands. Coats, of Glasgow, has observed hyperemia of the kidneys, with an accumulation of white corpuscles. The only characteristic macro- scopic change, according to Cooper Forster, is dilatation of the pharynx.] Dr. Bigelow states that the structural changes noted in hydrophobia are not essential and primary factors in developing the train of symptoms, but are in all probability secondary lesions, resulting from the terrible disturbance which the disease causes in the functions of the respiratory, vascular, and nervous systems. Such phenomena can hardly, therefore, be of any value in determining the pathogeny of the affection. He adds that though we have acquired new and important data by these observations, still we cannot affirm positively that we have found a characteristic lesion pathognomonic of hydro- phobia. [Middleton, of Glasgow, entertains a similar view.] It has been conjectured, according to Dr. Hammond, that hydrophobia may begin as a blood disease, and end as a nerve disease. " The nature of the hydrophobic virus is unknown. It is probably of the nature of a ferment ;" Dr. Barry, on the other hand, in his Experimental Researches, rejects the idea that the poison of hydrophobia is absorbed and mingled with the blood, as being directly opposed to all analogy. Diagnosis of Hydrophobia. — Dr. Dolan well says that the symptoms of hydrophobia are so characteristic that they should not be confounded with those of any other disease. To distinguish it from tetanus, Drs. Holland and Shinkwin point out the following differences : — (1) Tetanus results from injuries of the most varied character. (2) In tetanus the effects follow in a very short space of time, a week seldom elapsing between the injury and the development of the symptoms, while in the one hundred and twenty cases of hydrophobia collected by Dr. Holland, the shortest interval recorded between the bite and the first symptoms of rabies was twelve days, the longest three hundred and thirty-four days, and the average sixty-one days and eighteen hours. (.'!) The anxiety, horror, and convulsions at the sight of fluids, are not found in tetanus. (4) In tetanus, some of the muscles are often in a state of rigidity, and the convul- sions occur at much shorter intervals than in cases of rabies. (5) Delirium is a very rare symptom in tetanus, and a frequent one in rabies, hav- ing occurred eighty times in one hundred and twenty cases. (6) In tetanus, the secretion of saliva is seldom increased. (7) In tetanus, the muscles of the lower jaw are frequently in a state of tension. (8) Opisthotonos or emprosthotonos often terminates the case in tetanus. PROGNOSIS OF HYDROPHOBIA. 221 (9) As Fleming remarks, while physiologically tetanus is a disease of the true spinal system of nerves, rabies involves the brain also, as is evinced by the disorder of the intellectual functions and special senses even early in the disease. To distinguish hydrophobia from oesophagitis, Dr. Holland points out these essential differences : — In OESOPHAGITIS. 1. Pain in the pharynx, throat, or along the spine occurs as the earliest and invariable symptom. In Rabies. 1. Pain in the pharynx, throat, and along the spine, occurred in forty-two out of one hundred and twenty cases, or about once in every three cases, and not as the earliest symptom. 2. The attempt to swallow fluids, though not generally accompanied by in- tense pain, causes dyspnoea, convulsions, etc., while solids can be in most cases taken with comparative facility. 3. Horror of fluids the most prominent symptom in one hundred and nineteen out of one hundred and twenty cases. 4. No direct relation exists between the pathological state of the oesophagus shown after death, and the intensity of the dysphagia. 5. Saliva secreted in great quantity, often flowing spontaneously from the mouth ; these symptoms often occur among the last phenomena. 6. Thirst was urgent in about one-third of the cases. 7. Average duration of the disease seven days. 8. Invariably terminating fatally. 9. Death most probably resulting from asphyxia, coma, or relapse. Fleming says : Indeed it is not possible to mistake hydrophobia for any other malady, or to doubt its existence when it is present ; for if, during the stage of incubation, doubts and fears exist, all uncertainty comes to an end when the disease really appears. Prognosis of Hydrophobia. — Hydrophobia is regarded as one of the gravest of all the maladies which afflict humanity. It has been asserted that we have no well-authenticated instance on record of a cure of this disease. Yet, Dr. Dolan says that the evidence of the recovery of cases of hydrophobia is as conclusive as the evidence that such a disease exists. " To deny the exist- ence of such records of recovery, is simply to deny the existence of the dis- ease. We can only know rabies by the symptoms, and by the description we have furnished by those who have had cases under treatment. If the evidence is satisfactory and conclusive that rabies has existed, and, unfortu- nately, been too fatal, it is also equally satisfactory and conclusive that Dr. Offenburg has described the disease, and attended a patient who recovered, and that Dr. Austin Flint has offered similar testimony." Dr. Bigelow says : " The experiments made with oxygen by two Russian physicians, Drs. Schmidt and Zehender, with a well-authenticated cure of a case of hydrophobia from its administration, reported in the Lyon Midical, inspire the hope that at last science has struck the physiological key-note, 2. The attempt at swallowing solid food causes intense pain, and in aggravated cases swallowing of even fluids is accom- panied by pain, or may be totally impos- sible. 3. Horror of fluids reported to have occurred in one case. 4. The amount of difficulty in swallow- ing is in direct proportion to the extent and intensity of the pathological appear- ances found in the oesophagus. 5. Saliva abundantly secreted, expec- toration difficult, and the time of the occurrence of these phenomena not fixed. 6. Urgent thirst in perhaps all cases. 7. Average duration of the disease seven days. 8. Generally terminating in recovery. 9. Death caused by oedema of the glot- tis, gangrene, or rupture of the oesophagus. 222 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. and that in well-established instances of the disease the physician may look with a reasonable assurance to a successful termination." Treatment of Hydrophobia. — The treatment of hydrophobia resolves itself into that which is preventive and that which is curative. Preventive Treatment. — The essential influence producing hydrophobia is lodged in the fluid from the rabid animal's mouth, and not the wound made by the teeth. The first means to be employed in order to prevent the virus from entering the system is prompt suction of the wound, so as in this way to remove the poison from the part at once. The bitten person should do this for himself, and should wash his mouth, after spitting out its contents, with some fluid, and so by continued sucking and washing get rid of the poison as far as possible. The wound, when its situation permits, as when it is in an extremity, should be squeezed on its cardiac side at the same time ; it should also be well washed. Or a strap or handkerchief may be applied tightly above the wound, and a cupping-glass be applied to the part at once, and strong suction made. Cauterization should be practised as soon as possible, and the best possible means of cauterizing the part is with the hot iron. A knife blade, a nail, or an iron poker may be used ; the iron should be heated to a white heat, and the wound throughout its entire extent should be burnt with the greatest thoroughness and in the shortest possible time after the person has been bitten. Dr. Bigelow gives the following statement as taken from Fleming: In Al- geria, out of 16 cases of immunity, in 14 the patients had the wounds inflicted by rabid animals cauterized more or less promptly ; three persons were cau- terized twenty-four hours after being wounded, and a fourth not for thirty- six hours. The following Table gives the details of the 16 cases: — CASES. Immunity after immediate cauterization with hot iron . . 7 " " " with gunpowder . 1 " after late appearance cauterized with hot iron . . 1 * " after at least 24 hours 3 " " 36 " 1 " after immediate cauterization with muriate of antimony after 3 hours ...... 1 " without adopting precautions . . . . .2 In short, immunity in one-half of these cases may be supposed to have been due to immediate cauterization, in three-eighths to tardy cauterization, while in one-eighth the patients escaped without any treatment. Hugo speaks of seven persons who were bitten by a rabid dog ; three had their injuries cauterized twenty-four hours afterwards, and the four others cauter- ized themselves with two pieces of iron heated in the fire ; all escaped. The same dog attacked a child twelve years old, and, its wounds not having been attended to, it died of hydrophobia. Excision is strongly recommended by Foot, Fleming, Abernethy, and others. Foot gives eight cases in which excision was practised. In one case it was done at once; in another, six hours after the bite; and seventy-two hours ■ after the bite was the longest period in which it was performed in any of the eight cases. If excision is made dangerous from the neighbor- hood of large bloodvessels or nerves, caustics are recommended. Nearly all the caustics in use have been recommended by different surgeons as having been successful in their hands. "VVe must remember, however, that TREATMENT OF HYDROPHOBIA. 223 the immense majority of bites will not be followed by hydrophobia under any circumstances, and, on the other hand, that hydrophobia has occurred after free excision of the injured part. Mr. Youatt had great confidence in nitrate of silver. He was himself bitten seven times, and on each occasion contented himself with freely cauterizing the wounds with nitrate of silver. [The daily administration of large doses of bromide of potassium, during the whole period of incubation, is strongly recommended by Duboue, of Pan.] Curative Treatment. — "When the virus commences to evince its effects on the system, the second period, or that of development, begins, and the patient should now at once be placed in a dark room, and kept as quiet as possible, and free from all avoidable sources of irritation ; his strength, too, must be supported by such concentrated food and stimulus as can be taken, or by nutritious enemata. Dr. Watson, of Jersey City, 1 reports a case which was regarded by himself and by Prof. Austin Flint as a case of undoubted hydrophobia. In this ease a sixteenth, a ninth, and a sixth of a grain of curara were injected subcu- taneously at different times, when, after the third injection, the unfavorable symptoms abated, and the patient entirely recovered. Offenburg and Polli have also recorded instances of recovery from hydrophobia under the hypo- dermic use of curara. Dolan, too, gives the case of a woman, aged 24, who was bitten by a dog supposed to be rabid, in which case seven injections, each containing one-third of a grain of curara, were administered within four hours and thirty-five minutes, and the patient entirely recovered. In a case of hj-drophobia, to which I was called in consultation by Dr. Carroll, reported by myself in the American Journal of the Medical Sciences for April, 1878, the spasms were relieved by the inhalation of nitrite of amyl. The case was that of a man, thirty years of age, who was bitten on January 1, 1877, on the back of his left ring-tinger, by a terrier dog which was suffering from rabies. On the 20th of the following March, 79 days after the infliction of the wound, the scar assumed a red and swollen look, and an eruption appeared on the morning of the follow- ing day (March 21), disappearing on the 26th. On the morning of the 28th, the man was wild with excitement; his pulse was rapid and small, running at the rate of 140 beats to the minute ; his skin was leaky and cool, and his countenance anxious. He made violent efforts to drink a glass of milk, but was utterly unable to do more than grasp at it; he could not possibly take hold of the tumbler, and entreated us in a wild convulsive manner to take it away. At this moment I gave him 25 drops of the nitrite of amyl by inhalation. By the time the evaporation of the amyl had taken place, the man said, " What is that you have given me ? it is running all around my head." When two or three minutes had elapsed, his pulse was found to be 88, and his respira- tion quite natural ; he appeared to be perfectly calm. I then asked him if he thought he could take some milk, and he said that he thought he could. The milk was brought, and he swallowed a pint with the greatest ease ; he said he would take some more, when half a pint additional was given to him, with two ounces of brandy, and, when he had swallowed it, he asked one of the bystanders to give him a drink of water. The water pitcher was brought, and I poured out a full glass before him; when, taking the glass as composedly as any one could, he drank off its contents with the greatest comfort, and held the glass out for more. I filled it again, and, when he had drunk nearly all the water, he exclaimed, " Oh, but that's good !" I sat with him nearly two hours longer, during which time he was perfectly composed, and got some sleep. Then his pulse became more rapid, and his breathing more frequent. I asked him if he would take a little brandy and water. The mere suggestion of the brandy and water excited him very much, and, when it was brought near him, his excitement was fearful, and he exclaimed rapidly, " No, not until after breathing that stuff," as he called the 1 American Journal of the Medical Sciences, July, 1873. 224 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. amyl. It was immediately gi?en to him, and had the same happy effect as on the first occasion ; his pulse fell, his respiration became more calm, and he took half a pint of milk, three raw eggs, and half an ounce of brandy, which he swallowed very readily and with great comfort. He then fell asleep, ana I left him. I returned the next morning at 9 o'clock, liaving asked Dr. John Ashhurst to see him in consultation with Dr. Carroll and myself. We found that our patient had had some sleep, but that for an hour or more he had been very much excited. He could not have a glass of water brought near him now ; it was tried, and on its approach he shook convulsively. Nearly a teaspoonful of the nitrite of amyl was now administered, and he again became quite calm and drank nearly a pint of water, and soon after took some milk and eggs. At 3 P. M., however, the spasms returned, and, on attempting to give him the amyl, he exclaimed that he was choking, and immediately went into a convulsion which ended in death. No post-mortem examination was permitted. My friend Dr. Solliday, of Tamaqua, administered the nitrite of amyl in a case of hydrophobia in a girl, aged 17, who was bitten by a spitz dog which was suft'ering from rabies. The wound was inflicted on the lower lip, on Nov. 26, 1877 ; the wound was very slight, and healed quickly. On Dec. 20, three weeks and three days after the accident had happened, hydrophobia became manifest. The spasms came on every fifteen minutes, and the disease was well developed. In the evening, twenty-four drops of the nitrite of amyl were given by inhalation. She now complained of numbness in her extremities, and soon became very calm, and remarked that, if the room were quiet, she could sleep. At this moment a glass of water was given to her, which she swal- lowed without trouble. In fifteen minutes she was in a quiet sleep, which continued for four and a half hours. She was awakened by a violent storm of rain which made a great noise on the roof and shed of the house in which she lived. The spasms imme- diately returned, and were more violent than at any time previous, and continued until death took place, late in the afternoon of the 21st. No post-mortem examination was permitted. In both of these cases the relief on inhalation of the nitrite of amyl was very marked, and exceedingly comforting. It relieved the spasms in both cases, so that the patients could drink both water and milk to satiety. But in neither case did the amyl appear to stay the advance of death. In the Lyon Medical there is reported a case of hydrophobia in which, owing to the experiments of Drs. Schmidt and Zehenden with oxygen, that gas was inhaled, and the disease disappeared. The case was that of a little girl bitten in the hand by a rabid clog. The wound, after being cauterized, healed in a few days ; but a fortnight afterwards the evidences of hydrophobia were manifested. Three cubic feet of oxygen were then inhaled by the patient, and in the course of an hour and a half the distressing symptoms disappeared, and the child became calm. Two days afterwards the symptoms reappeared ; there were difficulty of breathing and swallowing, and convulsions ; the oxygen was again inhaled, and at the end of forty-five minutes the attack entirely subsided, and never returned. [Other modes of treatment which have been recommended are the inhala- tion <>f ether or el ilon d'orm; the application of an ice-bag to the spine (Todd, Erichsen); the persistent employment of a primary galvanic^ current (Ham- mond); transfusion of blood (Shinkwin); and intra-venous injection of saline solutions ((Silver), and particularly of bromide of potassium (Duboue). The monobromate of camphor is also credited with having effected a cure in some cases, j GLANDERS. 225 Glanders. Glanders is a contagious and infectious disease, which appears also to be sometimes spontaneously generated in the horse, the ass, and the mule, and which peculiarly belongs to those animals. While it is a general disease, affect- ing the whole system, it displays its greater force and virulenc e on the mucous linings of the nose and frontal sinuses, and on the submaxillary glands and lymphatics of the neck and ear. In 1821, Mr. Muscroft, in an article in the Edinburgh Medical and Surgical Journal, described the disease as existing in a man who had become inocu- lated by the dead body of a glandered horse ; and in 1840, a patient who had been admitted into St. Bartholomew's Hospital, London, died of glanders, and the nurse who had attended this patient took the disease and also died of it. Many similar cases are on record which show that the disease, though never spontaneously developed in man, can be readily conveyed to him, and that, when once inoculated, it can be easily communicated from one human being to another. It is said that the virus may be communicated through the blood, and Viborg believes that inoculation may also take place through such secretions as the saliva, the urine, and the sweat. It is well known that the disease may be produced by wiping the hands and face with cloths which have been used on an affected horse. 13ouley inoculated horses with the pus of glanders, and though the inoculated parts were cut out one minute after they were in- oculated, yet the disease rapidly manifested itself. Villemin, in 1868, declared his belief that glanders and tubercle were closely allied, and that they should be looked upon as nearly related species of the same genus. Symptoms of Glanders. — The disease manifests itself by an eruption of tubercles or nodules, and appears in two distinct forms. One of these in- volves the mucous membrane of the nose and the neighboring glands, and is the form which is particularly known as glanders ; it is termed morve in France, and Rotz in Germany. The other form affects the superficial lym- phatics and absorbents, either in the trunk or extremities, and is characterized by the development of small tumors beneath the skin, varying from the size of a pea to that of a walnut, hard, fixed, and very painful when touched. There is a corded and knotty condition of the parts, whence this form of the disease is termed Warm by the Germans, and farcin by the French. In Eng- land it is known as farcy-buds. These two forms are but different types of the same disease, and they may be found associated in the same patient. The period of incubation or latency of glanders varies from two days to a week, after which time the stage of invasion begins. Symptoms in the Horse. — The following description of the disease as it is observed in the horse, is taken from Youatt : — The earliest local symptom is a nasal discharge, which consists of an increased secre- tion, small in quantity, and flowing constantly. It is of an aqueous character, mixed with a little mucus. It is not sticky when first recognized, but becomes so afterwards, having a peculiar viscidity and glueyness. The discharge soon increases in quantity, and, in the advanced stages, becomes discolored, bloody, and offensive. On the other hand, the discharge may continue for many months, or even for two or three years, un- attended by any other symptom, and yet the horse be decidedly glandered. The glands under the jaw soon become enlarged, and are generally observed on the same side as that on which the nostril is affected ; the swelling at first may be somewhat large and diffused, but this subsides in a great measure and leaves one or two glandular enlarge- VOL. I. — 15 226 HYDROPHOBIA GLANDERS MALIGNANT PUSTULE. ments, which become closely adherent to the jaw-bone. The mucous membrane of the nose becomes of a dark purplish hue, or almost of a leaden color ; never the faint pink blush of health, or the intense and vivid red of usual inflammation. Spots of ulcera- tion will probably appear on the membrane covering the cartilage of the nose ; these ulcers are of a circular form, deep, and with abrupt and prominent edges, and become larger and more numerous, obstructing the nasal passages, and causing a grating or choking noise in breathing. The disease extends upwards into the frontal sinuses, and the integument of the forehead becomes thickened and swollen, causing peculiar ten- derness. The absorbents about the face and neck now become implicated, constituting farcy; these enlarge and soon ulcerate. The absorbents on the inside of the thigh, and then the deep absorbents of both hind legs, are next involved, causing these parts to swell to a great size, and to become stiff, hot, and tender. The constitutional symptoms are loss of flesh, impaired appetite, failing strength, and more or less urgent cough ; the belly is tucked up ; the coat is unthrifty and readily comes off. The animal soon presents one mass of putrefaction, and dies exhausted. Farcy as met with in the horse is, according to Mr. Youatt, but a different type of the same disease. Farcy is an affection of the absorbents and their glands, usually attacking the ex- tremities. It begins in a kind of glanderous chancre, or ulcer, and, as the virus passes along the absorbent vessels, these suffer from its acrimonious quality ; hence the corded veins, as they are called by the farrier, or more properly the thickened and inflamed absorbents following the course of the veins. At certain distances in the course of the absorbents are valves, and these belly out, and impede or arrest the progress of the matter towards the chest. The virus at these places causes swellings, which are very hard, more or less tender, and with perceptible heat about them. They are observed about the lips, nose, neck, axillary spaces, and thighs. Suppuration and ulceration next ensue. The ulcers are rounded, with elevated edges and pale surface ; and dis- charge a virus as infectious and as dangerous as the matter of glanders. While they remain in their hard aud prominent state, they are called buttons or farcy-buds, and they are connected together by the inflamed and corded absorbents. The constitutional symptoms are drooping, impaired appetite, loss of flesh, and a staring or prominent coat. The horse may then rally and appear to be restored to health, but by degrees the affection becomes general ; the millions of capillary absorbents that penetrate every part become inflamed and enlarged, and cease to discharge their functions ; hence arise the enlargements of the substance of various parts, swellings of the legs, chest, and head ; these are sudden, painful, and enormous, and are distinguished by a heat and tenderness which do not accompany other enlargements. Si/mptoms in Man. — The symptoms of glanders in man, as in the horse, may he divided into constitutional and local. Soon after inoculation, the constitu- tional symptoms commence with febrile excitement, loss of sleep, and impair- ment of appetite ; the patient suffers from chilly sensations, alternating with flushes of heat; the articulations feel stiff and sore; the back and limbs ache ; and swellings frequently appear in the groin, axilla, and neck. The fever soon takes on a more inflammatory character ; rigors ensue ; diarrhoea often occurs; and a decidedly typhoid condition is established. The pulse becomes quick and tumultuous (108 to 120 beats in the minute); the temperature rises to 102 J or 104° Fahr. ; the tongue becomes brown and dry ; and delirium sets in. Accompanying these symptoms are inflammation of the mucous membrane of the nose, with pain in the region of the frontal sinuses and soreness in the throat and larynx; the nose ana the whole face become hot, tumid, and pur- ple; the discharge from the nostrils is sanguineo-purulcnt, copious, acrid, and excessively offensive. In five or ten days, the second stage, or that of eruption, begins, and the specific character of the disease is at once developed; when the eruption is delayed for some weeks, the disease is said to be in a chronic form. The TREATMENT OF GLANDERS. 227 eruption of glanders is hard and pustular, and resembles that of smallpox. Yirchow thus describess the development of the eruption. There appear at first some reddish spots, which are very small, and resemble flea-bites, and which soon acquire a papular elevation, ultimately rising above the level of the surface like small shot, and assuming a yellow color. These shot-like knots are either flat or round, they do not lie in a bladder-like elevation of the epidermis, but in a kind of hole in the corium, as if this had been punched out; they are not always solitary, but often arranged in groups. The parts around are somewhat injected, and under the epidermis there is found a seemingly consistent puriform and yellow fluid, which is chiefly formed from softening of the knots. These are composed of a homogeneous yellowish substance, which is pretty firm and somewhat brittle, and which has great resemblance to tubercle. Microscopically examined, the knots present an amorphous granular appearance, and are mixed with cell elements and cell growths, and with numerous fat globules. The tubercles may be developed in the subcutaneous tissue, producing hard and painful swellings, which are oval and well defined. These breakfdown and give rise to excessive sloughing of the parts. The tubercles often appear throughout the mucous membrane of the respiratory apparatus. The kid- neys, the pancreas, the testicles, and the liver may be similarly affected in the latter stage of the disease. In the acute form, the disease is usually fatal in a few days, but in the chronic form, it may last for weeks and even months. Mr. Travers gives the history of a case which, at the end of two years and six months, was still running its course. The acute form of glanders may be accompanied with acute farcy, in which there is generally diffused suppuration in the entire limb. In chronic farcv, the tubercles often degenerate into foul ulcers, and sometimes terminate in an attack of acute glanders. Diagnosis op Glanders. — In regard to the diagnosis, the early general symptoms do not differ from those of other forms of animal poisoning, while in the early period the eruption has the shotty feel of smallpox; but the history of the case will almost always point to the true nature of the attack, it being generally found, on inquiry, that the patient has handled a glandered horse, or nursed another person affected with the disease. Prognosis. — The prognosis in this disease is always grave. The acute form nearly always ends fatally, fifteen cases collected by Rayer having given only one recovery. The chronic form of the disease is, however, not so fatal, ten cases referred to by Rayer having given seven recoveries and but three deaths. Youatt declares that glanders does not now produce one-tenth part of the ravages among horses that it caused thirty or forty years ago, and that generally speaking the disease is at present only met with as a common affection where neglect, filth, and want of ventilation are found. Treatment of Glanders. — In the treatment of this disease, supporting measures must be employed : Quinine, tincture of the chloride of iron, and brandy, are among the most useful remedies ; morphia should be used to con- trol the pain. The patient's apartments should be constantly well ventilated, and the utmost attention paid to cleanliness; abscesses should be promptly evacuated, and the parts washed out with a weak solution of chloral or of carbolic acid, and then wrapped up with cloths saturated with one or the other of these fluids. 228 HYDROPHOBIA — GLANDERS — MALIGNANT PUSTULE. Malignant Pustule. Malignant pustule is a general disease which originates from contact with the blood or tissues of diseased animals, such as sheep or horned cattle, which are affected with murrain. It primarily affects the skin and connective tissue, appearing in the form of a vesicle, and rapidly developing gangrene. The disease at times appears as an epidemic with a very destructive tendency, and, as the virus is readily conveyed to horses, mules, and hogs, immense numbers of these animals are swept off by its ravages. The virus is readily conveyed to man, and the true test of malignant pustule is found in the fact that it is capable of being conveyed by inoculation from the human being to the sheep. When the virus from a suspected case of the disease is inoculated in this ani- mal without effect, it may be assumed that the affection is not malio-nant pustule. From the nature of their vocation, herdsmen, butchers, tanners, and other persons who work among hides, and who skin and eviscerate the bodies of animals, are liable to inoculation ; the virus is also capable of being conveyed by Hies and insects from diseased animals to man. The hands and face are the parts usually attacked, being most exposed. Stone, of Massachusetts, reported in 1868 seven cases which occurred to persons working in curled hair, and Bourgeois relates the case of a workman supposed to have been in- oculated while picking the hair taken from an old sofa. Prof. Gross speaks of three cases which occurred in persons who had contracted the disease while picking and eviscerating buzzards for the purpose of extracting oil from those birds. The hands and forearms of each individual were inoculated, and violent local and constitutional symptoms appeared at the end of two days. The parts became excessively swollen and painful, and covered with numerous vesicles, which, when ruptured, exposed ill-looking ulcers, which continued to discharge a thin, sanious fluid, and remained open for many weeks. The inflammation reached the axilla, and some of the glands of that region became enormously enlarged, and finally suppurated. Prof. Gross adds that recovery took place only after a long time, and after great suffering, which reduced the patient to the utmost degree of exhaustion. It could not be determined whether the poison was actually generated by these birds, or merely conveyed by them through their feathers being charged with carrion. Symptoms of Malignant Pustule. — Malignant pustule begins as a red spot followed by a vesicle, which soon becomes pustular, and of which the char- ax -tcristics are the extreme smallness of its dimensions, its being surrounded by a vascular areola of leathery hardness, its constant itching, and its extreme sensibility. The vesicle soon becomes enlarged, and is rilled with a thin turbid serum; when it becomes pustular, it assumes a yellowish-brown color, and, increasing in size, soon bursts, and exhibits a foul gangrenous ulcer, which discharges a fetid excoriating fluid. While the vesicle is undergoing these changes, the parts become greatly distended with serum and lymph, very heavy, numb, and painful. If situated on the hand, the whole extremity becomes inflamed as far as the shoulder, and the axillary glands become in- volved. The number of vesicles may vary. In one of the cases observed by Prof. ( Iross, then' was only one ; in another there were two, one on the hand and one on the forearm ; in another they were so numerous that the whole arm and hand were literally covered with them. When the disease appears on the face, the whole eounteuanee becomes dark and greatly distorted; the eyelids generally are closed, thick, and difficult to move, and the disease fre- MALIGNANT PUSTULE. 220 quently extends to the throat, rendering respiration and deglutition very diffi- cult and painful. The constitutional symptoms which accompany these local manifestations are well pronounced : these are general uneasiness and anxiety, and afterwards high fever accompanied by rigors ; a typhoid state soon follows, and septic infection then becomes manifest, from which condition, as a general rule, few patients recover. The disease is more dangerous when the pustule is located on the face than when it is on the arm or hand. It frequently runs its course in less than a week from the time of inoculation, and after death rapid decom- position is apt to ensue. Pathology "of Malignant Pustule. — Davaine considers the co-operation of specific organisms as proven in malignant pustule, and the investigations of Hodges, of Boston, and of late those of Dr. Robert Koch, 1 appear to corrobo- rate this view. [Dr. Gerald Yeo considers the disease identical with that known as Mycosis Intcstinalis, and believes that the presence of an external' pustule is not an essential part of the affection.] Treatment of Malignant Pustule. — The treatment of this disease is local and constitutional. With regard to the local treatment, the pustule should be destroyed as soon and as thoroughly as possible, wherever may be its situa- tion, or whatever its stage of development. The best way to accomplish this, according to Dr. Devers, is lyy the application of the actual cautery at a white heat. This author asserts that the white-hot cautery has the advan- tage of destroying only the part which it touches, and that it promotes the effusion of a large quantity of serum, and induces the necessary reaction in the adjacent parts better than any other means which can be employed. He adds that if the epidermis is elevated by recently exuded serum, and separates itself around the necrosed part, the cauterization has not been sufficiently deep, and must be repeated. Mauserzin 2 recommends the extirpation of the pustule by the knife, and the subsequent application of the hot iron to the surface of the wound. Complete excision is also recommended by Prof. Gross. After excision and cauterization, the parts should be enveloped in a warm emollient cataplasm, and the patient kept at rest, and supported with nour- ishing diet. The constitutional treatment, when the system becomes infected, consists in maintaining a constant supply of fresh air in the patient's apartment, and in endeavoring to maintain his strength by the administration of strong animal broths, and milk with brandy, while pain is allayed by means of opiates. [Quinia and the mineral acids may also be given with advantage. Iodine both internally and externally is recommended by Cezard, and carbolic acid by Estradere.] 1 On Traumatic Infective Diseases. Translated by W. Watson Cheyne, F.R.C.S. London, New Sydenham Society, 1SS0. 2 Archives Generales de MCdecine, Mars, 1SG4. SCROFULA AND TUBERCLE. BY HENRY TRENTHAM BUTLIN, F.R.C.S., ASSISTANT SURGEON TO, AND DEMONSTRATOR OF SURGERY AT, ST. BARTHOLOMEW'S HOSPITAL, LONDON. Tubercle. Scarcely any task in medicine is now more difficult than that of writing clearly on Scrofula and Tubercle. The nature of both diseases, the structure of their morbid products, their relations, are all matters of uncertainty which modern pathology and the microscope have not yet succeeded in rendering plain. Indeed the confusion which prevails is almost greater than that of twenty years ago, in spite of the excessive labor which has in many countries been devoted, especially to the subject of tuberculosis. Nor can we yet be certain whether this confusion may not endure ; or whether out of it we may expect to see order and perspicuity established. We cannot even define either disease with accuracy. For there is a total lack of unanimity of opin- ion respecting some of the foundations on which an account of scrofula and tubercle should be based. We still hope, however, that from the shadowy lines which now exist, some master-hand may form a sketch, perfect in all its parts, firm and clear in outline, correct in its proportions, and delicately toned in light and shade. Until this has haply been accomplished, the only course which remains to each successive writer is to sum up, as it were, on the evidence which is laid before him, and to present to his readers an account, as clear as he is able, of each subject. I shall depart from the order usually observed, and shall treat first of Tubercle ; and as I am not able to define tuberculosis, and scarcely know how to describe it in accordance with all the most recent doctrines, I am almost compelled to adopt a course which for other reasons I prefer : — first, to relate certain cases which will, I believe, be regarded by almost all authors as cases of tubercle, and then to deduce from them an account of the disease. ■ Case I — A girl 15 years old, was admitted into St. Bartholomew's Hospital in July of the present year (1880). Occupying the submaxillary region of the left side, and extending across the middle line, was a greatly enlarged lymphatic gland, meas- uring about two and a quarter inches in length by half an inch in breadth, and as thick as it was broad. It was smooth, of oval shape, firm but elastic, and could be moved with tolerable freedom. Several of the glands in close proximity to this one were enlarged, but to a far less degree. The child was pale-faced, with gray eyes and fair hair; her skin not very thin, nor freckled ; her eyelashes not long; her superficial veins not large or prominent. Her mother told us that the tumor had existed in the girl's neck for fully six years, that no cause of its origin had been recognized, and that trom the onset it had very slowly continued to increase in size. It had never been (231) 232 SCROFULA AND TUBERCLE. painful, nor inflamed. There was no history of tubercle in the family ; and, with the exception of the tumor in her neck, the child had always enjoyed good health. The large gland and one or two of those which lay nearest to it were removed, and the wound healed as kindly as could be desired. No tubercles could be distinguished in the excised growths by the naked eye. They presented the appearance merely of hypertrophied lymphatic glands. Each was in- closed in a thin capsule. The consistence of each was a little less firm than that of a normal gland ; the color a little less dark. The surface of a section was finely granular, or homogeneous, not traversed by fibrous bands ; and nowhere was there pus or caseous material, or obvious degenerative change. Had it not been for Oskar Schiippel's 1 treatise, it could scarcely have been suspected that these glands were tuberculous. But the microscope discovered in every section numerous bodies of round or oval shape, each consisting of a central giant-cell surrounded by lymphoid and epithelioid cells, inclosed in a delicate reticulum, and the whole body often surrounded by a kind of fibrous capsule. These tiny bodies lay sometimes close together, but more often sepa- rated by lymphatic tissue. In no one of them could vessels be distinguished. Their microscopical characters corresponded so closely with those ascribed to tubercle, that the glands were regarded as tuberculous ; but in the future consideration of this case, it must be borne in mind that the diagnosis rested solely on the microscopical exami- nation. Case II. — F. S. , a young man, tall and thin, with brown hair and blue eyes, and with full-colored cheeks, was without any sign of general ill-health except a slight debility, apparently due to a restricted diet and rapid growth, for he was six feet high and had scarcely yet attained his majority. At the beginning of May, 1880, after jumping down from a height, he noticed that his left testis was enlarged and very slightly painful. It rapidly increased in size, but the pain subsided. He had never suffered from venereal disease. His father and his father's brother were said to have died of consumption. The left testis formed a smooth, oval tumor, about four inches long, bulging somewhat at both ends, but presenting no indication of a furrow between the epididymis and body of the organ, which parts seemed blended or fused together. The tumor was free from pain or tenderness. The scrotum was not reddened, but was a little puckered and adherent at the upper part. The cord was slightly thickened, but no enlargement of the glands could be distinguished. On the lGth of June, the tumor was removed. The tunica vaginalis was everywhere adherent ; the epididymis was hardly distinguishable until a section was made, when it was discovered to be but little altered, save that the globus major contained a mass of caseous material. Almost the whole tumor was caseous, but moist and firm, not friable. Towards the front was a little juicy material of a pale gray tint, which had not yet degenerated. No nodules or rounded bodies were visible to the naked eye. But microscopical examination revealed the presence of many bodies resembling those found in the glands in the last case. The giant-cell, surrounded by smaller cells in a deli- cate reticulum, was easily discernible, but the smaller cells were rather lymphoid than epithelioid, and very few of the tubercles were inclosed within a layer of fibrous tissue. There was a similar absence of vessels in the tubercles. The caseous material no longer formed a continuous and homogeneous mass, but was for the most part broken up into rounded bodies, often of small size and close together. From the microscopical exami- nation chiefly, but also from the general appearance of the testis, the diagnosis of tubercle was made. Case III A young gas fitter, aged 19 years, was admitted into the hospital in May, 1879. I lis mouth had been sore for about two years, but during the last three months his tongue had become ulcerated. Six weeks before admission an abscess had formed upon his face. His health had always been indifferent, but there was no family history of tubercular disease. While he was in the hospital, his cousin was an inmate of the same ward, convalescent from empyema, and suffering from chronic inflammation of the carpus. The patient was an ill-nourished, anaemic youth, with dark hair and eyes, 1 Untersuchungen iiber Lympli-drusen ; Tuberculosa Tubingen, 1871. TUBERCLE. 233 and a sallow complexion. But his lashes were not long, his bones were small, and his temperament was only dulled by the severity of the disease. The middle of the dorsum of his tongue was occupied by an extensive ulcer of irregular shape, not deep except in front, where it formed a long fissure or deep cleft ; its surface was pale and smooth ; its border slightly raised, not undermined ; and no induration was present, of either the border or the base. There were several superficial ulcers of the hard palate, and the cervical glands were, many of them, enlarged. During the following two months the ulcer continued, at first slowly, then rapidly, to enlarge, and its surface became foul and sloughy. The patient became more and more emaciated, and, quickly sinking, died at length on July 23, 1879. On post-mortem examination, it was found that in addition to the ulceration of the tongue and palate, and the affection of the glands, the soft palate was swollen, ulce- rated, and eaten out by numerous cavities containing caseous matter. The epiglottis was ulcerated, and thence the ulceration extended along the aryteno-epiglottidean folds and down the larynx to the true vocal cords, at which point it was arrested. The upper part of the right lung was adherent, and hollowed out by cavities many of which were filled with blood. In the tissues of the lung, around these cavities, were numerous bodies of small size and gray or yellow color, or gray with a yellow centre. In the left lung existed collections of caseous matter varying in size. The other organs of the body were normal. The diagnosis of tubercle in this case rested upon the characters of the ulceration in the mouth, and upon the enlargement of the lymphatic glands : it was confirmed by the presence of cavities in the lung, and of typical tubercles around these cavities. Case IV. — This series of cases may be well concluded by that of T. S., a farm laborer, 46 years old, who came to St. Bartholomew's Hospital in March, 1877, com- plaining of certain symptoms of stone by which he had been distressed for upwards of a year. During that period he had experienced constant difficulty and pain in micturi- tion, and had often passed water mixed with blood. His symptoms had increased in severity during the last two months, and the urine had become turbid; and for three weeks before admission his testes had grown larger, and had been painful. Previous to this illness the patient had always enjoyed good health. No member of his family had suffered from consumption. He was a strong-looking countryman who preserved the appearance of health in spite of the distress occasioned by his disease. He suffered continual pain over the region of the bladder ; was obliged to pass water at least every half-hour, by day and night, and each attempt at micturition was attended by straining and severe pain. His urethra was exquisitely sensitive, so that he could scarcely bear the passage of an instrument, however gently introduced. But there was no stricture, and no stone. Each testis was enlarged, and the epididymis especially was hard and nodular. His symptoms rapidly became more urgent, and to the rest were added others indicative of cerebral disease. On the 13th of April he died, as it appeared, from inflammation of the brain or of its membranes. But no inflammation was discovered after death, nor were any tuber- cles observed on the membranes of the brain. Indeed, to all outward appearance the contents of the skull were normal. The bladder wall was thickened, the mucous mem- brane generally inflamed and ulcerated. The right ureter was dilated, and its mucous membrane inflamed ; and the inflammation extended into the dilated pelvis of the kid- ney, the secreting substance of which contained large caseous masses. The pelvis and calyces of the left kidney were widely dilated, and scarcely any of its secreting struc- ture still remained. The epididymis of each side contained caseous masses, and in the body of each testis were numerous gray and semi-translucent bodies, from the size of a millet-seed to that of a pea. The liver, spleen, and lungs contained large numbers of bodies bearing similar characters, but in the lungs many of these bodies were of large size and yellow, and softening in the centre. Examined with the microscope, the smallest bodies generally contained a giant-cell, and around it lymphoid tissue or larger epithelioid cells in a delicate reticulum. In the larger bodies the giant cell was re- placed by granular debris, which often extended far beyond the area which might for- merly have been occupied by the giant-cell. No vessels could be distinguished in any of these bodies. 234 SCROFULA AND TUBERCLE. Analysis of the above Cases. — Since each one of these cases would he described by some noted pathologists as a case of tubercle, I shall venture to regard all of them as tuberculous, and to use them for the purpose of analysis. But if they be compared together, it will at once be seen that they do not accord in many of their prominent features. For example, the dura- tion of the disease was in one case twelve years, and the patient is still alive and well ; while in another case it was scarcely more than a year before it proved fatal. The lesions were in the first case limited (during many years at least) to the lymphatic glands, and even to a certain group of glands; in the third case they extended over a wide area of the respiratory tract, while in the last case they were distributed over many organs and tissues. The general appearances of the lesions differed conspicuously, for the disease of the lymphatic gland in Case I. bore the characters of simple hypertrophy ; that of the testis in Case II., those of inflammation with general caseous de- generation; and that of the affected organs in Cases III. and IV., the charac- ters commonly described as tuberculous. The patients themselves presented no common points of resemblance, in feature, in color of hair and eyes, in com- plexion, or in general configuration, while their ages varied from 15 to 52 years. Clinically, there appear then to be no characters which are common to them all ; no characters which we can describe as pathognomonic of tuber- culous disease. But, pathologically, we discover in every case, in some of the organs or tissues, small bodies, generally of spherical or spheroidal shape, but apt to lose their shape as they increase in size or become confluent. The larger of these bodies are plainly discernible with the naked eye ; indeed some of them are as large as peas or even larger. The smallest can only be discerned with the aid of low powers of the microscope, when they present a similar rounded or spheroidal shape. Morbid Anatomy of Tubercle. — Here then we seem to be in possession of the key to all tuberculous affections — the presence in the affected tissues of small bodies of rounded or spheroidal shape, which we call tubercles. But in truth, at this point the first difficulties arise, and the earliest departure from apparent uniformity occurs. It is impossible to rest content with a definition of tubercle so loose as this. We must dissect tubercle, must analyze it with the microscope and describe its minute structure with accu- racy. We must know, too, in what tissues it is found ; what is its nature ; what are the causes which tend to produce it ; and the conditions in which it occurs. On all these questions there exists diversity of opinion ; on some of them a diversity of opinion so considerable, that it seems now as if the conflicting views could never be reconciled. Take, for example, the question of the minute structure of tubercle. Some- times it appears to consist solely of retiform tissue — of leucocytes, or colls resembling leucocytes, in the meshes of a delicate reticulum. Such, accord- ing to Ziegler, 1 is the structure of those bodies which, with marked constitu- tional symptoms, attack almost simultaneously many tissues and organs. Sometimes tubercle is composed of endothelial elements, while some tubercles again consist of both these forms of cells. In the centre of some tubercles, a giant-cell is found, irregular in shape, furnished with many nuclei, and by certain pathologists regarded as an essential element of tubercle. Even the grouping of the nuclei, when they leave the centre free and approach the circumference of the cell, is thought to be characteristic of the giant-cell of tubercle. Some tubercles are caseous; others are composed in part of fibrous 1 Deber Tuberculosa and Schwindsucht. Samnilung klinischer Vortritge (Volkmann's), No. 1.01, 1678. ORIGIN AND NATURAL HISTORY OP TUBERCLE. 235 tissue. As with the elements of which tubercles are composed, so with the manner of their combination, there is an absence of uniformity ; nay, I might almost say, what appears to be almost an absence of design, save that we can often distinguish a relation between tubercles of a certain structure, and the tissues in the midst of which they lie. There is indeed one feature in the structure of these bodies which, I believe, is admitted by all observers, the absence, namely, of vessels in their interior. Whether a tubercle be large or small, whether it be degenerate or organized, whether it be formed of endothelium or of leucocytes, in every instance it is absolutely non- vascular. Origin and Natural History of Tubercle. — As long as uncertainty pre- vails on the fundamental proposition of what is a tubercle, it seems idle to discuss its origin and natural history. Yet no paper on the subject would be complete which did not discuss these points, and the only question is how they can be considered here with most advantage. Perhaps by making an arbitrary definition of a tubercle, and using the definition thus formed as a basis on which to build a history of the disease. We need not, however, make a purely arbitrary definition, but may assume that the word tubercle, employed most exactly, signifies what is perhaps the commonest form of the disease — those tiny bodies which often cannot be distinguished with the naked eye, but which are discovered by the microscope to consist of a central giant- cell surrounded by lymphoid and epithelioid (or endothelioid) cells, contained in the meshes of a delicate reticulum. ISTo vessels are present within them. These bodies may be found within the coats of small vessels (as in the pia mater), or in the various connective tissues. Indeed, with the exception of cartilage, of the connective tissue of the external musculature, and of the coats of the large vessels, in which they have not yet been discovered (Frankel), 1 tubercles may occur in every part of the body. They are found, too, com- monly in connection with endothelium, growing for example about the trabe- cule of the omentum; but apparently they do not grow in the midst of epi- thelium. As with the situation, so with the origin of tubercles. They may arise from the coats of the smaller vessels, from connective tissues, and from endo- thelium; but not from epithelium, although Cornil and Ranvier 2 have ex- pressed a contrary opinion. They may originate too from colorless blood corpuscles or wandering cells, as the glass disks of Ziegler proved. Ziegler's disks indeed proved more than this, for they showed that there was nothing specific either in the elements of the tubercle which we have described, or in the combination of those elements. For the body formed between these disks corresponded in all its characters with tubercle. Tubercles, once formed, may remain unchanged for a considerable time; or they may enlarge, and still for a time retain their form and structure ; but more often they become trans- formed. Sometimes the transformation is degenerative or destructive; the central portion slowly becomes caseous, or dies, probably from insufficient nourishment incidental to the crowding of its cells, and to the absence of ves- sels within it; the caseation may spread until the whole tubercle is involved, and wide areas of caseation may be produced by the degeneration of many tubercles in close proximity, and of the intervening tissues. Sometimes the transformation is towards organization ; fibrous tissue is developed ; indeed it is not uncommon to find tubercles of the smallest size surrounded by a kind of fibrous covering. 1 Tuberculose; Handbuch der Kinderkranklieiten (C. Gerhardt). Bd. 3. S. 153. Tubingen, 1878. 2 Manuel d'Histologie pathologique, p. 199. Paris, 1869. 236 SCROFULA AND TUBERCLE. Once formed, tubercles are not prone to disappear or to be resolved, although Lebert 1 states emphatically that tuberculosis at all ages, in all situations, and in all places of its development, is capable of cure. Far more commonly they are associated with inflammatory changes, the tendency of which is through- out destructive. Suppuration in and about lymphatic glands; disintegration and protrusion of the testis through an opening in the scrotum; ulceration of mucous surfaces and of the skin; these are the conditions of which tuber- cles are too often the precursors. These conditions are probably all more or less closely connected with the caseation or molecular disintegration to which tubercles are so frequently subject. Infection of Tubercle. — But there is another cause, more potent than even these, which tends to hinder or prevent the cure of tubercle, or, to speak more justly, of tuberculosis. A tubercle once formed seems to possess the power of generating its kind. A tuberculous tissue or organ is not only a source of danger in itself, but a source whence new tubercles may be acquired. The spread of the disease is not always in the same direction, or to the same ex- tent. Sometimes it remains limited to a single organ, which may be com- pletely filled with tubercles. An example of this may be found in the testis of the patient in Case II., in which, however, it must not too hastily be assumed that the condition was due to the spread of the disease, for there is no distinct evidence to show that all the tubercles may not have been formed at the same moment. Sometimes tubercle invades a group of organs, spreading slowly from the first affected to the others. Such an extension of tuberculous dis- ease may fairly be supposed to have occurred in Case I., where one lymphatic gland had been diseased for many years, and subsequently each gland of the whole chain of glandalce concatenates, had become enlarged, and (if we may judge by the examination of the smaller gland removed) probably tuber- culous. The infective material may probably be conveyed by various channels. It may be carried by the small arteries from near the root or hilum of an organ to its deeper parts. Or it may pass through the lymphatics to the neighbor- ing lymphatic glands, a method of extension so frequent that primary tuber- culosis of certain parts, the tongue and pharynx for example, is invariably associated (provided that the primary disease has been of sufficiently long duration) with tuberculous affection of the neighboring glands. Or it may travel through the veins, and reach the lungs from distant parts, and from the lungs again be disseminated through the body. Examples of this are numerous, but it will be sufficient to cite Case IV., in which the primary disease was, it may be believed, of the urinary mucous membrane, and in which, shortly before the patient's death, the lungs, the liver, and the spleen became diseased. Or, lastly, and this is one of the most common methods of extension, the disease may spread over the surface of a membrane first attacked, or the infective material be carried to distant parts of long tracts of membrane, and there produce new tubercles. Illustrations of these condi- tions may be found in Cases III. and IV. In the former, the aft'ection spread, as if by continuity, along the surface of the tongue to the pharynx and the larynx, and thence probably was conveyed by the air-passages, but without infecting them, to the lungs. In the latter, the disease attacked the genito- urinary tract, and, while it spread over the surface of the bladder, and through the substance of the kidneys and the testes, and was perhaps conveyed from one of these organs to the others, there were still wide tracts of normal or marly normal intervening membrane. ' Traite clinique et pratique do la plithisie pulruonaire, etc. Paris, 1879. NATURE OF TUBERCLE. 237 Nature of Tubercle. — The uncertainty which prevailed regarding the nature of tubercle, and the resemblance of some of its processes to those of the malignant tumors, led Virchow, 1 many years ago, to regard it as a malig- nant tumor-formation. Its structure, apparent incurability, and the manner of its extension, were the chief among the conditions which led Virchow to adopt this view. Certainly it is an attractive theory, and may yet, perhaps, be proved to be correct for some of the bodies which are included under the name tubercle. But against its universal application, several arguments may be advanced. First, the almost constant association of the disease with inflammation — an association so constant that tubercle is regarded by most authors as the product of inflammatory changes. Next, the absence of ves- sels within the tubercle, and the wondrous frequency of caseation, are both unlike the characters of a malignant growth. Caseation does indeed often occur in carcinoma and sarcoma, but not as if it were an almost necessary transformation of their tissues, or so largely as to produce great masses of caseous material. There are some peculiarities, too, in the manner of infec- tion of the primary disease, in which tubercle differs from the malignant new-formations ; in the manner, for example, in which it is often scattered over wide tracts of membrane. And lastly, we can do with tubercle what we have not yet succeeded in effecting with any of the malignant growths: we can produce it at will. Not in the human subject, but in certain of the lower animals, a body closely resembling tubercle in its essential attributes, may be produced by the introduction of certain substances within the body of the animal. This artificial tuberculosis may be produced most readily in the guinea-pig and dog. If we insert beneath the integument of either of these animals, a small portion of degenerated (caseous) tubercle, the animal falls sick and dies within a few weeks. Section discovers tuberculous inflammation of various organs, notably of the lungs. Or if we inject into the pleural cavity a fluid contain- ing caseous particles from a tuberculous lymphatic gland, the infective mate- rial first spreads itself over the surface of the serous membrane, producing at numerous points nodules of induration (tubercles); thence is conveyed along the lymphatic channels to the nearest glands, in which similar nodules are produced; and by the veins is disseminated through the body. The indurated nodules thus produced consist for the most part of masses of adenoid tissue, and do not exhibit the structure of the typical tubercle from which "we started, although in the lungs epithelioid cells enter largely into their compo- sition. These artificial tubercles, too, are subject to much more rapid and extensive caseation than are the tubercles of acute human tuberculosis. And, lastly, it is singular that, in the artificial tuberculosis of animals, the brain, so often the seat of the disease in man, is never attacked. These are the chief differences between the natural and the artificial, acute tuberculosis; but they are not sufficient to counterbalance the evidence in favor of the view that the artificially produced disease is in truth tubercu- losis. The story of the induction of tuberculosis does not, however, end here. The experiments of Sanderson and Fox 2 have made it clear that a mere injury inflicted in a certain manner, may produce tubercle as surely as the inocula- tion or injection of degenerated tubercle. For if a seton be introduced into a guinea-pig or dog, or non-tuberculous material be inserted, each of these inju- ries is equally followed by the formation, locally, of a cold abscess, and, later, by tubercles similarly distributed to those which follow the employment of a tuberculous agent. Moreover, it has been found that ouly certain animals ' Krankhaften Geschwiilste, Vorles. xxi. * Recent Researches on Artificial Tuberculosis. Edinburgh, 1869. 238 SCROFULA AND TUBERCLE. can be rendered thus with ease tuberculous, while others — the cat, for in- stance — resist the infection, and escape unharmed. The lessons taught by these experiments are, that tubercle may be artificially induced ; that any lesion which will produce a cold abscess, or, better still, caseation, may be the agent by which tuberculosis may be induced ; that there is nothing specific, therefore, in the infective material; but that, since certain animals are easily infected, while other animals as easily resist the infection, a certain predispo- sition to tubercle is probably essential. The characters of artificial tubercu- losis lend great weight to the theory of the inflammatory nature of the dis- ease, for all its processes are apparently closely associated with inflammation. The bearing which these experiments have on human tuberculosis can scarcely be over-estimated, and yet it may be very differently rendered. If tubercle can be produced in animals by the introduction into them of caseous material, whether tuberculous or not, why should not tubercle in man be in some such manner also closely connected with the presence of caseous matter in his body? Long before the institution of these experiments on animals, Buhl 1 had noticed the exceeding frequency with which caseous masses occurred in subjects who were tuberculous, and had been led on this, and other ac- counts, to regard tubercle as the product of infection. He came, indeed, to regard all tubercle, whether acute or chronic, whether general or local, as due to the absorption of infective material from caseous centres. ISTow, although this view cannot be maintained in the complete form in which it was advo- cated by Buhl, it is, nevertheless, with some slight modification, the view most commonly adopted at the present day. The infective or absorption theory of tubercle assumes that all tubercle is produced by the absorption of infective matter, but not necessarily of caseous matter, although caseous matter is one of the most powerful infective agents. But there are certain difficulties which prevent it from being universally accepted. For example, the centre of infection cannot always be discovered, even by the most careful seeking — a difficulty which may be explained by assuming that it has disap- peared, either by absorption, or, it may be, by suppuration. Again, if caseous matter be so powerful an infecting agent, how can those cases be explained — and they are not few- — in which caseous masses exist, or have existed, in the body for a lengthened period, and yet in which no tubercle is produced? In reply to this question, it is suggested that a certain predisposition or tendency to the formation of tubercle is necessary, and, as an illustration of this law, the marked difference which exists between certain groups of ani- mals in their relation to tubercle is cited — an illustration which, by the way, loses something of its point from the fact that the law, which in animals is applied to whole races or species, is in man applied only to individuals. And as the insufficiency of this answer has been plainly felt, it has further been suggested by Niemeyer, 2 that the masses of caseous matter, to infect, must be in a certain stage or condition, and must not be surrounded by a capsule; and yet one more reason is assigned for the infecting capabilities of certain caseous masses, for the infectious nature of certain sputa — that they contain micro- organisms — according to Klebs, 3 a form of coccus (the Monas tubcrculosum), according to Buhl, 4 bacteria. Pathology of Tubercle. — These, then, are among the problems which now perplex pathologists in the nature and processes of tubercle. If we are com- pelled to hold fixed views on any of them, those which suggest themselves as 1 Lungenentziindtmg, Tnborknlose mid Schwindsucht. 2 Text-book of Practical Medicine, translated by Humphreys and TIackley. 3 Handbuch der pathologisclien Anatomie. * Op. cit. TREATMENT OF TUBERCLE. 239 most acceptable and worthy of credence are that tubercle, in its most perfect form, possesses such a microscopic structure as that which we described in defining it; that some tubercles never attain this complete or typical struc- ture, while others either degenerate or become further developed ; that devia- tions from this type may and do occur, in accordance with the situation in which a tubercle is found ; that tubercle is an inflammatory production, not a malignant growth (as sarcoma and carcinoma are malignant); that a tuber- culous tissue or organ is a centre whence tubercle may be conveyed through- out the body; that the channels by which the conveyance is effected arc several ; that tubercle may be produced in the bodies of certain individuals by the absorption of an infective material. But the evidence which is fur- nished on the more advanced questions is not yet sufficiently convincing to permit us to form a decided opinion on them. We cannot yet assign to each tubercle its value. We cannot be sure whether all tubercles are due to the absorption of infective material, or whether they sometimes own another cause. Xor can we say with certainty whether the infective material is sim- ple, or whether it is specific. And although we may admit that a predispo- sition to tubercle is necessary ere it can be developed, we are not yet in a position to define the nature of this predisposition. A few years ago, inherit- ance was regarded as one of the chief predisposing causes of tuberculosis. Now, it is said that tuberculosis is not inherited, but that the offspring in- herits from the parent a tendency to the production of caseous masses, from which tubercle may be developed. 1 Treatment of Tubercle. — The tuberculous affections in which surgery is mainly interested, are those of which examples have been given; of the tongue, the pharynx, the glands, the urinary mucous membrane, and the testis. The bones or periosteum, and the synovial membranes, may be added to the list, while tubercle of the larynx and the choroid are more likely to be met with in the practice of the special surgeon, or the physician. It is not intended that this article should comprise a detailed account of the tuberculous affections of each part. These will be treated of in subse- quent pages devoted to the study of the special organs and tissues. It now only remains therefore to indicate the main lines on which the treatment of tuberculous disease is founded. Treatment is directed not only to the cure of those who are tuberculous, but to the prevention of tuberculosis. For our wider knowledge of the etiology of the disease, and of the course which it may not improbably pursue, leads us, not unnaturally, to adopt those meas- ures which seem calculated best to avert its cause, and to arrest its progress. We believe that the offspring of tuberculous parents are predisposed to tubercle. We cannot prevent the parents from begetting children, but we can place many of the children in conditions which will diminish their lia- bility to tubercle. By careful hygiene, by clothing and by food, we may lessen the number of the tuberculous among the children of the poor; while for the children of the more wealthy classes, in addition to these things, each should be advised, if possible, to select a calling which will not subject him to frequent or long-continued strain, or expose him to continued cold and wet. Residence, too, in places where the air is clear and dry, and the winter not too long or cold, should be strongly recommended. When tubercle is actually present, to these measures are generally added, often with the best result, the administration of certain drugs, the beneficial influence of which over the progress of tubercle has long been recognized. Cod-liver oil and syrup of the iodide of iron are exhibited with bark and alkalies, or acids, as 1 Billroth ; Pitlia und Billrotli's Haudbucli der Chirurgie ; Bd. I., Abth. 2, Hft. 1, S. 307- 240 SCROFULA AND TUBERCLE. may seem best to meet the requirements of each individual ease. For we believe that tubercle, however rarely, is capable of cure; both because persons who have seemed to suffer from tuberculosis of the lungs, have recovered, and because ulcers of the mouth and pharynx which have borne the typical tuberculous aspect, have been watched as they slowly but completely healed. But when a limited area which is easily accessible, is tuberculous, and there is no evidence that the disease affects more distant parts, it seems but reason- able, in appreciation of the infectious nature of the disease, to cut away the affected portion as if it were a malignant growth. Of late years this has been done with tolerable frequency. The testis has been thus treated, and so have tuberculous ulcers of the tongue, and tuberculous affections of the bones and joints. Of the propriety of all these operations, there can be no doubt, pro- vided that they are undertaken in fitting cases and performed with all due care. But opinion is not so unanimous as to the advisability of removing lymphatic glands containing tubercles. For, although the disease may remain long limited to a certain group of glands, it is not often limited to a single gland, but quickly spreads from one to another. A whole group of glands can rarely be removed, especially as the cervical glands are those which tuber- cle most commonly affects. And if one, perhaps the largest, of a certain group be taken away, the operation so far from being beneficial may even prove the reverse by exciting to activity the morbid process in the glands still left behind. A case illustrating this is that of a girl twelve years old, who for two or more years had suffered from a tuberculous gland in the middle line, beneath the floor of the mouth. Sometimes it suppurated, and unhealthy ulcers formed; and, again, the openings closed and all bid fair for cure. But the lump remained, and was a constant eyesore and source of annoyance to the patient. I removed it, therefore, with all due care, and the wound healed by the first intention. Now, however, the neighboring glands, which before the operation had been quiescent and scarcely at all enlarged, quickly grew larger, and, suppurating, formed scars and ulcers, more distressing and dis- figuring than the disease which I had removed. Further experience, based on numerous observations, is required to decide as to the propriety of ope- rating under such circumstances. Scrofula. Two cases, shortly recounted, will serve to preface the description of Scrofula. Each of them is typical in its kind, yet it will be seen that the difference is great between them. Case V The first is that of a boy, twelve years old, who came to my Out-Patient room nearly two years ago (February, 1879), with a swelling of the back of one hand. He was a well-grown lad, with fair hair, blue eyes, and a ruddy glow, as if of health. His skin was not very thin or freckled, nor was it so transparent as to permit the super- ficial veins to be seen clearly through it. The swelling of his hand had followed almost immediately upon a blow. It occupied the whole of the dorsum of the hand, but was most prominent over the third metacarpal bone, where the skin was reddened, hot, and tender. For many days or weeks it changed but little ; then slowly suppurated ; and :it the bottom of thfl suppurating cavity bare bone was easily distinguished. After a while, almost the whole of the metacarpal bone was removed by operation, and there seemed to be no reason why the wound should not fill up by granulations and become a healthy gear. Bu| the progress towards recovery was marvellously slow. The wound appeared to flag) apd sinuses burrowed through to the palm ; yet the general characters of good health were preserved, and no new local mischief in the bones or joints was discovered. At the end of a year of treatment, the hand was still unhealed. And now two ulcers NATURE OF SCROFULA. 241 formed immediately above one elbow ; of circular shape ; with glazed or waxy surface, but discharging an abundance of thin pus; with edges of a dull red color, thin and widely undermined ; and with congested integument around and between them, for they lay not far apart. A few weeks later, an abscess formed on the dorsal aspect of one foot, broke, and discharged a thin but curdy pus. Abscess, sinuses and ulcers, dis- charging all together, produced at length a sensible effect on the patient's health, in spite of good food, cod-liver oil, and preparations of iron and iodine. He was therefore sent for a while to the seaside, and when he returned, already benefited by the change, was taken on board his father's barge that he might enjoy the river air the whole day long. Slowly the discharge diminished and the wounds began to heal, and after several weeks some of them were really closed, and his general health improved. After which he ceased to attend the Hospital. Cask VI. — The second case occurred in a very different subject — a woman, whose age was only fifty-nine, but who was prematurely old. She was white-haired, anaemic, weak, and withered. The first phalanx of her left forefinger was greatly enlarged, and covered with thin, red skin, glazed and ulcerated. Sinuses passed directly into the inte- rior of the bone, which was as if blown out into a thin-walled cavity, containing a soft material in which were numerous grits of bone. On the upper aspect of each foot was a circular ulcer, with thin, red, undermined edges, through which rough and carious bone could # be reached. And over the left patella were two small ulcers, implicating the skin and subcutaneous tissue, but not connected with disease of bone. Her history was free from any record of specific disease. She had been always delicate, and about five years ago had become completely blind from amaurosis. Within the last two years, abscesses and ulcers had formed, first on the finger and then on the feet ; and tiny frag- ments of bone had come away at intervals. She was kept under observation during several weeks, and was well fed and warmly clad. Quinine and iron were administered, and the wounds were dressed with a slightly stimulating ointment. But she made little or no progress towards recovery. Xature of Scrofula. — To complete the account of scrofula by clinical illustrations would require many more cases than these, but these two patients presented certain common features of disease which are almost universally regarded as scrofulous. In both of them inflammation was set up by an ex- citing cause so trivial that only in one could it fairly be assigned. In each case the inflammation, thus excited, proceeded to suppuration ; and ulcers were formed, the characters of which were for the most part of a certain definite type. The disease, once established, exhibited a disposition to main- tain its hold ; the affection of the bones slowly progressed to their partial or complete destruction ; the ulcers, if they did not spread, certainly did not heal ; and several regions of the body became the seat of similar disease. In these few sentences, scrofula is almost defined, as far indeed as it ap- pears capable of definition ; for the essence of the disease lies rather in several tendencies or predispositions, than in any clearly defined conditions. In the two cases recorded, for example, there was nothing so characteristic in the signs or course of the inflammations, but that it might be imitated in the inflammations of those who are not suffering from scrofula. Xor were the ulcers such that they could be at once and certainly distinguished as scrofu- lous. Yet no one would, I imagine, be disposed to deny that these patients were suffering from scrofula. For scrofula may be described as a condition of the body, or of certain portions of the body, in which inflammations are easily excited ; in which the}^ tend towards suppuration and ulceration ; and in which the power of spontaneous recovery is very feeble. It has been defined by Virchow 1 as consisting in "a greater vulnerability of parts and a greater pertinacity of disturbances," than is natural, and these expression*; form the basis of the large majority of later and longer definitions. Yqt j ic l Krankliaften Gescliwulste, Vorles. xxi. 242 SCROFULA AND TUBERCLE. Morbid Anatomy of Scrofula. — There is not in scrofula, as in tubercle, a pathological body, either microscopical or of larger size, peculiar to the dis- ease. All the changes are those of inflammation, but the products of scrofu- lous inflammations may be analyzed, chemicall}' and histologically, without the discovery of any substance or structure which may not equally occur in any or indeed in every inflammation. One thing certainly is noticed of the lymph produced in scrofulous inflammations ; not only that it tends to sup- purate, and is little prone to organization, but that it has a very strong tendency to degenerate into caseous material, by absorption of the fluid parts, and by withering and distortion of the cells. These, mixed together, form a yellow substance in which fatty molecules abound, and in which plates of cholesterine and the debris of tissues which 'have been disorganized are found. But caseation, although it is so common, is not a constant result of scrofulous inflammation. And even if it were so, it is a condition so frequently occur- ring in connection with other forms of inflammation, the tuberculous, for example, that it could not be regarded as in any way distinctive of scrofula. The abundance of lymphatic elements, too, which has been noticed by Frankel 1 in scrofulous inflammations, is not more distinctive of them than is caseation. Diagnosis of Scrofula. — Although scrofula is a disease thus difficult to define, and though its lesions are not separated by any well-marked limit from those which may result from other debilitating diseases, it is never- theless not difficult to diagnose in such instances as the two which I have described. Even in less advanced cases, it may be recognized by certain characters presented in its lesions, which though they are not pathognomo- nic, are more uniformly observed in scrofulous affections than in any other. Let us leave for a moment the tissues and organs which are the seat of dis- ease, and examine the characters of the lesions wherever they occur. The inflammations are very slow in progress, lingering often for weeks before suppuration is established. Yet the signs by which they are accom- panied are sometimes almost acute ; the superficial redness is intense, the swelling considerable, the pain extreme, and even the heat is notably in- creased. All the signs predict an early suppuration and quick recovery. But the prediction is not fulfilled, for even the suppuration appears un- accountably delayed. Far more frequently, however, all the signs of inflam- mation are chronic throughout, and the abscess which results is cold or lymphatic. Yet even these abscesses often point, and break with superficial redness, and heat, and pain. The ulcers of scrofula are generally circular in form ; with red or livid edges, not raised and scarcely thickened, but under- mined sometimes over a wide area; with pale and flabby granulations, often large and flattened; and with an area of chronic congestion surrounding them. The discharge from these ulcers is generally abundant, but thin and watery. They remain apparently unchanged in size or characters for weeks, or even months, or, under unfavorable conditions, grow larger; and, where several of them lie not far apart, gradually approximate until they are only separated by thin, undermined bands or strips of red integument, or join to form larger sores with incurved borders. Even the sears which remain after healing, nre characteristic of the disease. They are strangely puckered and distorted, often presenting prominent crests or ridges, and retaining the dull red or livid hue of the borders and surrounding ureas of the ulcers. Occa- sionally the thin belts between the ulcers fail to become united with the sub- jacent healing surface, but, maintaining their vitality, heal separately and 1 Handbuch der Kinderkrankheiten (C. Gerhardt), Bd. iii. S. 120. Tubingen, 1878. TISSUES AND ORGANS AFFECTED BY SCROFULA. 243 remain as thin, clastic strips of skin, attached at each end and bridging over a slightly depressed, scarred surface. The disfigurement produced by these scars is often most distressing, especially when they occur, as they are apt to do, about the face and neck. Tissues and Organs affected by Scrofula. — The affections due to scrofula are unfortunately very numerous. Eczema and lichen affect the skin — not always readily recognizable as scrofulous, unless associated with other lesions, bat always obstinate and difficult to treat. Still more intractable and more destructive than these eruptions, but with a pathology less clear, is the lupus called scrofulous or tuberculous, which occurs so frequently about the upper lip and nose. Ulcers and abscesses, bearing the characters just now described, attack the skin and subcutaneous tissue ; and chronic inflammation and sup- puration, the lining membrane of the cavities and passages of the nose and ear — often with the permanent establishment of ozsena and otorrhcea. Inflam- mation affects the follicles of the eyelids ; chronic and phlyctenular inflamma- tions the conjunctiva and even the cornea, leading to irritable ulcers which too frequently result in scars injurious to the sight. The tonsils are often permanently large and prone to inflammation, and sometimes a deeper and more extensive ulceration occurs about the fauces, which can with difficulty, if indeed at all, be distinguished from tuberculous angina. The mucous membrane of the larynx and trachea is not uncommonly the seat of inflamma- tion ; and bronchitis and pneumonia attack the lungs. The vaginal mucous membrane of scrofulous girLs is occasionally the scat of chronic congestion and discharge. But of all structures, the lymphatic glands are perhaps most frequently affected by scrofulous inflammations. Those of the neck are so often thus inflamed, that chronic enlargement of them has come to be regarded as nearly the most important sign of scrofula. In some cases, but a few glands, those behind the ear and sterno-mastoid, for example, are enlarged, while in other instances the whole chain of glands on either side is implicated. The mere fact of enlargement of the lymphatic glands cannot, however, be regarded as a sign of scrofula, for (1) non-scrofulous inflammations are common, especially in the neck, where so many causes may exist to induce secondary affection of the glands ; and (2) the cervical glands are those which are chiefly liable to non-inflammatory diseases, of which examples may be found in lymphade- noma and lymphosarcoma. To add to the difficulties of early diagnosis, the scrofulous inflammations of glands probably rarely or never arise spontane- ously, but are always secondary to primary affections of a like kind to those which induce non-scrofulous inflammations ; to carious teeth ; to eruptions about the ears, and face, and head; to stomatitis, and to similar affections. The only features in which the scrofulous glands at first differ from those which are not scrofulous, are their indolency, and the absence of pain and of the more acute signs of inflammation. But in their later course, the} T devi- ate more and more widely from what may be regarded as the natural course of inflammation in a healthy subject. The primary cause upon which the inflammation depends, may disappear, but the enlargement of the gland endures; nay, other and neighboring glands become enlarged. And in one or other of them, the solid feel gives place to fluctuation, the skin reddens, and at length an abscess points and breaks. Suppuration may occur in the inflamed gland or in the surrounding tissues, excited apparently by the con- tiguity of inflamed structures. In either case, the typical ulcers of scrofula are frequently produced, and disfiguring scars may finally result. Or in place of ulcers, sinuses are formed, which lead directly into suppurating 244 SCROFULA AND TUBERCLE. cavities lined with caseous material ; and, as long as any of this material remains, the sinuses continue to discharge. The scrofulous maladies of bones and joints, if not so frequent as those of the lymphatic glands, are not much less so, and are among the most import- ant of all scrofulous affections. The bones are very liable to subacute and chronic inflammation, affecting more often the periosteum than the substance of the bone, or attacking both the periosteum and the bone, and leading, in a large number of instances, to caries and necrosis. It is not uncommon to find several bones in the same subject thus carious, as in the older of the two patients whose cases have been related. The bones, too, are the parts of the joints in which scrofula frequently commences. The articular ends become enlarged, and are slightly hot and tender; the cancellous tissue is infiltrated with the products of inflammation ; caseation ensues ; the inflammation ex- tends towards the joint ; the cartilage ulcerates, or is stripped off; and the whole joint becomes inflamed. Instead of the bones, the synovial membrane is often the structure first attacked. It becomes thickened, though the fluid in the joint may not be much increased ; the inflammation slowly extends to other structures ; suppuration takes place, with the formation of sinuses ; and the joint is at length destroyed. The " white swellings" of joints are in many instances scrofulous affections, in which the disease has had its origin in the articular extremities of the bones. Relation of Scrofula to Tubercle. — Many of the affections thus described as scrofulous can only with difficulty be distinguished clinically from those associated with tubercle, and even when the diseased structures are examined after removal or death, the appearances presented by the two diseases are so similar that the diagnosis can be made only by microscopical investigation. This clinical difficulty has so long been recognized, that the custom has obtained of classing both diseases under the common term strumous, a custom objectionable solely because the word is not always employed in this clinical sense ; and some confusion of terms has on this account resulted. The strik- ing similarity between the lesions of scrofula and tubercle, has, not unnatu- rally, suggested that the two diseases are closely related. Indeed, some authors refuse to recognize even a pathological difference between them, and the fact that in the principal works on surgery and medicine they are almost invariably included in the same section or chapter, shows how largely the impression of their near relationship prevails. Yet it is not easy accurately to define the tie by which they are connected. It appears almost certain that tuberculous parents may beget children who are scrofulous, and probably tuberculous children may be derived from scrofulous parents. But since either disease may apparently be acquired without inheritance, under certain favoring conditions, it is difficult to prove that anything more is inherited than a, weakly constitution, in which under certain conditions scrofula or tubercle is developed. It has become the fashion, of late years, for those who distinguish between the two discuses to regard scrofula as an affection which disposes more than any other to tubercle, J not merely by the general weakness it induces, but on account of the frequency with which caseous material is produced. If in this theory it he implied that persons who have for years suffered from typical scrofula, frequently fall victims to typical tuberculosis, I must confess that I have not often observed the sequence. But a different method is employed to prove the relation. Rindfleisch, 2 for example, holds that the very large 1 Frankel, Birch-Hirschfeld, Rindfleisch, Billroth, etc. * Ziemssen'a Handbuch, Bd. v., Abth. 2, S. 149. Leipzig, 1874. MODIFICATIONS PRODUCED BY SCROFULA IN OTHER DISEASES. 245 majority of tuberculous lymphatic glands are secondary, not to primary tuberculous affections of the parts whence the lymphatics traverse them in their course toward the main lymphatic trunks, hut to primary scrofulous affections of these parts. The scrofulous inflammations tend in most cases to caseation, and from the caseous material thus produced infection of tubercle occurs (secondaiy tuberculosis). Only one fault can be found with this inge- nious theory, but unfortunately it is a grave one: the diagnosis of the primary scrofulous affection rests upon too slender a base. Because caseation is a frequent result of scrofulous inflammation, it is assumed that the presence of caseous material is a proof that a disease is scrofulous — an argument in a circle which cannot be permitted. If there really exists a closer relation than that of similarity of morbid or pathological conditions, it must I think be admitted that we have not yet succeeded in defining it. Modifications produced by Scrofula in other Diseases. — The affections significant of scrofula have been described, but the account of the effects of scrofula is only partially complete. For (1) we may believe that all simple processes of disease may be modified by scrofula. The epididymitis, for example, which complicates gonorrhoea in a scrofulous subject, does not pursue the rapid course of an ordinary epididy- mitis, and disappear under treatment in a few days. It may set in with equal severity, and the acute symptoms may rapidly subside ; but thickening and induration of the epididymis remain, with slight heat and tenderness ; or the inflammation may extend to the body of the testis, and, in spite of treatment, suppuration, and even hernia testis, may take place. So, too, the primary affection, the gonorrhoea, instead of passing off as usual under appropriate treatment, subsides into a gleet most difficult to cure. And (2) we know that the processes of certain specific diseases are largely influenced by scrofula. In no disease is this more marked, perhaps, than in syphilis, the secondaiy and tertiary manifestations of which are aggravated by scrofula in an extreme degree. As I write, the miserable condition of one unfortunate young man, the subject of both diseases, is present to my mind. First treated in the hospital for scrofula, one of the most characteristic features of which was a white swelling of one knee, he was so indiscreet, when only partially recovered, as to expose himself to the contagion of syphilis. When some three or four months later he was again an inmate of the hospital, he was suffering from secondary symptoms of the severest kind. The profuse eruptions on his face and body suppurated, superficial ulcers and large, foul scabs were formed, and frightful disfiguration was produced. Both eyes were attacked with iritis, which lasted long, and left them perma- nently injured. His tongue and fauces were extensively and deeply ulcerated. The glands in various regions of the body became permanently enlarged. And with these local lesions was associated much greater constitutional dis- turbance than is usual. And, as the scrofulous disposition appeared to render every manifestation of syphilis more grave, so the syphilis appeared to aggra- vate the scrofulous lesions; for the knee, which had previously exhibited signs of improvement so clear that the disease seemed nearly at an end, again became actively inflamed, and threatened suppuration. It has not yet been shown that there is any relation more intimate than this between syphilis and scrofula or tubercle. 1 The children of syphilitic parents are not more prone to these diseases than other children whose constitutions are habitually feeble. !STor does acquired syphilis increase the liability to scrofula and tuber- cle, unless by inducing serious exhaustion. 1 Bumstead and Taylor ; Venereal Diseases, 1879, p. 498. 246 SCROFULA AND TUBERCLE. Another disease sometimes influenced by scrofula is gout. To this Sir James Paget 1 thus refers in his Clinical Lectures and Essays: "It is not very rare to find gout mingled with scrofula The real mingling of gout and scrofula is found in elderly persons. In these a gouty inflamma- tion may drift into true scrofulous inflammation, and the risk, though it be not great, should always be kept in mind." And further: "I believe that we may hold cases such as these to be due, mainly, to the coincident inheritance of both gout and scrofula; and I may mention two other sets of cases which may be referred to the same unhappy lot in life. In the first, an acute attack of gout is followed, as any fever may be, by some evidence of scrofula. In the second, among the cases of what I have called senile scrofula, some occur in old persons whose tissues have degenerated in long-continued or almost constant gout." Causes and Course of Scrofula.— Scrofula occurs chiefly at two periods of life; the limits of the first period extending from about the third to the fif- teenth year, while the second period scarcely commences before the age of sixty. But though it is most common in childhood and old age, no time of life is free from its occurrence. It attacks persons in every rank of life, spar- ing neither male nor female, rich nor poor; but the children of the poor are so much more liable to scrofula than the children of the rich or comfortable classes, that poverty is justly regarded as, at least, a predisposing cause of scrofula, on account of the indifferent and insufficient food, the foul and heavy air, the scanty clothing, constant exposure to wet and cold, and the hundred other evils with which it is associated. But the most powerful cause of scrofula is universally admitted to be inheritance, the inheritance of a predis- position to the disease ; for it does not appear that children are ever born suf- fering from scrofula. It may probably be inherited either from parents who are scrofulous, or from those who are tuberculous ; and the predisposition may be so strong as to amount almost to preordination, when, for example, the disease is not averted even by the most ample and ably directed means. Some children who are born thus predisposed to scrofula, are said to present certain general features of character and form which are significant of the disease. The dark type of strumous subject so frequently described, is per- haps more often met with than any other, but the cases related above show that the disease is not confined to the individuals of any type or types. On the other hand, the features of the individual are liable to be seriously modi- fied by scrofula. The upper lip may become large and tumid, the face coarse, the eyelids red and swollen from repeated attacks of inflammation; so that scrofula may often be easily recognized by the changes it has thus induced. Even the anaemia so frequently observed in scrofulous subjects, is said by Birch-Tlirschleld 2 to be a result and not a precursor of the disease, which occurs as often in those who are full-blooded and in whom the normal ratio of the two forms of blood-corpuscles is preserved. Prognosis of Scrofula. — The manifestations of scrofula are the same at all periods <>f life, and similar tissues and organs are liable to be attacked. But while there is said to be a natural tendency towards recovery in .young sub- jects,aged persona and oubtedly grow worse, not better. The prognosis depends, however, not tnerely on the age of the individual, but on the parts which are affected. Affections of the skin and mucous membrane, for example, may exist for many years with scarcely an appreciable effect upon the general 1 Clinical Lectures and Essays, 2il ed., p. 3nrt. 2 Ziemssen's Cyclopaedia, vol. xvi. English translation, London, 1877. TREATMENT OF SCROFULA. 247 health; but suppuration in connection with large bones and joints is peculiarly fatal, on account of the diseases which it may induce, such as hectic fever and amyloid degeneration. Treatment of Scrofula. — Fortunately, scrofula at all ages and in all its phases, is fairly amenable to treatment. The disposition, which is inherited, cannot perhaps be eradicated, but most of the lesions may by appropriate means be much improved, if, indeed, they cannot be completely eared. The treatment must be both general and local, for many affections which resist either form of treatment alone, will yield to the combined influence of both. The chief obstacle to successful constitutional treatment is the lack of ample means to carry out what is most desirable. For as the children of the poor furnish by far the most numerous body of patients, chiefly by reason of their poverty, so one of the main difficulties in treatment is the continual struggle with poverty. The parents are recommended to clothe their children warmly, to feed them on plain but good and nourishing diet, to place them where they may drink the purest water and breathe the finest air, to preserve them from frequent wet and cold, or send them where they may enjoy the advantages of sea-air and warm sea-baths — advice for the most part admirable, but as im- practicable as admirable, for all these things are far beyond the reach of the poorest classes. By the establishment, in large towns, of hospitals especially devoted to cer- tain scrofulous affections, an attempt has been made to supply the food, warmth, and attention, which poor people cannot obtain at home ; and by the foundation of country convalescent homes, something has been done to allevi- ate the sufferings of the scrofulous poor. But in the large cities of the old world, scrofula in various forms abounds, and the good which is accomplished by charitable institutions produces scarcely an appreciable effect upon a mass of misery so vast. It has been suggested that the air of hospitals is injurious to scrofulous patients, particularly where numerous suppurating wounds are treated. But while it may certainly be admitted that country patients are not likely to derive benefit from a prolonged residence in the hospital of a large city, there can be just as little doubt that the poor dwellers in large cities often owe their lives to the cleanliness with which their scrofulous sores are treated in hospitals, and to the food and medicines which they there receive. 1 !N"ot only are food and air and clothing useful, but certain medicines enjoy a well-merited reputation for their efficacy against scrofula. Of these, cod- liver oil is probably the most valuable, administered either alone or in com- bination with other remedies. It should be given once or twice a day, in doses varying from one to two or three fluidraehms, quickly after the taking of a meal, when it is least likely to produce gastric disturbance. Its use may be continued during many weeks or months, but it is better at intervals to leave it off. It may, for example, be drunk every day for fourteen days, and then remitted for a week; by this means the indigestion and nausea it is liable to produce may be avoided. It can scarcely ever be tolerated in the summer, but fortunately is not then so necessary as during the cold season. In the summer too it quickly becomes rancid unless kept in a perfectly cool place, and on this account is not a suitable medicine for out-patients (luring the hot season of the year. Children speedily learn not merely to tolerate, but even to like the oil, and will often take it greedily, especially when cer- 1 With regard to the advantages of sea-air and 'warm sea-haths, there exists at present some difference of opinion. It has, for instance, lately heen asserted that on scrofulous affections of the eye, the effect of sea-air is positively prejudicial, and that inflammations of lymphatic glands and hones remain stationary at seaside places. (Birch-Hirschfeld, loc. cit.) 248 SCROFULA AND TUBERCLE. tain syrups are mingled with it; and many adults acquire a certain taste for it, or at least cease after a while to regard it with disgust. In cases, however, in which the distaste is so great that it cannot or will not be overcome, cod- liver oil may be given in a peculiarly refined form, that, for instance, of the 'perfected cod-liver oil, or in combination with certain preparations which almost completely deprive it of its obnoxious qualities, such for example as maltine. Next in value to cod-liver oil are the preparations of iron, the syrups of the iodide or the phosphates, administered either alone or in combination with the oil. They are indicated where anaemia is a prominent feature of the dis- ease, and may in all cases be employed in the intervals between the adminis- tration of oil, or during the summer. It need scarcely be remarked that when other diseases are associated with scrofula, the remedies which are employed should be such as are appropriate for their treatment as well as for that of the scrofula itself. Thus, when syphilis is acquired by a scrofulous subject, the milder preparations of mer- cury, such as the bichloride, may be exhibited together with iron and cod- liver oil ; and iodide of potassium may be given with iodide of iron with the Oest result. The local treatment of scrofulous affections is exceedingly important, although in most of them the same general principles are involved as in the treatment of non-scrofulous affections of the same structures. The rest which is essen- tial for most joint-inflammations, is quite as essential for joint-inflammations which are scrofulous. But if rest can be obtained by the aid of some appa- ratus which does not necessitate rest for the whole body, a great advantage will generally be gained. Operations are performed for the removal of necrosed or carious bone, equally whether the patient is scrofulous or not, although in the former case the prospect of cure of the disease by operation is greatly lessened. Many cases of scrofulous caries are, however, better not treated by operation. Of such are the swollen and " blowm-out" phalanges, of which the fore-finger of the old woman furnished an example. They occur frequently in children; sinuses forming, through which soft, carious bone, or a soft pulp in which lie grits of bone, may be distinguished. The temptation is strong to interfere, to cut through the thin shell of bone and clear out the cavity within. But the usual effect of operation appears to be to light up fresh inflammation, or to leave wounds which will not heal; while the original disease, had it been left to itself with a strip of lint or other covering around the finger, would have almost surely healed with less delay — with shortening of the finger, no doubt, and with puckered scars, but with less deformity 'than after operation. Carious patches of the bones of old people who are scrofulous, should be operated on only with the greatest cau- tion, if at all. For the parts are apt to resent the injury of an operation, and the wounds inflicted show no tendency to heal. Of scrofula in the aged, it may be generally stated that the ordinary specific remedies, local and con- st it'nfional, are much less efficient than when employed for younger persons, and that good food, warmth, and rest, are, in such patients, more than ever necessary for Its treatment. 1 Scrofulous abscesses, if they are not very large, may be opened in the usual manner; but the extensive 'cold abscesses of the pelvis and abdomen, gene- rally associated with diseased bones or joints, should be left to point and break; or if they will not do so, but slowly burrow between the structures of the thigh or buttock, should be evacuated with every antiseptic precaution. Small abscesses about the neck and face may often he treated with thehap- piest result by aspiration. Even when matter is pointing, and the skin so 1 Sir James Paget, loc. cit., p. 344. TREATMENT OF SCROFULA. 249 thin and red that it seems as if it must give way, breaking may often he pre- vented by thrusting an aspirator-tube through the normal tissues at some distance from the abscess, into its cavity, and drawing off the pus. The gen- tle pressure of a pad and bandage will prevent refilling. By this means not only is tedious suppuration avoided, but no appreciable scar remains. Scrofulous ulcers are often very difficult to treat successfully. They com- monly recpiire stimulation, and frequent change of stimulation. One of the best applications is finely-powdered iodoform, not pure, but mixed with thrice its bulk of oxide of zinc or starch. The ulcer should be cleansed and dried, dusted over with the powder, and covered with a piece of soft rag or lint. Nitric oxide ointment of mercury [Unguent, hydrarg. oxidi rubri], black wash, and other similar applications, may also lie advantageously em- ployed. But when the progress of an ulcer is very tedious, and its edges are undermined, I have often seen a marvellous improvement produced by freely cutting away the edges to the surrounding healthy tissues. The area of the ulcer is by this means widely extended, but healing generally rapidly ensues, and the remaining scar is far less unsightly than that which might be ex- pected from the healing of the ulcer as it existed before the operation. The treatment of enlargement of the glands is most unsatisfactory. The apparent cause of the enlargement may be removed, and the health improved by various constitutional measures, but the glands remain enlarged, or vary in size from time to time. No local treatment appears decidedly to influence their course. The action of counter-irritants is so uncertain that, although they are used, they often do more harm than good, appearing to excite rather than allay the unhealthy processes. The question of removal of such glands is scarcely more settled than the question of removal of tuberculous glands. Where only one or two glands are enlarged, and the enlargement has existed for many months or years, operation may be practised with suc- cess; but the danger is ever present that the wound may heal indifferently, and be a source of more distress than the disease for which it was inflicted. The obstinate sores and sinuses connected with caseous cavities in glands, may best be treated, not by excision of the glands, but by opening up the wounds, and scraping carefully away the caseous material with a silver spoon or scraper. Lastly, it is sometimes advisable that the unsightly scars left by old scrofu- lous sores should be treated. More than once I have been applied to by young women, otherwise well-looking, whose necks were disfigured by nu- merous scars, the remains of scrofula in childhood. Thus prevented from obtaining good situations as servants or governesses, they are urgent for an operation. Nor is there any sufficient reason wh} 7 , if all active signs of scro- fula have long ceased to exist, an operation should not be practised. The m< »st prominent ridges may with advantage be removed, and deeply indented scars be raised by the operation recommended by Mr. Adams. 1 1 Observations on Contraction of the Fingers, .... also on the Obliteration of Depressed Cicatrices, etc. London, 1879. RACHITIS. BY J. LEWIS SMITH, M.T). CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. Rachitis, or rickets, is, in the plan of this work, considered as a constitu- tional disease, but it would seem in some respects equally in consonance with observed facts, to regard it as a disease of the osseous system, in which, in certain cases, other systems are secondarily affected. It occurs in the first years of life, and, therefore, during the period of most active growth of the skeleton. It is characterized by an abnormal nutrition and changed physio- logical action of the bone-producing tissues, namely the epiphyseal cartilage and the periosteum, and by the arrest, more or less complete, of the deposi- tion of lime salts in these tissues. Frequency of Rachitis. Rachitis is a common result of faulty diet and of anti-hygienic conditions, and is, therefore, frequent among the poor of cities, and especially in fami- lies who dwell in crowded tenement houses. It has, heretofore, been pre- valent in the city infantile asylums, but of late years, as regards at least the city of New York, it is much less common, in consequence of the greater attention now given to sanitary requirements in the management of these institutions. Mild cases of rickets are often overlooked, since physicians may not be summoned to attend them, while even if they be summoned, many, who have not given particular attention to this disease, are apt to err in diagnosis, and to refer the symptoms to some other than the true cause. Commencing gradually and insidiously, rachitis not infrequently continues for months, even in its typical form, before a correct diagnosis is made. In the absence of deformity, which is a late symptom, the fretfulness, tender- ness of surface, and perspirations, receive a wrong explanation. Practitioners who have heretofore given little attention to this malady, and who believe it to be rare, if they are instructed in reference to its characteristic signs, and look for them in their visits among the city poor, are surprised at the num- ber of cases with which they meet. A few years since, in the Xew York Infant Asylum, my attention was directed to a rachitic child, whose head had so changed from the normal shape that the nurses, as well as the physician, had remarked the difference. Prompted by the occurrence of this case, which had gradually developed under my eyes, I made a careful examination of all the infants, and discovered, what I had not previously suspected, that about one in every nine had become rachitic. In most of the infants the disease was mild, but with symptoms so characteristic that it was readily recognized. By effecting certain improvements in the diet, among which was the daily (251) 252 RACHITIS. allowance of beef-tea to the older infants, rachitis, unless of a mild type, has since been rare in this institution. The late Dr. John S. Parry, of Philadelphia, stated that at least twenty- eight per cent, of all the children, between the ages of one month and five years, who came under his observation in the Philadelphia Hospital during the three years preceding the publication of his paper, in 1872, were rachitic. This is certainly a larger proportion of those who present indubitably ra- chitic symptoms than occurs in any of the three, New York institutions for children with which I have an official connection. In the New York Foundling Asylum, with its sixteen hundred inmates, and in the Bureau for the Relief of the Out-door Poor, where over eight thousand children are annually treated, rachitis is certainly less frequent than is indicated by the statistics of Dr. Parry. In Europe, from the testimony of many observers, both continental and British, rickets is very common among the families who seek medical advice in institutions of charity. Ritter von Rittershain finds that thirty-one per cent, of all the children who are brought to the Prague Medical " Poliklinik," are rachitic, and Prof. Henoch states that the propor- tion is equally large in the families of Berlin, who are in similar reduced circumstances. According to Dr. Gee, whose statement was, however, made as far back as 1867-68, of the patients under the age of two years, in the London Hospital for Sick Children, 30.3 per cent, are rachitic. Both Dr. Hillier and Sir Wm. Jenner not only allude to the frequency of rachitis, but state that it is the cause of many deaths in London families. It appears, therefore, that this malady, though not rare in the American cities where ill-fed and ill-housed families congregate, is less prevalent than in families similarly situated in Europe. The greater immunity in this country must be due to other causes besides difference in nationality, for the poor of the American cities are largely of foreign birth. But rachitis does not occur exclusively among the poor. Children of well- to-do families are also liable to it, provided that the conditions soon to be enumerated are present. Ignorance or disregard of the hygienic requirements of young children, and especially the use of improper diet, leads to the de- velopment of rachitis in wealthy as well as in destitute families. Merei, in his treatise on the Disorders of Infantile Development (London, 1855), states that in Manchester, where his observations were made, one child in every five, in families in comfortable circumstances, presented rachitic symptoms; and he believes that this cannot be much above the real proportion in "the whole of the wealthy classes." Rachitis, in its milder form, is not uncommon in affluent families in this country, the cause of the delayed dentition, fretfulness, and perspiration, not being suspected in many instances, as I have had opportunities to observe. ( M'tcn family physicians are not consulted in reference to such symptoms, and when they are called in, so little attention has rachitis received on the part of many practitioners, that they arc very apt to overlook the true pathological state which is present. Still, admitting the fact that many cases are not diagnosticated, I repeat that, though rachitis is not uncommon on this side of the Atlantic, its percentage of frequency falls below that "observed in Eu- ropean cities, a fact which may be due to less crowding in their domiciles, and to a more liberal and better supply of food among the families of the poor in this country. Age at which Rachitis Occurs. Rachitis is, with few exceptions, a disease of infancy, commencing prior to the age of two and a halt' years. Now and then, it, or a state closely re- AGE AT WHICH RACHITIS OCCURS. 253 Fig. 9. sembling it, occurs in the foetal state, causing deformities, such as are present in typical cases. In the Ivinderspital Museum, at Prague, is a specimen showing this, and described by Hitter. Ilink and Winkler also describe such cases, and Virehow alludes to a specimen in the Wurzburg Museum, which exhibits such deformities as characterize rachitis. Bednar even regards foetal rachitis as not uncom- mon (Hillier, Parry). In the "Wood Museum of Bellevue Hospital, is a skeleton which is probably similar to those in the Prague and Wurzburg Museums. It shows in a striking maimer the deformities of this congenital disease. The case occurred in my practice, and the dissection was made by Prof. Francis Delafield. The infant, born at term, died a few hours after birth from atelectasis, apparently produced by the contracted state of. the thoracic walls. The parents were hard working English people, whose mode of life and surroundings were such as are known to conduce to rachitis. They were free from syphilitic taint. The accompanying wood-cut (Fig. 9) represents this skeleton. The following remarkable case of supposed foetal rachitis was related to me by Heitzmann, whose interesting experi- ments will be presently detailed : — ■ A woman who had frequently inhaled the vapor of lactic acid, each day, for many months, as she was employed to feed animals with this agent, gave birth to an infant, at term, which died imme- diately after it was born. It exhibited the signs of congenital rachitis in a high degree. The skull bones were completely absent; in the cartilages of the bones of the extremities, and in those of the ribs, there were scanty depositions of lime salts, and numerous infractions. The death of the child was evidently due to the absence of the skull bones, inasmuch as the pressure of the womb during delivery had caused cerebral hem- orrhage. All the organs of the chest and abdomen were found in full development and healthy. We will see, hereafter, that the theory which attributes rachitis, in certain instances, to a chemical irritant, is proved by experiment, and that it has already been shown that two such agents, phosphorus and lactic acid, may cause this disease. Now, as the irritating action of phosphorus on the osse- ous system occurs when it is inhaled in the form of vapor, as well as when received in the ingesta, so lactic acid, if the above case be rightly interpreted, produces its special effect upon the bone-producing tissues when inhaled, as decidedly as when received in the ingesta or generated in the system. These remarks seem necessary for an understanding of this unusual case, although they anticipate what will be said under the head of etiology. In the New York Journal of Obstetrics for November, 1870, Prof. Abraham Jacobi also pub- lished the description of a case of congenital rachitic craniotabes. Whether or not we accept as genuine all the reported cases of foetal rachitis, there can be little doubt, from the number of observations already made and carefully recorded, and from the opinion of high authorities like Virehow, that such cases do occur. Enlargement of the costo-chondral articulations, known as the " rachitic rosary," which is one of the earliest and most reliable signs of rickets, has been^ observed, though rarely, in infants only a few weeks old. Dr. Parry saw it as early as the sixth week after birth, 1 and Dr. Gee at the third or Skeleton of a rachitic infant, which died a few hours after birth. American Journal of the Medical Sciences, January, IS* 254 RACHITIS. fourth week. 1 This should not, however, he regarded as a sign of rachitis, unless the enlargement be so great that it can be readily appreciated by ex- amination through the integument, or by sight, for in young children, with the bones in the process of normal development, these joints usually have a diameter a little larger than that of the ribs. Rachitis, with few exceptions, begins within the first eighteen months of life. Though first detected and diagnosticated at a later date, it will ordinarily be ascertained, on inquiry, that its symptoms had an earlier beginning. Still, according to certain ob- servers, it may have a considerably later commencement, Glisson, Portal, and Tripier state that they have seen it commence in children who were well on towards the age of puberty. Sir Wm. Jenner states that he has seen children of seven "and eight years, who were only beginning to suffer from rachitis. 2 The following are the aggregate statistics of Bruennische, von Rittershain, and Ritsche, relating to the age at which rachitis occurs : — No. of Cases. During the first half year, ....... 99 " " second half of first year, ..... 259 " " " year, 342 " " third year, 134 " " fourth year, ........ 31 " " fifth year, 17 Between the fifth and ninth years, ...... 21 Aggregate, 903 Causes of Rachitis. Inheritance. — In some infants there is an undoubted hereditary predispo- sition to rachitis. Feeble digestion and defective assimilation in the infant, which are, as we shall see, important factors in producing the rachitic state, are often traceable to disease or cachexia of one or both parents. The offspring of a tubercular, syphilitic, or otherwise enfeebled parent, is more likely to become rachitic than those of healthy and robust ancestry ; and it appears that disease of the mother is more apt to entail a rachitic predisposition than that of the father. Among the parental causes may be mentioned poverty, hardships, and defective nutrition of either parent ; age of the father, and exhausting discharges of the mother, such as purulent, hemorrhoidal, or uterine fluxes. Food. — Of the exciting causes, the most common is the use of food not sufficiently nutritive, or, if nutritious, not suited to the age and digestive powers of the child. Thin and poor breast milk, and artificial food of poor quality, or not suitable for the stage of growth and development, are common causes of rickets. Those children who have been prematurely weaned, and who have been given a food which is not a proper substitute for the natural aliment, and those too long wet-nursed and not allowed the additional aliment which they require, are especially liable to this disease. Those whose di- gestive power is feeble, from whatever cause, are more apt to become rachitic than those who, in a state of robust health, have a hearty digestion. Hence we meet with rickets as a sequel of various protracted and exhausting mala- dies during infancy. 1 St. Bartholomew's Hospital Reports, vol. iv. 8 Lancet, December 11, 1880. ARTIFICIAL PRODUCTION OF RACHITIS. 255 It might be supposed, from the nature of rachitis, that the use of food de- ficient in phosphoric acid and lime was the common cause of rachitis; but facts show that this is not the correct view of its etiology, as it commonly occurs, although in its treatment these agents are of undoubted value. The disturbed and altered nutrition of the osteo-plastic tissues, namely of the epi- physeal cartilage and the periosteum, is the important factor in producing the rachitic bone disease, and this may occur although the ingesta contain a sufficient amount of phosphoric acid and lime. Deficiency of these substances probably tends to diminish the amount of lime deposition, but is not the essential element in the causation of the malady. This is to be found in the unhealthy condition and action of the cartilage and periosteum, or rather in the agencies, now partly ascertained, which produce the abnormal state and altered nutrition of these tissues. Artificial Production of Rachitis. The important fact has been ascertained by experiments on young animals, that rachitis can be produced, as I have already stated, by at least two chemi- cal agents, which may be admitted into the system in the ingesta, and which exert an especially irritating action on the osteo-plastic tissues. Senator states, in Ziemssen's Encyclopaedia, that "Wegner . . . has recently brought experimental evidence to show that true rickets may be artificially produced by the continued administration of very minute doses of phosphorus . . . together with a simultaneous withdrawal of lime from the food." The fact being established that it is possible to produce rickets by certain deleterious principles in the ingesta, opens an interesting field for experimental inquiry. Since improper feeding and indigestion are known to sustain a causative rela- tion to rachitis, experiments have been made to ascertain whether some chemical agent, developed in the system during the digestive process, or intro- duced with the food, may not cause rachitis as it ordinarily occurs in the infant. Among the foremost in that line of experiment has been Dr. Ileitz- mann, a resident of Vienna when his observations were made, but now a citi- zen of ^ew York. In young children, acids, especially the lactic, are commonly produced, and often in lftrge quantities, as the result of improper feeding, of indigestion, and of intestinal catarrh. The acidity of the infant's stools, under such conditions of ill health, is well known. What more natural, then, than the supposition or belief that this acid, thus generated, sustains the same causative relation to rickets, as phosphorus in the experiments which have been made with that agent. But the acid which is produced so abundantly in disturbed states of the digestive apparatus in the infant, believed to be chiefly the lac- tic, must, in order to reach the bones and influence their nutrition, pass through the blood, which is always alkaline. This difficulty in the way of the theory that lactic acid is the irritating agent, is removed by plivsiolojists who tell us that among the organic acids the existence of lactic acid in healthy blood is not entirely beyond doubt, but that it has been found in the latter under abnormal conditions. 1 Lactic acid has also been found, after having made the circuit of the system, in the excretion from the kidneys. Ileitzmann, in order to ascertain whether this acid sustained a causative 'relation to rickets, made a series of experiments, which have passed into the literature of this disease, and he has kindly furnished me with their details, as follows: — ' Heinrich Frey, of Zurich. 256 RACHITIS. Marchand, Ragsky, Lehman, Simon, and others have found free lactic acid in the urine of persons suffering from rickets and osteo-malaeia. C. Schmidt discovered lac- tic acid in the liquid of malacic shaft-bones, which were transformed into globular cysts. Encouraged by these chemical researches, I undertook a series of experiments on the action of lactic acid, administered both by the mouth and by subcutaneous injection, upon the bones of living animals, which experiments were begun in April, 1872, and continued until the end of October, 1873. The experiments were made upon five dogs, seven cats, two rabbits, and one squirrel. On dogs and cats under one year of age, the lactic acid, given either by mouth or injection, in combination with restricted ad- ministration of calcareous food, produced swelling of the epiphyses of the shaft bones and of the anterior ends of the ribs, at their attachments to the costal cartilages. This result was plain in the second week after the beginning of the lactic acid treatment. Up to the fourth and fifth weeks, the swelling of the epiphyses and of the ends of the ribs kept increasing, and then was accompanied by curvatures of the bones of the ex- tremities. As accompanying symptoms, I noticed catarrhal inflammation of the con- junctiva, of the mucosa of the bronchi, the stomach, and the intestines, with emaciation and convulsive movements of the extremities. The microscopic examination of the epiphyses gave an image fully identical with that of the epiphyses of rickety children. Upon continuing the administration of the lactic acid, the SAvelling of the epiphyses of the shaft bones gradually increased, and so did the curvatures of the shaft bones. Af- ter four or five months of lactic acid treatment, under often repeated catarrhal inflam- mations of the above named mucous layers, the shaft bones became soft to such a degree that they could be bent like the branches of a willow-tree. After from four to eleven months of the same treatment, the microscopic examination of the bones gave a result corresponding with that obtained from the bones of women who have died with osteo- malacia. On the three herbivorous animals no swelling of the epiphyses was noticeable. One rabbit died three months and the other five months after the commencement of admin- istration of the lactic acid, but with symptoms of inanition. No marked evidences of rachitis or malacia were traceable in the bones of these animals. The squirrel, on the contrary, which died after thirteen months of treatment with lactic acid, gave all the features of osteo-malacia. My experiments (jive the result that by continuous administration of lactic acid, at frst rickets, and afterwards osteo-malacia, can be artificially produced in flesh-eaters ; while in herbivorous animals, osteo-malacia sets in without preceding symptoms of rickets. Through these experiments I have proved the identity in nature of these two diseases, the differences in their course being due to the difference in the age at which the solution of the lime salts is established. . . Rickets can be produced on dogs and cats only under the age of ten or twelve months. Mr. Hess fed with lactic acid a dog of the age of one and a half years, and failed to produce rickets. This result is in full agreement with my experiments. 1 maintain that lactic acid, though not free in the blood, if in contact with the tissues producing bone, or with fully developed bone, owing to its great affinity for lime, either prevents the formation of bone (rickets), or dissolves ready-made bone (osteo-malacia). On the other hand, rachitis sometimes occurs in infants who present no history of indigestion or of intestinal catarrh, and in whom there is no ground for the belief mat lactic or any other acid is produced in undue or injurious quantity. In a considerable proportion of such eases, inquiry elicits the fact of anti-hygienic conditions, hut there is no evidence of imperfect digestion, or of gastro-intestina] catarrh, such as produces lactic acid. In the cases oc- curring in the Now York Infant Asylum, alluded to above, some of the chil- dren had manifest gastro-intestina] derangement; but others, who were wet- nursed, gave no evidence of faulty digestion, though the nutriment which they received was probably insufficient; for, as already stated, by providing a more liberal diet, by allowing among other articles the juice of meat, rachitis became much less frequent, and is seldom observed at present among the in- fants of that institution, unless in a very mild form. Vircnow and others have suggested that the prime factor in causing rachitis ANATOMICAL CHARACTERS OF RACHITIS. 257 is the use of a diet that is deficient in calcareous salts, and we have seen that in the interesting experiments of Dr. Heitzmann, the administration of cal- careous food to the animals was restricted. Still, as Xiemeyer has well said, deprivation or restricted use of the chalky salts cannot possibly cause the most important histological change in rachitis, namely, the proliferation of the epiphyseal cartilages and periosteum, and we must look tor some other factor in the causation. Pathology furnishes many examples of chronic disease attended by pro- liferation of tissue, the causes of which are not uniform. Cirrhosis, with its proliferation of hepatic connective tissue, which, as we shall see, presents a similitude in some respects to rachitis, is sometimes undoubtedly produced by the irritating action of a chemical agent, to wit, alcohol ; but all physi- cians know that there are many cirrhotic patients who refrain entirely from the use of alcohol in any form. In like maimer, it seems to me that, if we admit, as we must in the light of experiments, that certain chemical agents, notably phosphorus and lactic acid, introduced into the system or produced in it, cause rachitis by their irritating action, there are other typical cases in which there is no reason to suspect the operation of such agents. "We must, therefore, remain in the belief that rachitis, like many other pathological processes, does not result from a fixed and uniform cause, but from conditions which vary to a certain extent in different patients. Anatomical Characters op Rachitis. For convenience of description, the course of rachitis is divided into three periods : (1) That of proliferation and altered nutrition of cartilage and peri- osteum ; (2) That of curvature and deformity ; (3) That of reconstruction. Anatomical Characters in the Stage of Proliferation and Altered Nutrition. — Ossification of a long bone occurs from the epiphyseal cartilages, and from the periosteal or fibrous membrane which surrounds, nourishes, and protects the bone. Growth in length is from the former, in thickness from the latter. As regards the flat bone, while growth in thickness occurs from the periosteum, that in breadth is from the cartilage of its border, which cor- responds with the epiphyseal cartilage of the long bone. Cartilaginous Changes. — If we examine the epiphyseal cartilage of a long bone during normal ossification, we observe, first beginning at the distal end, a white zone, consisting of the hyaline matrix, in which are the usual carti- lage cells. This constitutes most of the cartilage. Underneath this, and nearer the bone, is the zone of proliferation, the "cartilage in which is- softer and more yielding than that of the distal zone, in consequence of cell forma- tion, and absorption of the matrix to make way for cell-groups. Each car- tilage cell in the proliferating zone has divided into two cells, and each of these cells into two other cells, and the division has been repeated so that eight cells instead of one are observed, surrounded by a common capsule. The capsule becomes distended by the cell multiplication, and by the swelling of each cell, the size of which is considerably greater than that of the parent cell. Near the bone, namely, along the extremity of the diaphysis, the cell- groups, inclosed in their capsules, nearly touch each other, the matrix having, for the most part, been absorbed. The end of the diaphysis is covered with a layer of these cell-groups, about to undergo ossification, with almost no intervening matrix. The proliferating zone lias very little depth. It appears vol. i. — 17 258 RACHITIS. to the naked eye as a very thin, scarcely perceptible layer of a reddish-gray color upon the end of the shaft. It is so shallow that it does not perceptibly increase the thickness of the cartilage. In rachitis, the state of affairs is different. The zone of proliferation, in- stead of being confined to a single, or at most double, layer of cell-groups, con- sists of many layers involving nearly the whole epiph} T seal cartilage. The cells, still inclosed in their distended capsules, undergo a more frequent division than in health, so that instead of groups of eight cells, as in the normal state, each group consists of from thirty to forty cells. Therefore, in rachitis, the proliferating cartilaginous zone is a broad cushion, very soft, of a grayish translucent appearance, causing the characteristic swelling ob- served around the joint. Over the distal end of the proliferating cartilage, there may still be a layer or zone, though perhaps of little depth, of normal cartilage, like that in health. Osseous Changes. — While this occurs, the ossifying process is also arrested. "We indeed perceive an effort in the direction of bone formation. The Haver- sian canals, surrounded by capillary loops, extend from the bone into the pro- liferating zone of cartilage. Their extension is effected by absorption of the matrix and appropriation of cell-groups which lie in their way. The cells in these groups, as they enter the Haversian system, become much smaller by a rapid segmentation, forming medullary cells. We also find, as further evi- dence of the attempt at bone-formation, granules and masses of lime scat- tered through the cartilage, and here and there spiculse and nodules of true bone, springing up from the bony substratum of the shaft. Some of the canals extend far into the cartilage, nearly indeed to its free surface, but most of them terminate in its lowest portion. The growth of bone in thickness occurs from the under surface of the periosteum. In health, a soft, vascular, germinal tissue springs from the periosteal surface, and rapidly receives lime salts, and is transformed into bone. This germinal tissue, consisting largely of capillaries rising from the fibrous tissue of the periosteum, is a very thin substratum, barely visible, transient, and constantly changing from its conversion into bone. In rachitis, this vascular sub-periosteal tissue, not undergoing, or under- going slowly and imperfectly, the osseous transformation, and at the same time increasing more rapidly than in health, under the irritating influence of the rachitic disease becomes a thick layer. Its color and appearance are like spleen pulp, so that the older observers supposed that there was a hemorrhagic extravasation between the periosteum and the bone. There is, however, no extravasation of blood, unless it accidentally occur from the numerous delicate capillaries. The resemblance to extravasated blood, or spleen pulp, is due to the abundant growth of large and thin-walled capillaries from the under sur- face of the pen< >steum, as shown by the microscope. This vaseular outgrowth is, for the most part, quite uniform over the diaphysis of the long bones, while upon the cranial bones its thickness is much greater in one locality than in another. The attempt at ossification also appears in this tissue. Lime salts are scantily and loosely deposited through it, forming osteophytes — vascular and fragile — rather than true bone. The question naturally arises: how does rachitis affect bone which is already formed when the rachitic state begins? Virchow's answer is the following: "Rachitis has ... by more accurate investigation been shown t.o consist, not in a process of softening in the old bone, as it had pre- viously I" 1 ''!! considered to be, but in a non-solidification of the fresh layers as they form; the old layers being consumed by the normally progressive forma- tion of medullary cavities, and the new remaining soft, the bone becomes ANATOMICAL CHARACTERS OF RACHITIS. 259 brittle." 1 It seems, however, from the experiments of Heitzmann, that this opinion should be modified, at least as regards rachitis produced by lactic acid. Moreover, in rachitic cranio-tabes, occurring in infancy, there is certainly bone absorption, for portions of the occipital and parietal bones are absorbed to cause the soft spaces. We must, therefore, believe that there is in rachitis more or less absorption of lime salts in the bone, in addition to that required in the normal growth of medullary cavities and canals for vessels. In healthy bone, the earthy salts are in excess of organic matter, nearly in the proportion of two to one ; but in rachitis the proportion is reversed, the organic matter being much in excess. The following table gives analyses of rachitic bones by Marehand, Davy, Boettger, and Friedleben : — Femur. Ei dins. Vertebra Inorganic. Organic. Inorganic. Organic. Inorganic. Organic. Case I. II. III. IV. 20.60 37.80 20.89 52.85 79.40 62.20 (conval.) 79.11 47.15 21.24 20.00 78.76 80.00 IS. 68 81.32 32.29 67.71 As might be expected, the relative proportion of organic and inorganic matter A r aries greatly in different cases, and at different stages of the same case. In severe rachitis many bones are affected. It is stated that there is no bone in the entire skeleton that may not suffer, but in mild cases only a few are involved, at least to such an extent as to produce structural changes, appreciable to touch or sight. Pathology of Rachitis. — In this connection, it is proper to consider the pa- thology of rachitis. What is its nature?. Niemeyer in my opinion expresses the correct view, when he says "it seems to me that the most probable hy- pothesis regarding the cause of rachitis is that which refers it to inflammation of the epiphyseal cartilages and periosteum." The increased vascularity of the periosteum, the proliferation of periosteum and cartilage, the tenderness and pain on motion, and the febrile movement in acute forms of the disease, indicate inflammation rather than any other recognized pathological state. The rachitic inflammation as it affects the osseous system, appears to be of a chronic or subacute character, presenting an analogy with certain other well- known inflammations, such as cirrhosis and certain forms of chronic ne- phritis, in which proliferation of connective tissue and sclerosis occur. The eburnation rather than normal ossification, which terminates the rachitic process, may properly be considered an osteo-sclerosis. Conformably with the theory of the inflammatory nature of rachitis, the periosteum is found infiltrated and thickened, and of a reddish hue from hyperemia, and from the presence of the newly-formed capillaries underneath, which have been described above as forming a layer of considerable thickness, known as the "germinal, vascular tissue." Moreover, as in inflammations, a secretion or exudation occurs over the bone from the under surface of the periosteum ; it has a reddish, gelatinous-looking appearance. The various interspaces in long, short, and flat bones, the diploe, cancelli, and inter-lamellar openings, contain a substance similar to that exuded under the periosteum, resembling, says Trousseau, "red, pale gooseberry jam." It appears, like that under the periosteum, to be an inflammatory exudation. 1 Cellular Pathology, Chance's Translation, Lecture xix. 260 RACHITIS. Anatomical Characters in the Stage of Deformity. — Rachitic bone, when the disease has continued for some time and is still in its active period, presents a bluish or dusky-red appearance, from its increased vascularity. After a variable time, weeks or months according to the severity of the disease, de- formities begin to appear. Spiegelberg's description of the appearance of the rachitic foetus corresponds for the most" part with what I observed in the one whose skeleton is repre- sented in Fig. 9. According to this writer, the body and limbs are plump: the latter short and curved ; the abdomen large and prominent ; and the head sometimes hydrocephalic. The skin is thick and loose, and the adipose tissue well developed ; the liver large ; the epiphyses swollen and soft; the short and curved diaphyses sometimes broken. The rotundity of the thorax is preserved, and the sternum is not carried forward, since there has been no respiration ; the ribs, in softness and liability to fracture, correspond with the long bones of the extremities. The sternum, most of all the bones, shows the delay in ossification ; the clavicle is among those least affected. The cranium may be represented by a membranous bag with plaques of bone, or the cranial bones may be formed and in shape, but thickened and softened ; the sacral promontory is pressed forward and downward ; the sacral vertebrae flattened; the ilia flattened and widened ; and the pubic arch increased. It is interesting to compare these deformities with those in the child, since they occur under conditions so very different. Eachitic bone seldom retains its normal form or shape ; its projecting points are rounded, and, as soon as it softens, it begins to yield to pressure exerted upon it. Hence the curva- tures, so common and characteristic. The portion of a long bone which is formed after rachitis commences, contains so little earthy matter that it bends readily in its fresh state, either by muscular action or by the weight of the trunk, "in the manner," says Vogel, "of a quill or willow stick." The in- terior of the bone, which was formed before rachitis began, and which con- tains nearly or quite the normal proportion of lime, is apt to break instead of bending, but, as it is surrounded on all sides by the soft tissue, the frag- ments are not displaced, and probably do not crepitate. So scanty is the calcareous deposition in typical cases, that, says Trousseau, " the bones . . . . can be cut with a knife with as much ease as a carrot or other soft root," and the dried specimen weighs but from one-sixth to one-eighth as much as normal bone. One writer states that the dried rachitic bone is sometimes so porous, from the small amount of lime which it contains, that it is possible to respire through it, as through a sponge. In ordinary cases, the bones which exhibit most strikingly the rachitic change, and which, therefore, should be carefully examined in making the diagnosis, are the cranial bones, the ribs, and the radius- — the sternal ends of the former, and the lower end of the latter. It is seldom that these bones do n<.t give evidence of the disease, if it be present, and in greater degree than other bones. They are the first to be affected to an extent that is appreciable to the observer. Changes hi the Cranial Bones. — Tn these bones interesting and important alterations occur. Their edges, which correspond with the epiphyseal carti- lages, undergo proliferation, and become thickened like the latter. This thickening, and the delayed union of the sutures, produce grooves, which can be traced by the fingers between the bones, and which are sometimes appre- ciable to the sight. Rachitis causes sonic enlargement of the cranium, but the enlargement seems greater than it really is, on account of the retarded growth of the facial hones. In a discussion on rachitis in the London Pathological ANATOMICAL CHARACTERS OF RACHITIS. 261 Society, reported in the Lancet,' it was stated that in seventeen rachitic chil- dren, with an average age of 4.72 years, the average circumference of the head was 21.22 inches, while in the same number who were non-rachitic, and with an average age of 6.05 years, the average circumference was 19.95 inches. The retarded ossification is manifested not only in the open sutures, but also in the large size and patency of the fontanelles, which are not closed till long after the usual time. The anterior fontanelle should be closed between the fifteenth and twentieth months, but, in the rachitic, it remains membra- nous till after the second year, even into the third or fourth year. Since ex- amination of the anterior fontanelle is important in determining whether or not rachitis be present, it should be borne in mind that, in the normal state, this space increases in size till the seventh month, when it is at its maximum, and that after the ninth month it becomes progressively smaller. The shape of the rachitic head varies. In general, instead of its normal rounded form, it approaches a square shape. Another type is sometimes ob- served in which there is no marked angularity, but in which the anteropos- terior diameter is enlarged. In the square head, the forehead projects, and both the frontal and parietal protuberances are unusually prominent. The. sutures are depressed to a certain extent, as has already been mentioned, and the anterior, lateral, superior, and posterior surfaces of the cranium are more flattened than in health. The lambdoidal suture, which should close by the fourth month, and the sagittal, which should close by the end of the first year, have made little progress towards union when the second year begins. The undue prominence of the frontal and parietal bosses takes its origin from the exaggerated proliferation of the periosteal or fibrous covering of the bones. Craniotabes. — Thinning of the cranial bones in places, so that the brain lacks proper protection, has long been noticed in the examination of rachitic heads, but the injury that results to the infant was overlooked till pointed out by Dr. Elsasser. Craniotabes occurs for the most part in patients under the age of one year, and a large proportion are under eight months. Its occurrence in the foetus, as shown by a case published in the New York Ob- stetrical Journal in 1870, and by Heitzinann's case, has already been alluded to. The factors in producing this thinning are rachitic softening of the bones and pressure; pressure of the brain from within and of the pillow from without. Consequently, the portions of the cranial arch in which the thinning occurs are the posterior and lateral, the occipital bone and the posterior half of the parietal. If the infant lie chiefly on one side, in its crib, on this side the craniotabes occurs, while those portions of the cranium which are not pressed upon, as the frontal bone, exhibit no thinning. (The soft spots are yielding when pressed upon, and in the cadaver they are seen to be translucent when held to the light. The amount of absorption varies greatly according to the degree of rachitic softening, and the amount and continuance of the pressure. There may be in some instances simple depressions, like erosions in the bone, with a continuous but thin bony layer remaining, but in other cases, such as have been particularly examined and studied by physicians, the bone absorption is complete over areas of greater or less extent, so that the pericranium and dura mater are in contact. In examining a child for cranio- tabes, it should be borne in mind that the margins of the bones, even when there is no thinning, but thickening from the cartilaginous proliferation, are flexible in the rachitic. The pressure must be made in a direction away from the sutures, to ascertain whether craniotabes has occurred. The pressure > Lancet, 1880, vol. ii. p. 1017. 262 RACHITIS. should at first be made lightly and cautiously, with the fingers, for if there be total absence of bone, unless of very little extent, deep and forcible pressure might injure the brain, for so soft and delicate an organ, covered only by the scalp and dura mater, badly tolerates pressure. If the first ex- amination detect no soft place, the fingers may be pressed more firmly against the scalp, when, if the bone be much thinned, so that there is only a small layer of the lime salts underneath, it will be found to yield. The sensation communicated to the fingers, when there is an open space in the cranium, and the dura mater and seal}) are in contact, has been likened to that experienced when pressing upon a fully distended bladder. At a meeting of the London Pathological Society, reported in the Lancet for November 20, 1880, Dr. Lees presented statistics to show that craniotabes was one of the lesions of inherited syphilis; but whether it may result from syphilis or not, the evidence that there is a cranial softening which is strictly rachitic, appears, from repeated observations, to be sufficient. Symptoms of Craniotabes. — As craniotabes gives rise to peculiar symptoms quite distinct from those of the general rachitic disease, they may be pro- perly considered in this connection. Craniotabes usually occurs during the first year of infancy, and most frequently prior to the tenth month. The brain at this age is soft and yielding, since it contains a large percentage of water. Unless handled with care, at an autopsy, it is readily lacerated, and moderate pressure upon it is seen to disturb and move it at a considerable distance from the point of contact. It assists to a proper understanding of the symptoms of craniotabes to recall to mind the fact, well known to sur- geons, that slight depression of even a small portion of the skull is apt to produce grave symptoms. It is not surprising, therefore, that craniotabes when there is a space of considerable size in the cranial arch, destitute of bone, is attended by symptoms due to the mechanical effect of external pres- sure, whenever a substance less yielding than the brain comes in contact with the unprotected part. Since pressure from the pillow without, and from the brain within, is be- lieved to be the cause of the absorption, the craniotabes must obviously occur in the posterior and postero-lateral portions of the cranium. Corresponding with this explanation of the causation, the thinning actually occurs in the occipital and posterior portions of the parietal bones, while the anterior halves of the parietal bones, and the frontal bones, are even thicker than normal, from the cartilaginous and periosteal proliferation occurring along the sutures and on the surface of these bones, as already described. It is well known that long-continued pressure produces absorption of calcareous matter even more readily than of soft tissues, as is shown in the absorption of a tooth of the first set by the growth of the dental pulp of the second set. In the nor- mal growth of the" skull, constant absorption of the under surface of the cranial bones is going on to make room for the enlarging brain, and when no calcareous deposition occurs upon the external surface to compensate for the loss within, we might expect even a greater amount of craniotabes than ordi- narily occurs. Every rachitic infanl is fretful, but one with craniotabes is especially so, if the open spaces be of considerable size. If it lie upon the pillow, in its ac- cu8tomed manner,and as is most natural for it, the unprotected portion of the brain may be so pressed upon by the weight of the head, that it feels uncom- fortable. " It does not have quiet sleep, probably because the cerebral circula- tion and functions are in a measure disturbed; it is apt to awaken readily and often, and frets till it is taken in the nurse's arms. Sometimes it in- stinctively seeks a position on the edge of the pillow, with the face down- wards, and it becomes more quiet when resting over the nurse's shoulder with ANATOMICAL CHARACTERS OF RACHITIS. 263 the face backward. But if fretfulness, disturbed sleep, and the necessity of closer attention on the part of mother and nurse were the only ill effects of craniotabes, it would possess much less pathological significance than pertains to it. Pressure upon so delicate and important an organ as the brain, involves risks and produces serious symptoms in proportion to its degree. Even a slight injury of the skull which produces depression, though it may be of trifling amount, will cause serious forms of nervous disorder. So cra- niotabes is believed to sustain a causative relation in certain cases to one of the most dangerous of the neuroses, namely laryngismus stridulus, an affec- tion which is also designated "internal convulsions," "spasm of the glottis," and " Kopp's asthma,' although Kopp was not the first to describe and recognize the malady. The etiology of this neurosis has not been fully elu- cidated. It is certain that a large proportion of those who suffer from it are rachitic, and that it is more common and severe where rachitis is prevalent, as in England, than where it is rare, as in the rural districts of America. It is not often the cause of death in this country, and the fatal cases that do occur are only seen in cities, whereas in parts of Europe, where rachitis is much more common than with us, it causes many deaths. Certain infants, when in a state of excitement, have what are termed "holding-breath spells." The face is flushed, and breathing ceases for some seconds, after which respiration returns and is normal. These attacks are unimportant, but they appear to be the same in nature with the more severe and dangerous seizures of laryngismus stridulus. They have no pathological significance, excepting as they show the same neuropathic state as that in laryngismus, and as they may be precursors of this disease. Laryngismus stridulus, or glottic spasm, is usually preceded by more or less impairment of the general health, and often by fretfulness, which is characteristic of the rachitic state; but the attack occurs suddenly, without premonition, and is of short duration. It begins with an arrest of respiration, a true apncea, as if from paralysis of the respiratory centre in the medulla. The lips may be livid ; a pallor spreads over the face ; sometimes more or less rigidity of the limbs occurs, with carpo-pedal contractions, and after a few seconds, a quarter or a half minute, a long and deep but difficult inspiration through the narrow chink of the glottis follows, accompanied in many patients by a whistling or crowing sound, and the attack ends with, per- haps, a momentary look of bewilder- ment or dread upon the child's face. Now this disease, like eclampsia, does not have a uniform causation. In certain cases, it appears to be a reflex phenomenon, due to an irritant in some part of the system, as in the intestines ; but many observations have established the fact that ra- chitis, also, sustains a causative rela- tion to it. A large proportion of the infants, affected with laryngis- mus, exhibit unmistakable rachitic signs, and, in the opinion of many experienced observers, the exposed state of the brain affords explana- tion of the fact that so many of the rachitic have this neurosis. Still, from observations which I have made, and from tllOSe Of Other Ob- Head of a rachitic child in the New York Infant Asylum Fig. 10. 264 RACHITIS. Fig. 11. servers, like Senator, it is certain that laryngismus stridulus is common in the rachitic who do not have craniotabes, so that there must be a causative rela- tion in rachitis to laryngismus independently of the cranial softening. The preceding wood-cut represents the rachitic head of a child in the New York Infant Asylum. This patient had also attacks of laryngismus stridulus. Changes in the Vertebra, etc. — The short bones which participate in the rachitic disease, become softer and more yielding, and their cancelli are tilled with a reddish pulpy substance. In many rachitic cases, the vertebrae are but slightly involved, so that no deformity of the spinal column results ; but occasionally, when many bones are affected, the vertebrae and inter-vertebral cartilages soften, ami spinal curvatures result. The curvatures are due to the weight of the shoulders and head on the spinal column. They are, with some deviations, an exaggeration of those present in the normal state. Ra- chitic curvatures are, therefore, mainly antero-posterior with some lateral deflections. Where there is much curvature, the vertebrae become wedge- shaped, narrowed upon the concavity, and thickened upon the convexity. The inter-vertebral cartilages are also more or less changed by the pressure, being thinned where the vertebrae approximate to each other, on the concave aspect of the curvature, and of normal thickness or thicker than normal upon the convexity. The accompanying wood-cut exhibits the nature and appearance of rachitic spinal curva- ture in the adult. Rachitis, having occurred at the usual age, resulted in the permanent deformity here illustrated. In extreme cases, fortunately rare, the functions of important organs may be seriously im- paired by the curvature and consequent compression, as in Pott's disease. Thus, according to Miller, the aorta has been so doubled upon itself as to materially diminish the flow of blood to the lower extremities, and to thus sensibly impair their nutrition. The effect of so great curvature upon the functions of the heart and lungs must obviously be detrimental. At first the spinal curvatures disappear when the child reclines, or is lifted by the axilla?, so as to raise the head and shoulders from the spine, but when the deformity has continued so long that the vertebrae and cartilages have become wedge-shaped, it remains for life, or cau only be rectified slowly and with dif- ficulty by mechanical appliances. As seen in the wood-cut, the common curvature in the dorsal region is backward (kyphosis), while to compensate the pa- tient instinctively carries the neck forward, with the head thrown back, causing cervical lordosis, a similar anterior curvature being common in the lumbar re- gion. Lateral curvature (scoliosis) may or may not bo present, even when there is considerable antero-posterior flexure. Scoliosis is sometimes produced by the nurse, in carrying the infant habitually over One arm. Rachitic spinal curvature in an ailult. (From a specimen in the Wood Museum, Bellevne Hospi- tal.) Changes in the Maxilhe. — Fleischmann has investigated the changes which rachitis produces in the maxillary bones. Stunted growth of the facial bones, generally, has long been known, and has been remarked upon by various writers ; but, according to Fleischmann, other interesting changes occur in the jaw-bones, which affect the direction and position of the teeth. According ANATOMICAL CHARACTERS OF RACHITIS. 265 Fie. 12. to this author, the arched shape of the lower jaw becomes polygonal, and the direction of the alveolar process also changes, so that it inclines inward. This deviation in the arch, and in the alveolar process, which begins in the region of the canine teeth, necessarily causes shortening of the lower jaw. Commencing soon after, a change is observed in the upper jaw-bone from the zygomatic arch forward, so as to cause lengthening of this bone, changing here also the shape of the arch and the position of the teeth. The lateral incisors, instead of being in front, have a lateral position, and the incisors and molars diverge, so that when the jaws are closed they overlap the corre- sponding teeth of the lower jaw in front and upon the sides, a condition the opposite of that seen in the jaws of old people. Fleischmann attributes these changes in the lower jaw to the action of the masseter and mylo-hyoid mus- cles, and perhaps the genio-glossus, and to pressure of the lip, the deficiency of earthy salts in the bone rendering it more easily acted on by the muscles. The change in the upper jaw-bone he attributes to lateral pressure of the zygomatic arches. Changes in the Ribs. — The ribs are early affected in rachitis. The swelling of their anterior ends, where they unite with the costal cartilages, producing the " rachitic rosary," has been already alluded to as one of the first and most conspicuous signs of rachitis. The costo- chondral articulations are enlarged in all directions, appearing as nodules under the skin. If an opportunity occur of inspecting, at an autopsy, the pleural surface, the nodular prominences are seen to be even greater and more distinct there than under the skin. The deformity of the thorax conse- quent upon softening of the ribs is inter- esting. Commencing with the spine, the ribs extend nearly directly outward ; at the union of the dorsal and lateral re- gions, they make a short curve forward, and then turn inward, also with a short curve toward the sternum (Fig. 13). This abrupt bending of the ribs, which, in their softened state, has been caused by atmospheric pressure during respiration, produces a depression in the thoracic wall at about the point where the ribs and their cartilages unite. A groove ex- tends on the antero-lateral surface of the thorax from the second or third rib downward, and a little outward. Sometimes the bottom of the groove is oc- cupied by the costo-chondral joints ; in other cases these joints are a little to one side of the deepest part of the groove. The transverse diameter, therefore, of the anterior half of the thorax is much less than in health. This necessarily diminishes the lateral expansion of the lung in inspiration, and causes unusual prominence of the sternum. Hence the expressions "pigeon- breasted," "resemblance to the prow of a ship," etc., applied to this deformity. The presence of the heart renders the groove more shallow on the left side, at the fourth and fifth ribs, than on the opposite side, since this organ affords partial support to the chest-wall. On the other hand, the right groove is Rachitic child with characteristic deformity of head, ribs, and radius. (From a patient in the Xew York Foundling Asylum.) 266 RACHITIS. not as long as the left, as the lower ribs on this side are partially supported by the liver. On both sides, however, the lower part of the thorax, that below the seventh, eighth, or ninth ribs, widens, being pressed outward and sup- ported by the abdominal viscera. There is, therefore, in addition to the longi- tudinal groove, an antero-posterior depression, sometimes also spoken of as a furrow or groove, on either side, lying between the sixth and ninth ribs. The ribs with their attached muscles are important agents in respiration, but the soft and yielding nature of the ribs, in the rachitic, retards, and to a great extent prevents, the lateral expansion of the thorax which is necessary tor normal and full inspiration. The action of the respiratory muscles, and the pressure from within of the air descending along the air passages, is Fig. 13. Deformity of chest in rachitis. not sufficient to fully overcome the external atmospheric pressure, in the ab- sence of proper resiliency of the ribs. Consequently, with each inspiration, we observe more or less sinking in of the thorax on either side, just as when a moderate obstruction to the entrance of air exists in the larynx or trachea. As the ribs become firmer from the deposit of lime salts, resjiiration is more regular and normal. Changes in Bones of Upper Extremity. — Although swelling of the lower end of the radius (see Fig. 12) is one of the earliest signs of rachitis, the bones <>!' the upper extremities are less frequently curved and distorted than those "of the lower extremities. The clavicle sometimes softens and bends, producing two curvatures, one backward, near the scapula, and another of larger size nearer the sternum, directed forward and a little upward. Careful examination shows, in some rachitic patients, thickening of the margins of the scapula, like that of the cranial bones. The humerus is occasionally bent, ANATOMICAL CHARACTERS OF RACHITIS. 267 and usually at the point of insertion of the deltoid, in consequence of the powerful action of this muscle in raising and supporting the arm. The radius and ulna are bent outward and twisted. This deformity is attributed by Sir William Jenner to the fact that ricketty children support themselves, while in the sitting posture, upon the palms of the hands pressed upon the floor or couch. Supporting the weight of the body in this way, not only, in his opinion, causes bending of the ulna and radius, but also aids in producing the deformities of the humerus and clavicle. Changes in Bones of Pelvis. — The deformities of the pelvic bones, resulting from rachitic softening, are, in the female infant, the most important of any which the skeleton undergoes. They are produced by pressure from above of the abdominal organs, serving to widen the brim of the pelvis, and also by pressure of the spinal column, sustaining the weight of the trunk, shoulders, and head, pressing forwards the promontory of the sacrum, in the sitting pos- ture, and thus diminishing the antero-posterior diameter of the pelvic brim. There is, moreover, twofold pressure from below, that caused by the heads of the thigh bones, in standing, and that exercised by the tuberosities of the ischia, in sitting. Both these forms of pressure have a tendency to narrow the outlet of the pelvis. Hence the marriage of the female who has been rachitic in infancy may involve serious consequences. Many of the tedious Fig. 14. Fig. 15. Fig. 16. Rachitic deformities of the pelvis. (From specimens iu the Wood Museum.) instrumental labors in the families of the city poor, which severely tax the patience and endurance of young practitioners, are attributable to rickets in early life. Changes in Bones of Lower Extremity. — The curvature of the femur is usu- ally forward, or forward and outward. The neck of the femur sometimes Fig. 17. Fig. IS. Rachitic deformities of the femur. (Wood Museum.) bends by the weight of the body, or by use of the legs, so that the angle which it forms with the shaft is changed. The annexed wood-cuts show the 268 RACHITIS. rachitic bend of this bone in an adult, years after rachitis had ceased, and when the bone had become consolidated by the new deposition of lime salts. The curvature of the tibia and fibula varies. In those under the age of one year, it is apt to be outward, so that the knees are separated from each other. In those old enough to stand, the weight of the body usually determines a forward bending of these bones. In one case in my practice, an anterior cur- vature so abrupt that an angle of about 70° was formed, existed about four inches above each ankle. This patient, though old enough to walk, almost constantly sat during the day with the feet extended beyond the sofa, so that the edge of the latter corresponded with the concavity of the legs. It seemed to me that the weight of the feet must have been a factor in causing these curvatures, especially as the case was one of very marked rachitic softening of different bones. Still, tibial and fibular bending at this point has been noticed by different observers, who have attributed it to the weight of the body in walking. Various other cur- vatures, besides those mentioned, occur in the bones of the lower extremities, the direction in which the limbs bend being determined by the particular cir- cumstances of the case. Fig. 19. Fie. 20. In mild cases of rickets, most of the deformities described above are lacking, but in typical cases cer- tain of them stand out prominently, so as to be read- ily detected by one familiar with the disease. In all such cases the diagnosis is easy beyond that of most other maladies, for the changes which occur are not only conspicuous, but pathognomonic. Rachitis produces another important effect on the skeleton. Its growth is stunted, not only during the rachitic period, but subsequently, so that those who have been rachitic in childhood, unless very mildly, have less than the average stature in adult life. The stunted growth is apparent, though ample allowance be made for curvatures. The arrest of development is greater in some bones than in others. It is greatest in the bones of the face, pelvis, and lower extremi- ties. Stunted growth of the pelvic bones of the fe- male infant conjoined with the deformities alluded to above, may seriously affect her subsequent life, and a rachitic pelvis in the female, exhibiting both stunted growth and deformity, constitutes a valid reason tor avoiding marriage. As a rule, the older the child is when rachitis begins, the less is the skeleton affected, and the less conse- quently is the deformity. Effect of Rachitis on Dentition. — As might be expected from the nature of rachitis, dentition suffers severely. It' the disease show itself before any tooth lias appeared, the first teeth, to wit, the lower central incisors, will probably not appear before the ninth or tenth month, or even later. Sir Wm, Jenner considers the non-appearance of a tooth by the ninth month, with few exceptions, a- sign of rachitis. Teeth which appear during the rachitic state arc frail, deficient in enamel, and crumble readily. They become carious, rot, and break before the usual time. If certain teeth have ap- peared when rachitis begins, several months elapse before others cut the gum. It is even said that a child who has rachitis severely may never have a tooth ; Rachitic deformities of the fe- mur, tibia, and fibula. (Wood Mu- seum.) ANATOMICAL CHARACTERS OF RACHITIS. 269 may remain toothless for life: but I have never observed such a case. Ordi- narily, when the rachitic state ceases, and the health is fully restored, denti- tion goes on as before. The arrest of teething, so easily observed, has long been considered one of the most reliable diagnostic signs. The physician cannot justly pronounce on the nature of the disease in a case of suspected rachitis, unless he first carefully inspects the gums. Changes in the Soft Tissues. — Although the conspicuous lesions of rickets pertain to the skeleton, the soft tissues are also more or less implicated. The ligaments become relaxed and flabby, giving unusual mobility to the joints, and unsteadiness to the movements. The fibrous bands which unite the ver- tebra?, as well as the ligaments of the extremities, participate in the relaxa- tion. In certain patients, the muscles throughout the system, partly, perhaps, in consequence of the gastro-intestinal disturbance, indigestion, and mal-nutri- tion ; partly, perhaps, from want of use (for the rachitic are apt to be quiet), become shrunken and flabby. The spleen is frequently enlarged, as ascertained by palpation and percussion. Ritter Von Rittershain found this organ deci- dedly enlarged in ten out of thirty-five cases which he examined after death. The enlargement is the result of cellular proliferation, common in diseases which are attended by dyserasia. The liver in many patients undergoes no perceptible change, except that it may be pushed a little downwards." It is occasionally found enlarged from fatty infiltration, but no special significance attaches to this, for fatty liver is common in various forms of disease attended by innutrition and wasting. It is common in tuberculosis, and in protracted intestinal catarrh, and its pathological significance appears to be the same in these various diseases. There can be little doubt that Sir Wm. Jenner errs when he states that albuminoid infiltration of the liver is common in rachitis. Parry, Gee, Dickinson, and Senator agree that it is rare, and that if it does occur, it is by coincidence. In a discussion on rachitis, in the London Pathological Society, Dr. Dickinson 1 spoke of enlargement of the spleen, liver, and lymphatic glands, which he had observed in rachitic cases. According to him, the spleen undergoes the greatest enlargement, the lymphatic glands the least, and, of the latter, " the mesenteric glands show the most de- cided swelling." Exceptionally, the spleen is so large that it occupies the greater part of the left half of the abdominal cavity, but a less degree of enlargement is the rule. The liver is apt to extend one or two inches below the ribs. The swelling, Dr. Dick- inson adds, is not amyloid. " There is no new growth or deposit, only an irregular development of the proper tissues of the organs." Both the corpuscular* and intersti- tial elements are increased in the liver, spleen, and lymphatic glands. But other members of the society had observed this enlargement only in occasional cases, and they considered it due rather to the state of health which caused rachitis than to rachitis itself. Dr. C. Hilton Fagge stated that he had failed to find swelling of the liver, spleen, or lymphatic glands, in a large majority of cases. 2 An undue development of the lym- phatic glands from hyperplasia is very common in children in various states of ill-health. and the mesenteric glands are especially apt to become enlarged from this cause in pro- tracted cases of intestinal catarrh or irritation. The abdomen is protuberant from various causes. The lateral depression of the thoracic walls causes the liver and spleen to descend a little lower in the abdominal cayfty than natural. The enlargement of the liver and spleen, the feeble tonicity of the intestinal muscular fibres, and consequent distension of the intestines with gas, and the rachitic shortening of the spinal column, which causes approximation of the ribs and pelvis, tiecessarilv produce ab- dominal protuberance. ' Lancet, December 11, 1S80. 2 Lancet, November 20, 1880. 270 RACHITIS. The kidneys themselves are not diseased in rickets, but there is an exagge- rated discharge of phosphates in the urine, and, as stated above, lactic acid and free phosphoric acid have been found in this excretion. The urine is commonly pale ; its urea and uric acid are diminished ; and it sometimes con- tains a sediment of oxalate of lime. The brain is usually well developed, and appears healthy, with the normal proportion of white and gray substance. In one case the weight of this organ Mas ascertained by Dr. (?ee to be fifty-nine ounces, and in another forty-two and a half ounces. In both brains the proportions of white and gray sub- stance, and their color and consistence, seemed normal. Anatomical Characters of the Third Stage, or that of Reconstruction. — This stage will be better understood, if we recollect what has occurred during the first and second stages. The very vascular periosteum is drawn tightly over convexities, the pressure upon which diminishes the hyperemia and the amount of exudation underneath. Over the concavities the periosteum is loose ; it is hypertemic, with abundant new capillaries, the interspace between it and the bone being tilled with the gelatiniform substance already described. The reparative process goes forward more rapidly, and the deposition of lime salts is more abundant upon the concave surfaces, where there have been free exudation and no compression of the capillaries, than elsewhere. The lime salts are deposited from the blood. Consequently, from the increased capillary circulation and hyperamiic state of the periosteum produced by rachitis, the chalky matter is rapidly effused wherever there is an open space under the periosteum, and where the capillaries are in a state of engorgement. Hence the reconstructed bone is thicker and firmer upon the concave aspect of the long bones than elsewhere, and thinnest upon the convex aspect where the periosteum is more tense, and its capillaries more or less compressed. It is a question whether true ossitication occurs at first during the repara- tive stage. The deposition of chalky matter is designated by some writers as a petrifaction rather than a true bone-formation. Trousseau likens it to the formation of callus after a fracture. It certainly produces a substance more compact than ordinary bone. The term "eburnation" has been applied to this new osseous formation, and I have designated it "osteo-sclerosis." Some years since I examined microscopically an adult bone which exhibited the rachitic curvature in a marked degree, and was very hard. It contained the elements of true bone, but I was in doubt whether the part examined was formed during convalescence from rickets, or in the subsequent growth. Recovery from rickets is gradual. Little by little, the cartilaginous and periosteal proliferation ceases, the hyperemia abates, and the bone-producing tissues return to their normal state. Certain of the deformities are perma- nent, but others disappear in the further growth of the skeleton. Symptoms of Rachitis. Preceding and accompanying rachitis, symptoms may be present which are due to indigestion and intestinal catarrh, such as flatulence, unhealthy stools, and poor or capricious appetite. When rachitis begins, the infant becomes fretful; its sleep is apt to be restless and disturbed, and it awakens often. It repels attempts to amuse it, and is apparently annoyed by them. Nurse and mother speak of it as a cross child. It perspires freely from the head and neck, both when awake and when asleep, while the extremities and trunk arc dry. its pillow is wet with perspiration during sleep, and sweat drops may be seen upon forehead and face. If the surface be dry, a little excitement or COMPLICATIONS AND SEQUELS OF RACHITIS. 271 elevation of temperature causes the perspiration to appear. The rachitic child does not well tolerate the bedclothes, and attempts to throw them off from its limbs, even in cool weather, lying exposed, and causing considerable annoyance to the nurse who strives to prevent its taking cold. Sometimes miliaria, due to the moist state of the skin, appear upon the face and neck. The subcutaneous veins which return blood from the head are large, and the jugular veins full. Another symptom is soon observed, to wit, tenderness over a considerable part of the surface, perhaps largely due to the morbid state of the periosteum over so many bones, though it is also experienced when pressure is made upon soft parts, as the abdomen. The tenderness is probably, in part, the cause of the fretful disposition. The little patient appears to dread to be touched ; its flesh is sore ; it repels attempts to amuse it, and wishes to be quiet. Dand- ling it upon the arms, swinging it, or even walking with it, which delights the healthy child, and elicits a smile or notes of glee, only adds to its discom- fort. It is most at ease when left alone, upon a soft cot or pillow, or, if it have craniotabes, when quietly held over the shoulder. Languor, disinclination to •use the limbs, or to play, moderate thirst, with other symptoms referable to the digestive apparatus, which are present in many cases, and which have al- ready been described, are soon followed by changes in the skeleton, which are perceptible to the sight and on palpation. The pulse and temperature in a large proportion of the ordinary chronic cases, do not deviate from the healthy state, except that in some patients there is a slight febrile movement in the latter part of the day. Although rachitis is ordinarily a chronic disease, insidious in its commence- ment, gradual and progressive in its development, occupying months, there is an acute form which is attended by more marked febrile movement and ten- derness, and in which the articular swelling appears more quickly. A bruit de soufflrt, of greater or less intensity, synchronous with the pulse, has frequently been heard in rachitic cases by applying the ear over the ante- rior fontanelle. Drs. Whitney and Fischer, New England physicians, first called attention to this murmur, believing it to be a sign of chronic hydro- cephalus. MM. Billiet and Barthez heard it in cases of rachitis, and, there- fore, concluded that the American physicians had confounded the two diseases. More recent observations have established the fact that this bruit has little diagnostic value. It is heard whenever there is sufficient patency of the an- terior fontanelle, both in health and disease, for sound is conducted better through a membrane than through bone. Dr. Wirthgen heard the bruit in 22 out of 52 children, of whom all except four were in "good health. I have auscultated the anterior fontanelle in 29 infants, who were with two excep- tions between the ages of three and thirty months. All were well, or affected merely with trivial ailments which did not affect the cerebral circulation. In most of them a murmur could be distinctly heard, synchronous with the respiratory act, and in 15 of the 29 cases no other sound could be detected, while in the remaining 14 a bruit could be detected, synchronous with the pulse. Complications and Sequelae of Rachitis. These have been in part described in the foregoing pages, but there are cer- tain other results of the disease to which it is proper to call attention. If the deformity in the thoracic wall, namely, the lateral depression of the ribs and anterior projection of the sternum, be great, we would naturally expect that the two important organs underneath, the heart and lungs, would receive some detriment. Upon the surface of the heart, at the point where it sup- 272 RACHITIS. ports the softened ribs, a white patch is often found, due to thickening of the pericardium and proliferation of the endothelial cells, just as thickening of the skin in the palm of the hand occurs from friction and pressure upon that part. It is probable that this pressure does not seriously impair the function of the heart, but it may increase the weakness of its movements in any asthenic disease which may occur during the rachitic period. The injury sustained by the lungs is greater and more apparent. If the ribs be flexible, and much depressed, full inflation of the lung cannot occur in those parts where the depression is greatest. Semi-collapse of certain lobules is apt to occur, and even complete collapse of the distant thin edges of the lung. The stress of respiration falls unequally upon different parts of the lung. The anterior portion, which ascends with the sternum as that is propelled forward, is more fully dilated than the lateral and posterior parts, and hence is apt to become emphysematous. If in this state of the thorax and lungs, severe bronchitis or broncho-pneumonia arise, the state is one of great peril. The mucus and pus being expectorated with difficulty, clog the tubes and produce dyspnoea. Full inspiration in the lateral and depending portions of the lung, which is required in order to expel the mucus, not occurring, the result may be unfavorable, even in comparatively mild forms of inflammation. Bron- chitis and broncho-pneumonia are the causes of death in not a few cases of severe rickets. Certain writers state that chronic hydrocephalus, diarrhoea, and eclampsia may complicate rachitis. I have not seen any case in which rickets seemed to sustain a causative relation to either hydrocephalus or diar- rhoea, but we know that diarrhoea frequently precedes and accompanies rachitis, and its relation to it is that of cause rather than effect. This sub- ject has been sufficiently treated of in preceding pages. Rachitic infants ap- pear to be more liable to eclampsia than those who are healthy. This would be inferred from their liability to laryngismus stridulus, for there is a simili- tude in the nature of these neuroses. Diagnosis of Rachitis. Rachitis in many instances continues a considerable time before its nature is suspected, the symptoms to which it gives rise being overlooked, or attrib- uted to other causes than the true one ; and yet it is important that an early diagnosis be made, for it is much more amenable to treatment in its early than in its later stages. The deformities which mar the beauty, and to a certain extent impair the activity and usefulness, of so many who have been rachitic in childhood, may often be prevented by early diagnosis and treatment. Many with this disease do not show the usual signs of faulty digestion and innutrition, especially on casual inspection, for there may be considerable adipose development and rotundity of features and form in a rachitic child ; while, on the other hand, there are numerous instances of mal-nutrition and wasting without rachitis. Early diagnosis, when the affection is of a mild type, is necessarily difficult, but a watchful and painstaking physician will commonly detect the disease before it has run many weeks, if he bears in mind its frequency, and looks carefully for it. If called to a suspected case, we should inquire into the history, and par- ticularly whether there have been signs of intestinal catarrh or innutrition* The gums should be inspected to ascertain whether there is backwardness in dentition, and the head, to note its shape and size, whether it is elongated, or whether it approximates the square shape, with broad forehead and large protuberances. We ahould notice also the state of the fontanelles and sutures, and whether there are softening and thinning of the cranial bones. The PROGNOSIS OF RACHITIS. 273 costo-chondral articulations and those of the wrist, should also be carefully examined to ascertain if there is any enlargement, and the shape of the tho- rax, which begins to exhibit the rachitic deformity at an early stage of the disease, should likewise be noticed. We should also examine the child in reference to other less prominent signs, such as spinal curvature, abdominal protuberance, muscular weakness, and relaxation of ligaments (which produce feeble and unsteady use of the limbs), perspirations upon the head and neck from slight excitement, and during sleep, fretfulness, etc. If rachitis be pre- sent, certain of these signs will be observed. The late Dr. Parry called attention to the importance of making a differ- ential diagnosis between the pseudo-paraplegia of rachitis and true paraplegia, which is the prominent symptom of infantile paralysis. The rachitic child, from muscular weakness and ligamentous relaxation, and from the soreness and tenderness common in this condition, may seldom use his legs ; may sit or lie quietly at the age when healthy children, if awake, are constantly moving their limbs. If we attempt to make him walk or stand, his legs may be so limp and powerless that they give way under his weight, but this is a different state from paralysis. In paralysis, the fault is in the nervous sys- tem — usually in the nervous centres — whereas, in rachitis, it is in the mus- cles and ligaments. The rachitic child, when sitting or lying down, readily moves his legs if his feet be tickled or pinched, while the paralyzed limb responds to the irritation imperfectly. In infantile paralysis, the loss of mus- cular power is, with few exceptions, confined to the muscles of the lower ex- tremities ; but in rachitis, the muscular feebleness is more general, being noticeable in the arms as well as in the legs. Great relaxation of the liga- ments is in most instances due to rachitis. It is especially noticeable in the ankle and knee-joints, and is a diagnostic sign which should not be overlooked in the examination of a suspected case of the disease. ■ Prognosis of Rachitis. The prognosis of rickets is usually favorable, provided that no serious com- plication, arises. Rachitis is not in itself fatal, under ordinary circumstances. If there be much lateral depression and narrowing of the thorax, the func- tions of the heart and lungs may be embarrassed, and if the patient have a severe bronchial catarrh, or broncho-pneumonia, the condition becomes one of danger. Rachitic children seem to be especially liable to catarrhal attacks of the air passages, and even a moderate catarrh, with a deformed thorax, may prevent proper decarbonization of the blood, and cause livid ity and dyspnoea. Therefore, now and then, a rachitic child succumbs to an attack of inflam- mation of the respiratory apparatus, which would not have been fatal if there had been no rachitic deformity. We have seen that in whatever way it may act to produce this form of spasm, rachitis is a cause of laryngismus stridulus. Occasionally spasm of the glottis is fatal, but cases with such a termination are rare in America, though not infrequent in some European countries. Of the diseases of childhood which rachitic children tolerate badly, and which may prove fatal in consequence of rachitic bone-softening and de- formity, pertussis should be mentioned. If this be severe while the ribs are soft and yielding, and there be lateral depression of the thorax, the spasmodic cough produces great suffering and involves danger. Lividity, feeble action of the heart, pulmonary and cerebral congestion, and eclampsia, may occur. Measles, if it be attended by considerable bronchitis, and especially if it be complicated by broncho-pneumonia, is also one of the dangerous intercurrent diseases. The gravity of these inflammations of the respiratory apparatus is vol. i. — 18 274 RACHITIS. usually proportionate to the degree of recession of the ribs during inspiration. With these exceptions, and with that of risk to the married female who has deformity and stunted growth of the pelvic bones, the rachitic are not liable to any ulterior serious consequences. Minor deformities, in mild cases, not infrequently disappear in the subsequent growth of the skeleton. The older the child is when rachitis begins, the milder is ordinarily the form of the disease, and the more speedy, consequently, the recovery, and the. less the deformity. In the gravest cases, the disease will almost always be found to have begun under the age of one year. Treatment of Rachitis. The correct treatment of rachitis is evident when we consider its character and the nature of its causes. The obvious indication is to restore healthy nutrition. This requires both hygienic and therapeutic measures. The apartment in which the child resides should be dry, airy, and plentifully supplied with light. He should be taken daily into the open air, in order to invigorate his system, but in such a way as not to increase his suffering, on. account of his general tenderness. Residence in the country is far preferable to that in the city, because of the better hygienic conditions which it pro- cures. The purer air, the better diet, and consequently the more robust de- velopment gained by rural life, are important advantages, to obtain which is abundantly worth pecuniary sacrifice when the children of a family are rachitic. The diet in rachitis should receive particular attention, since indigestion and gastro-intestinal derangement sustain a causative relation to so many cases. Good breast milk ought if possible to be obtained until the child has reached the age of ten months, and, if the mother's condition be such that she cannot furnish it, a wet-nurse should, if practicable, be employed. But after the age of six months additional nutriment is required. As a rule, the infant should be weaned at the age of twelve months, but longer nursing may be best under certain conditions, as the presence of hot weather, an abundant supply of good breast milk, and, on the part of the infant, feeble digestion and easily deranged digestive organs. In case breast-milk cannot be obtained, cow's milk, properly diluted, according to the age, with water, or with a solution of one of the foods for infants which the shops contain, is probably the best substitute. I have stated that rachitis seldom appears before the age of three or four months. For an infant of four months, cow's milk should be diluted with about one-fourth part of water, but after the age of six months no dilu- tion is required. I prefer to sweeten the milk not with cane sugar, but with Liebig's infant's food, prepared by Hawley, Horlick, or Mellen. Condensed milk is now much used in the cities, and is prepared by American companies as well as by the Anglo-Swiss company, but it possesses no advantages over ordinary milk, if the latter can be obtained fresh and sufficiently often. It possesses only the advantage that it can be longer preserved without fermen- tative change. Infants over the age of five or six months require the admix- ture of farinaceous food with the milk, at first in small quantity, but in greater proportion as the age increases. Barley flour, oatmeal, stale bread crumbled fine, Ridge's food, imperial granum, etc., of the shops, form suita- ble additions to the milk diet. For infants of the age of nearly one year, considerable variety may be. allowed in the diet: a potato, baked and mashed like lour, the juice of beef, stale bread and butter, soda cracker and butter, etc., may be allowed. I have elsewhere stated that in one of the institutions of New York, rachitis from being common was made to disappear almost TREATMENT OF RACHITIS. 275 entirely, by allowing a more generous diet, a part of which was the daily use of a little beef-tea. Xo absolute directions can be given, however, as regards the diet. Variation must be allowed according to the season of the year, and individual peculiarities. Cow's milk disagrees with some infants, and in hot weather with many; so that it is necessary to substitute for it some farinaceous food, with perhaps juice of meat, or the white of egg. Medicines which improve the nutrition and general health are all more or less useful in the treatment of rachitis, but, from the nature of the disease, lime is specially indicated. I have not, like some observers, discarded the use of cod-liver oil, believing that it answers a good purpose in improving the general nutritive process. The following prescription will be found useful in most cases: 8. Olei morrhuse, fliv-viij ; Aqwe calcis, Syrupi calcis lacto- phosphatis, aa fsiv. — M. Of this, one teaspoonful may be given four or five times daily to an infant of one year. It may be too laxative in the summer months, when lime-water in milk, which is constipating, should be used instead. Fleischmann recommends the fluorine compounds in order to increase and harden the enamel of the teeth. I have had no experience with these remedies, but the theory of their use appears to be sound. He recommends the employment of fluorine between the tenth and eighteenth months, in the form of the tooth pastilles of Ehrhardt or Hunter, which con- tain the neutral fluoride of potassium. One of them is administered daily. Among other agents which may be found useful may be mentioned the compound syrup of the phosphates, the citrate of iron and quinia, wine of iron, the various preparations of cinchona, calomba, etc., since such tonics when judiciously administered aid in the restoration of healthy nutrition. When complications arise, the treatment should be modified to meet the exigencies of the case. Most of the diseases which complicate rachitis require similar treatment to that which is appropriate in their independent form, but all measures of a depressing nature must be uniformly avoided. SCURVY. BY PHILIP S. WALES M.D. SURGEON-GENERAL OK THE UNITED STATES NAVY. Synonyms. Latin, Scorbutus ; French, Scorbut; Spanish, Escorbuto ; Italian, Scorbuto; German, Scharbock. These appellations are derived from the old Saxon word Scnrbock (ulcer of the mouth), or from the Sclavonic word Searb (disease). We may define scurvy as an acquired, constitutional disease, determined by the use of improper diet, and almost wholly by abstention from succulent vegetable food. It is characterized by certain alterations in the vital, physical, and chemical properties of the, blood, and by disturbances of the textural integrity of nearly all the constituent tissues and organs of the body. The perverted nutrition is manifested by lassitude, weariness, debility, breathlessness, loss of muscular power, depression of spirits, and hemorrhagic extravasations, par- ticularly into the skin of the lower extremities; the cutaneous blotches (pete- chice, vibices, ecchymoses) are of varying size, color, and form. The skin occasionally is the seat of bleeding, inveterate, and sloughing ulcerations. Ecchymotic discoloration occurs also in the mucous membranes; the gums become spongy, and bleed easily, and the sanious discharges from them infect the breath with a foul odor. Blood is sometimes poured out into the visceral cavities and canals, giving rise to the various forms of local hemorrhage. The serous membranes display alterations of varying aspect, caused by effu- sive or inflammatory action. It may happen that exudative products occur in the substance of the viscera and organs, in which case they are exceedingly apt to light up inflammatory disturbances. History of Scurvy. There is no reliable evidence to be found in ancient medical literature that this disease was known as an independent and distinct pathological entity. Certain scorbutic phenomena were recognized, but always as allied and linked with those of other and diverse morbid conditions, as ergotism, typhus, diphtheritic stomatitis, malarial cachexia, splenic disorders, and icterus. There can be no doubt, however, that the conditions for its development were in early times frequently supplied by the prevailing and wide-spread igno- rance and neglect of the plainest facts of sanitary prevision, by the frequent famines from failure of crops or other national calamities, by the movements (277) 278 scurvy. of large armies through uncultivated territories or desert wastes where food-supplies were impossible; by the recurring sieges of large cities; and, lastly, by the total neglect of horticulture which existed until a comparatively late period. These are the circumstances, at least, which in modern times have made a record teeming with the most destructive outbreaks of the dis- ease. These a priori considerations tend strongly to an affirmative conclusion as to the prevalence of scurvy at all periods of the world's history, and render it probable that the failure to identify it was simply due to a lack of patho- logical discrimination. Various allusions to diseases presenting scorbutic phenomena can be gleaned from early authors. Hippocrates, 1 speaking of enlargement of the spleen (anx^ /**'yas), enumerates such symptoms as a pallid skin, offensive breath, disease of the gums, and ulcers of the legs ; and again in his description of the i&ibs a^artr^, or convolvulus sanguineus? he covers still more of the scorbutic symptoms, mentioning, in addition to the fore- going, epistaxis and impaired locomotion. Celsus, 3 Aretasus, 4 Caelius Aure- lianus, 5 Paulus vEgineta, 6 Avicenna, 7 and others, have done little else than paraphrase the clinical descriptions of Hippocrates. Pliny, 8 in referring to the army of Cresar Germanicus, states that a peculiar disease of the mouth, called stomacace, or sceloturbe, affected the soldiers while encamped in Ger- many, near the sea-coast, and was attended with dropping out of the teeth and impeded locomotion ; and he adds that in treating this malady the Herba Britannica and fresh vegetables were used with success. And Strabo 9 tells a similar story of a dangerous disease named aro^axdxr;, assailing the army of .zEtius Gallus in Arabia. Marcellus 10 alludes to an ulcerative affection of the mouth, oscedo, for which he too recommends the Herba Britannica, a plant now believed to be identical with the Bumex aquaticus. So run the historical and medical records as far as antiquity has shed any light upon this disease, and they are altogether too deficient and obscure to authorize any conclusion as to the real nature of the pathological processes intended to be described. The phenomena of scurvy are so peculiar, and the conditions of its occurrence so special, that it may well excite surprise that it was not recognized in the earliest times by those writers who, even now, are accorded the highest credit for their clinical acumen and precision. An explanation might be sought in the fact that the disease did not really pre- vail to any great extent in the mild climate and fertile lands of the south of Europe, in which the literary and medical writers of antiquity chiefly flourished, .and where, it is well known, succulent vegetables grew luxuri- antly, and formed a part of the common diet of all classes of people. It is stated in the 13ook of Numbers (chap, xi.), that the children of Israel, in going through the wilderness, longed for the leeks, garlic, and onions upon which they bad led in Egypt, whilst Herodotus 11 tells us that not less than one thousand six hundred talents were paid for radishes, onions, and garlic consumed by the workmen employed in erecting one of the pyramids. In Rome, garlic (scorned by Horace 12 as only fit for the "dura messorum ilia") was also employed as a condiment, and the well-known proverb, " fit's xpe^^ edvaros" proves thai iii Greece cabbages must have formed the most plebeian fare (Curran). So favorable a climate and such dietetic customs would not afford the same opportunities for observing the disease as the cold, inhos- 1 I'rorrbeticorum lib. ii. 2 Liber do internis afl'ectionibus. s De medicina, HI), ii. cap. vii. 1 !><• causis et si^nis diutumorum morbnrum, lib. i. cap. xiv. 6 Morborum cbronicorum lib. iii. cap. iv. 6 De re medica, lib. iii. cap. xlix. 7 Canonis medicinre lib. iii. fen xv. tract, i. cap. v. 8 Naturalia historise lib. xxv. cap. iii. 9 Geographicorum lib. xvi. 10 De medicamentis, cap. xi. " Hist. lib. ii. Euterpe, cap. exxv. u Epodoil lib., carin. iii. HISTORY OF SCURVY. 279 pitable, and unfertile fields of the Northmen, where the difficulties of pro- curing abundant and varied food would be greatly enhanced, and where, as gardens were not cultivated, the people lived on salted or smoke-dried meats and fish. This rarity of horticulture finds illustration in the fact recorded by Hume, that Catherine of Arragon, Queen of Henry VIII., sent a mes- senger all the way to the Netherlands for the materials of a salad. Following the current of history, a long period intervenes in which not a vestige can be found to indicate the occurrence of scurvy (unless we accept the rather doubtful story of the Xorman hero Thorstein, who with a number of his fellows was supposed to have been destroyed by this disease in an expe- dition to Greenland in 1002) until the thirteenth century, when the religious agitation in Christian Europe led to attempts to rescue the Holy Land from the hands of the infidel. Hordes of undisciplined people, as well as regularly organized forces, then assembled for the invasion of Egypt and Syria. The lack of discipline, fatiguing marches, exposure to climatic vicissitudes, imper- fect quality and quantity of the water supply, uncleanly camps, and depress- ing moral emotions from defeat, furnished the necessary conditions for the development of scurvy, and enormous loss of life followed. The first and fullest accounts were given by Jacob de Vitry, who describes the sufferings of the troops under Count Saarbriicken, lying before Damietta during the years 1218-19, after an overflow" of the Xile, accompanied by heavy rains and the cold weather of December. He says : — Invasit prreterea multos de exercitu qusedam pestis, contra quam pbysici nullum ex arte sua remedium invenire poterant ; dolor repentinus pedes invasit et crura, et con- junctim caro corrupta gingivas et dentes abducit, mastieandi potestatem auferens ; tibias horribilis nigredo obfuscavit, et sic longe tractu doloris afflieti cum patientia multa migraverunt ad Dominum plurimi ; quidam usque ad vernale tempus durantes, beneficio caloris evaserunt liberati. A still more terrible epidemic afflicted the army of Louis IX., besieging Damietta in 1249, and was graphically described by Jean, Sire de Joinville. 1 The disease was attributed to the nature and scarcity of the army's food, which was chiefly fish, and to the character of the water; and it increased, says the historian, " to such a degree in our camp as to cause large masses of dead flesh to spring from the gums of our people. The barbers were forced to cut away the dead flesh to enable the patients to eat ; the flesh of our legs shrunk up, and the skin was covered with red and black spots. Bleeding at the nose was a sign of approaching death." Another gap, running over the period of nearly two centuries, and marked by total silence as regards scurvy, succeeded ; Fabricius 2 was the first to relate the occurrence in 1446, in the north of Europe, of a new and unheard- of disease presenting scorbutic symptoms, which proved extremely fatal at various places in Norway, Sweden, Siberia, Russia, and Germany. The social and material condition of the masses of the people was of the most deplor- able character; they inhabited foul, overcrowded, and closely-built dwellings, which exposed them to the worst consequences of impure air and bad drain- age, while poverty added the ills of scant and improper food, and the rigorous effects of exposure to atmospheric vicissitudes. Although the districts bor- dering on the Xorth and Baltic Seas were more particularly affected by these evils, yet the largest cities then presented a squalid aspect in striking con- trast with the present spacious avenues, gardens, and imposing structures everywhere seen. Voltaire states that, about the year 1500, industry had 1 Histoire de St. Louis IX., par le Sire de Joinville. Paris, 1761. 8 Annales urbis Misnicae. 280 SCURVY. not yet changed those huts of wood and plaster of which Paris was composed, into sumptuous palaces. London was still worse built, the Strand being composed of mud walls and thatched houses. These wretched hovels swarmed with people until after the great tire of 1666, when the houses were less crowded, one person occupying as much space as two in the old citv. Yet, with this amelioration, the deaths from scurvy between the years 1671 and 1686, were 9451. For the period from 1686 to 1701, there were 1569 deaths, and only 226 between 1701 and 1776. This remarkable decrease took place pari passu with hygienic improvements both in the dwellings and food of the people. The earliest account of the disease occurring at sea, is that related of a Venetian merchantman during a voyage to Norway in 1431. A little later (1497), the crew of Yasco da Gama, 1 in a voyage to India, experienced the most frightful sufferings from this cause, so that — " The livid gums with growth prodigious swelled Breathing infection that depraved the breeze." 2 The sixteenth century was marked by frequent epidemics at various points in Europe and in North America, and during long voyages, and the disease was alluded to by numerous writers. Thus Euricius Cordus 3 in his Botanolo- gicon, published in 1534, states that the herb Chelidonius minus, called by the Saxons Scarbock crout, is an excellent remedy for the disease, and the same fact is also alluded to by Julius Agrieola 4 in his work Medicina Herbaria, published in 1539. Jacques Cartier 5 relates in an account of his second voy- age, in 1535, that an epidemic of scurvy broke out among the natives of Stadacona, in the month of December, and also affected the people of his ships, so that — "By the middle of February, of 110 persons there were not ten whole. Some did lose all their strength and could not stand on their feete ; then did their legges swel, their sinnowes shrinke as black as a cole. Others also had all their skins spotted with spots of blood of a purple colour ; then did it ascend up to their ankels, knees, thighes, shoulders, armesand neckes ; their mouths became stinking, their gummes so rotten that all the flesh did fall off, even to the rootes of the teeth, which did also almost all fall out." He learned from a native the virtues of a decoction of the bark and leaves of a tree called hanneda (probably the American swamp spruce), the use of which cured his men. The frequency of events analogous to the foregoing, both on shipboard and on land, invested the subject of scurvy with an interest and an importance that could not fail to lead to a more thorough investigation into its nature and causes. The first special treatise was published by Echthius, 6 a physi- cian of Cologne, in_1541, in which he presented a fair summary of the phe- nomena of the disease as he had seen it, and differentiated it from other bathe-logical conditions with which it had up to that time been confounded, lie attributed the disease to alterations in the blood, and not to those of the S ], I,. en or other viscera, as had been erroneously done by his predecessors. Olaus Magnus, 7 in liis history of the northern nations, bearing date 1555, gives, ;1 , of one of the diseases peculiar to them, a Lengthy description of scurvy, vulgarly called Scharbock; ascribes its origin to the character of the food; and ' Haklnyt Society's Publication, p. 72. 2 Camoens, The Luaiad ; Canto V. 3 Botanologicon. Colon. 1534. < Medicina herbaria. Basil. 1539. ■• Hakluyt, Principal Navigations, etc. London, 1598. e ]),- Bcorbuto epitome. Wittbg. 1585. 7 Hist, de gentibus septent. Romne, 1555. HISTORY OF SCURVY. 281 recognizes its more frequent occurrence during famines and sieges : " est enim morbus castrensis, qui vexat inclusos et obsessos." Two of the most important treatises were by contemporaries of Echthius, both based upon actual observation of the disease as it occurred in Holland. One was written by Ronsseus, 1 in 1564, and the other by "Wierus, 2 in 1567. The former fell into the error of attributing the disease to splenic disorder. He regarded its prevalence in Holland as due to the peculiar damp air of the country, the use of impure water, and the perpetual diet of sea-birds and salt meats. Allusion is also made to the fact that seamen on long voyages cured themselves of the disease by eating oranges. On the other hand, AVierus adopted the views of Echthius as to the nature of the disease, and rightly attributed its cause to dietetic errors, and recommended for its cure the expressed juices of antiscorbutic herbs, or fresh herbs boiled in cows' or goats' milk, or whey. He regarded the disease as peculiar to the inhabitants of the countries bordering on the North Sea, and had never seen it in Spain, France, or Italy, nor in Asia or Africa. The treatise of AVierus was the standard authority until the end of the sixteenth century. The publications that followed — the chief of which were those of Langius, 3 Lommius, Dodonreus, 4 Brucseus, 5 Albertus, 6 and Forestus 7 — added little if anything to the information therein contained, but at the same time they rendered service by disseminating the knowledge already gained of the disease in those coun- tries — Holland, Flanders, Brabant, etc. — where it was habitually present, and often epidemic. The most ample opportunities were furnished during the seventeenth century for the attainment of correct notions of the nature and causes of scurvy, by the frequent wars and sieges on land, and by the maritime adven- tures and naval operations afloat. Among the most memorable may be noted the recital of Van der Mye, 8 of the suffering of the garrison of Breda during the siege by the Spaniards in 1624. The soldiers and the inhabitants of the town were generally affected, 1608 of the former having been attacked by the disease up to the fourth month of the siege, and the numbers increasing daily until the place surrendered in the following June, after an investment of eight months. The weather had been very wet, and the sufferers had been compelled to live on rye thirty years old, on cheese, and on dried fish. After the fall of the fortress, and the return of warm weather, the disease disappeared with the use of better food and a supply of vegetables. On the sea, the disease was rife everywhere. Sir R. Hawkins 9 relates, in the account of his voyage to the South Sea in 1593, that, during his twenty years of service afloat, upwards of 10,000 mariners had died of scurvy under his own observation. And, in 1609, three of the four ships that left England to establish the East India Company, lost nearly a fourth of their men by the time that they arrived at the Cape of Good Hope ; while the fourth ship, the Commodore's, escaped almost entirely, in consequence of the men having been served each with a daily allowance of lemon-juice. On other occasions, the mortality of the East India Company's ships amounted to half of their effective force, and this devastation continued as late as 1775, when the hygienic reforms that had been introduced from time to time culminated in a better state of affairs, so that one ship made the entire voyage with the loss of but one man. 1 De magnis lienibus, etc. Antuerp. 1564. 2 Obsorvationes med. Basil. 1567. 3 Medicinal, epist. misc. * Medic, observationes, etc. Lugd. 1585. 6 De scorbuto propositiones. Rostock, 1589. 6 Scorbuti liistoria. Wittbg. 1594. 7 Obs. et curat, medic. 8 De morbis, etc., 1627. 9 Hakluyt Society's Publication. 282 scurvy. Scurvy appeared in 1631 in the Swedish Army at Nuremberg, 1 and again in 1633 in Augsburg, and at the close of the century (1699) at the Hotel Dieu, Paris. These examples serve to show how little advantage had been taken of the knowledge already gained of the causative influences determin- ing the disease. In tact, the treatises that appeared at this time were inferior to those of the preceding century, and the most notable example was the book of Engalenus, 2 published in 1604, which, from the great esteem in which it was held for more than a century, served to disseminate the most absurd views concerning the pathology of scurvy. Scarcely an ailment was attributed to other than scorbutic influences, and certain peculiarities of the pulse and urine were regarded as the most certain and characteristic signs of their presence. This confusion — created first by Engalenus, and further extended by other writers who had adopted his opinions, such as Sennertus, 3 "Willis, 4 and Lister 5 — induced not a few to doubt, and even to deny, the existence of scurvy as a distinct affection. The eighteenth century, however, furnished the most marked examples of the devastation produced by scurvy, commencing with the siege of Thorn 6 by the Swedes, in 1703, in which 5000 of the garrison, besides many of the inhabitants, were destroyed by the disease, while the besiegers were abso- lutely exempt from it. When the investment ended, and succulent vegetables were permitted to enter the town, the disease quickly disappeared. It also occurred in Cronstadt, 7 Viborg, and St. Petersburg, 8 between 1731 and 1738, when thousands of common soldiers were cut off, but not a single officer suffered. The disease was so widespread and fatal that Kramer, 9 physician to the army, requested a consultation of the College of Physicians of Vienna. Their advice was, however, of no avail, for the disease, which had broken out at the end of winter, continued until the approach of summer, when succulent vegetables were procurable. Of four hundred cases treated with calomel, every one died. At the siege of Azof, 10 in 1736, the Prussians suf- fered severely, as did also the Russian Army, in 1742, at Viborg and other places. The malady was greatest during the winter and spring, and was ascribed to the unwholesome character of the food, and the want of fresh succulent vegetables. The dreadful misfortune of Admiral Hosier, who commanded the English fleet in the West Indies in 1728, presents an example of tragic interest : he lost two crews from the disease, and in consequence died himself, broken-hearted ; and, a little later, the fleet of Admiral Rodney, on the same station, suffered severely. In 1740, Lord Anson left England with a squadron to circumnavigate the globe, and, after the most harroA\ ing experiences from tempest and scurvy, returned with less than a fifth of his original force. The disease was fatally rife, though the men were abundantly supplied with fresh animal food. The fleet under the command of Admiral Geary, in 1780, returned to England with 2400 cases of scurvy, and the Channel fleet under Lord Howe was completely disabled from the same cause In 1749-50, the disease reigned in Friesland, and at Riga, P>reslau, and Venice; and the British troops, 5000 in number, as related by Smollett, 11 were at the siege of Quebec, in 1760, so distressed by want of vegetables and the ex- cessive cold, that before the end of April 1000 men died of scurvy, and more i Rotenbeck et Horn, Specnl. scorbuti. Norimb. 1(533. 2 De morbi scorbuto, 1(504. s Tractatus de scorlmto. Wittbg. 1(524. 4 Tractates de Bcorbuto, 1(5(57. 6 Tractatus de quibusdarn morbis, etc., 1699. 6 Bachstrom, Observat. circa scorbut., 1734. 7 Sinopeus, Parerga medica. Petersb. 1734. 8 Nitzsch, Abhandlung des Scharbocks. Petersb. 1747 9 Medicina castrenais. Norimb. t73. r >. 10 A. Nitzsch, TheoretiBch-practiache Abhandlung des Scharliockes. 11 History <>f England. HISTORY OF SCURVY. 283 than twice that number were rendered unfit for service. Though the course of this century was marked by these lamentable occurrences on land and at sea, yet slow but steady hygienic improvements were discernible. The most eminent example of intelligent appreciation of their importance was that of Captain Cook, in a voyage of circumnavigation in 1772-75, which was accom- plished with the loss of but a single man. This result was obtained by minute attention to the dryness, cleanliness, and ventilation of the ship, and by the use of suitable food. This example was not lost, for although the anti-scor- butic influence of fresh vegetables and fruits had long been a familiar fact, yet it was not until 1795 that the use of lemon-juice was made an integral portion of the ration of the British Navy by official order. The hygienic condition of that service has gradually improved since this period, so that scurvy has been well-nigh banished. These ameliorations have been chiefly due to the labors and writings of James Lind and Sir Gilbert Blane, the observations of the former having been printed in 1749, and those of the latter in 1785, and both having gone through several editions. The nineteenth century has been marked by notable progress in hygienic knowledge, and scurvy has become restricted to narrower limits and to excep- tional occurrences. At the siege of Alexandria, in 1801, which was com- menced in May and ended in August, and which furnished, according to Larrey, the conditions for an outbreak of the disease, viz., cold, dampness, and bad food, 3500 cases were admitted into the military hospitals of the city, and many died. The disease was finally controlled by the issue of vine- gar, dates, coffee, and syrup. The officers, who were well rationed, did not sutler. In 1809, the United States troops encamped in the Lower Mississippi, lost over 600 men from the disease. The army of Ibraheem Pasha, in Arabia, was so sorely beset by scurvy, that out of an army of over 100,000 men few returned to their homes, on account of insufficient food, harassing marches, and fatigue. The English troops in the war in Siam and Ava, supplied a large quota of cases of scurvy, and of scorbutic dysentery and ague ; and in 1837, in the Caffir war, they were severely afflicted, for, although they were abundantly supplied with good fresh meat, they had long been without fresh vegetables and fruits. A similar experience occurred in the Punjaub, in 1848-49. Scurvy had been seldom or never seen in Great Britain from the end of the last century up to 1847, except in jails and penitentiaries, as at Millbanke in 1823 ; but in the early months of 1847 and 1848, it made its appearance in many places, owing chiefly to the potato blight which destroyed the usual food supply. At this time the most terrific devastation from scurvy was reported in several of the Russian provinces. The total number of cases was estimated at 260,444 of which 67,958 proved fatal. Dr. Gale 1 reported the sufferings of the American troops in 1820, in their march to Council Bluffs, which place was reached in October after weeks of the greatest hardships in navigating the boats up the Missouri River, during which time the men were exposed to the midday sun, evening dews and chilly nights, with food consisting chiefly of salted or smoke-dried meats, without vegetables or groceries of any sort. In the following January, scorbutic cases began to show themselves, but the disease proved fatal to few until February. when nearly the whole regiment sank beneath its influence, and it continued unabated until April when wild vegetables appeared. The strength of this post and of that at St. Peter's, was 1016 ; the number of cases 506 ; and the number of deaths 168. But one officer was affected, and the hunters who lived in the woods and subsisted on game were in no instance unhealthy. The 1 Forry, American Journal of the Medical Sciences, N. S., vol. iii. p. 77. 284 scurvy. United States forces 1 also suffered to some extent in the Florida and Mexican wars. Among the troops in Texas, between the years 1849 and 1854, of an aggregate force of 4450, 510 cases of scurvy occurred, of which three proved fatal. The disease was due to the frequent movements of the troops, and to the fact that the sandy and sterile nature of the soil in the vicinity of some of the posts offered insurmountable obstacles to the cultivation of gardens. The disease also prevailed at posts in the northwestern territory. Dr. Day remarks that during the winter of 1848-49, the disease appeared among the Indians. Their diet was poor and insufficient, but the scorbutic tendency among them was not nearly as great as among the whites ; their powers of digestion and assimilation (when they have anything to digest and assimi- late) being certainly better than those of almost any other people. Dr. Coale 2 reports the occurrence of scurvy in 1838, among the crew of the United States ship Columbus, in a cruise around the world. The ship left Norfolk, Virginia, in January, 1838, with a crew broken down in health, and, after leaving Rio, smallpox ran through the vessel. Off the Cape of Good Hope, a few weeks later, during a spell of cold weather in which the decks were almost continually kept wet, the first cases of scurvy appeared ; and others continued to appear until January, when the ship reached the East Indies, where dysentery first, and afterwards diarrhoea, were added to the miseries of the crew. Dr. Coale remarks that the most fatal cases occurred among the most vigorous men ; there were three cases of lryctalopia. The provisions served out contained Only the ordinary navy ration, defective in fresh vege- tables. Dr. Foltz 3 gives the history of an outbreak of scurvy in the United States squadron cruising in the Gulf of Mexico, during the summer of 1846. On board the Potomac, with a crew of 500 souls, 350 were disabled, and symp- toms of the disease were present in most of those who remained on duty. The other ships suffered to a greater or less extent, particularly those that had been long in commission in the West Indies. The Mississippi, a steamer, made short passages at sea, and the crew, being enabled to procure fresh vege- tables, suffered only to a trifling extent. In the British Navy, 4 between the years 1837 and 1843, there were 93 cases of scurvy returned from the East India squadron, 5 from the east coast of Africa, 13 from the West Indies, and for the other squadrons a still smaller number. Since that time the disease has had but a nominal existence. The allied armies of England, 5 France, Sardinia and Turkey, during the Crimean war of 1854-56, underwent hardship and suffering of the most aggravated description, from vicissitudes of weather, physical fatigue, and deprivation of wholesome food and vegetables. The result was that in the British army there were reported during the whole period, 2096 cases of frankly expressed scurvy, while the taint was widespread, complicating other diseases, such as diarrhoea, dysentery, and malarial fevers, and greatly exagge- rating their mortality, especially during the first six months of the siege. Of the total number, 178, or 8.4 percent., died, the mortality having been almost entirely confined to the winter and spring of 1854-5. The disease began in October, 1854, gradually increasing during the following year, 1855, and in February reached its height, viz., 641 admissions. From this time it gradu- ally subsided, so thai by August the admissions were only three. In Septem- ber of the same year it again increased, until January, 1856, when it reached its maximum, and then again it rapidly declined. The increased and • Statistical Report of the U. B. Army, 1839-54, p. 369. 2 Americas Journal of the Medical Sciences, N. S., vol. iii. p. G8. 3 Ibid., p. 59. * Statistical Report of the Health of the Navy. 5 Medical and Surgical History of the British Army, 1854-50". ETIOLOGY OF SCURVY. 285 decreased prevalence noted, exactly accorded with the character of the food supply as to quality and quantity. In the early part of the war, this was of the most wretched kind ; afterwards the greatest improvements were made, and with the most satisfactory results. The French fared even worse than the English forces, as regarded their supplies, and the consequence was the rapid appearance of the disease, so that 20,000 cases were reported ; yet for the month of February, 1855, fresh meat of good quality, though lean, was issued, at first twice and afterwards five times a week ; there was an irregular supply of bread, but rice was occasionally allowed, with dried vegetables such as peas and beans. With the opening of spring and the growth of vegeta- tion, especially dandelion, which the men procured for food, the disease abated only to be renewed in the following July, when the hot, dry weather destroyed the greens attainable earlier in the year. The Sardinian and Turkish forces suffered, if anything, still more severely than their English and French allies. During the war of the Rebellion, 1861-65, both the United States and the Confederate forces occasionally suffered from scurvy, or from its influence in other diseases. The cases of scurvy occurring in the various naval services, are isolated and infrequent, in consequence of the rigid hygienic measures now adopted. It has not been banished from the mercantile marine as it should be, yet the condition of the men in this service has been greatly improved by wise legal enactments. Since the passage of the Shipment Act, in Great Britain, in 1867, scurvy has decreased about 70 per cent. The "Dreadnought" Hos- pital-ship 1 still continues to receive annually an average of 90 cases, or about one twenty-fifth of all the cases admitted, due to the issue of improper food, or of rations defective in vegetable matter and acid juices. According to the report 2 of the U. S. Marine Hospital Service, there were admitted in 1873, 47 cases; in 1874, 59 cases; and in 1875, 25 cases; an average of nearly 44 for each of those years. The latest record of the general occurrence of scurvy was during the siege of Paris by the Germans, in 1872, from the usual cause — food deficient in fresh vegetable material. Etiology of Scurvy. Scurvy has no geographical limitation. It has prevailed in the extreme high latitudes of both the northern and southern frigid zones, on vessels engaged in arctic explorations, and among the native Laplanders and Esquimaux; almost everywhere within the temperate zones, m the eastern and western continents ; and on numerous occasions both ashore and afloat in torrid re- gions 3 of the equator. It affects alike all races, the Caucasian, Malay, Negro, and Indian. Xor has it been confined to mankind, for at least one authentic case has been recorded by Berenger-Feraud, 4 of a Gorilla having suffered from scurvy. All classes of society, rich and poor, high and low, are equally liable, whenever surrounded by circumstances that preclude the attainment of the requisite nutriment. The disease has been observed at all ages from infancy to senescence ; the orphan asylum at Moscow was invaded, alike with the asylum for the aged at Christiania. The crews of affected ships, and the forces holding besieged towns or fortresses, have suffered without regard to age. In epidemics, and 1 Scurvy in Merchant Ships, 1865. 2 Report of Supervising Surgeon-General, U. S. Marine Hospital Service, 1876. 3 The seasons exercise no control over the occurrence of the disease other than that arising tVoin their influence upon the growth of vegetation and upon human health, through the physical qualities of heat, cold, and dampness. Of the 68 epidemics, referred to by Hirsch, in which the season was noticed, 37 occurred in spring, 21 in winter, 8 in summer, and 2 in autumn. 4 Comptes Rendus, 1S58. 286 scurvy. principally in those occurring during famines, observations have been made which seem to indicate a partiality of the disease to attack adults. Curran says that in all of his cases during the Irish famine, the age of the patients exceeded eighteen years, whilst at least two-thirds of the patients were beyond the middle period of life ;* a circumstance that might easily be explained by the difference in the degrees of exposure, at different ages, to the determining causes of the disease. Nor would the youthful portion of a community be apt to be exposed in the same degree to the disturbing influences of tempestuous weather, exhausting labors, and depressing emotions. Old age brings with it mal-nutrition and debility that invite the speedy invasion of morbific causes. Sex cannot be accused of any predisposing influence : statistical returns will, of course, show an excess of males, for the reason that they are more often under those conditions which determine the disease. It has occasionally hap- pened, however, that more women than men have been attacked, as in the epidemic of 1813 in Southeastern Hungary; and in Croatia, in 1707, women only were affected. In the Irish famine, the proportion was about eleven males to one female. It has been surmised that a low temperature, particularly when associated with dampness, fatigue, and mental depression, was a powerfully predisposing cause, if it did not actually originate the disease. M. Scoutetten, 2 in a com- munication to the Aeademie de Medecine on the epidemic at Giret, insisted upon these influences as all-powerful — an opinion which seemed to be sus- tained by the Academy. The Austrian war ship Xovara, in her passage from Madras to Singapore, although, it is represented, abundantly supplied with fresh vegetables and acid fruit, was invaded bj r scurvy. The disease also oc- curred at Rastadt, 3 among the Austrian troops, when, according to Opitz,the only assignable causes were dampness and cold, the food not being defective in fresh vegetables. So, at Ingolstadt, the French prisoners in 1871 suffered, although abundantly supplied with potatoes and meat. In opposition to these views, it may be stated that the hottest and driest parts of the earth, as in India, the West Indies, and the interior of Africa, have been the scenes of as destructive outbreaks as those regions where the reverse conditions hold good. The greatest hardships have been undergone, without the slightest evidence of scorbutic taint affecting the sufferers, as long as proper alimentation could be maintained. On the other hand, inactivity lias been regarded as a predis- posing cause, and the alleged greater frequency of the disease among marines and skulkers of war ships, than among the seamen, is said erroneously to be due to this cause. Depressing emotions, fear, anxiety, despair, etc., have been said to be able to determine the disease, and those of a reverse character to be able to check its progress ; and our credulity is not a little taxed when we read the statement of Lind', that he has seen the scurvy, very prevalent and increasing in the fleet, at once arrested and quickly got rid of by the news of a successful engagement, <>r even the anticipation of one; or, more apochryphal still, the story of the Prince of Orange having arrested the disease by distributing a little colored water which was believed by the soldiers to be a wonderful and most expensive elixir. Monneret, 4 Fleury,and Papavoine, 6 have even asserted that they have seen scurvy result from mental influences alone in isolated eases. 1 Dublin Quarterly Journal of Med. Science, 1847. 4 Gazette MSdicale de Paris, Juillet, 1847. n Vierteljahrsselirift fur die praktisohu Heilkunde, Bd. i. S. 114. 4 Compend. de M6d., t. vii. p. 507. 5 Journal llebdom., t. ix. p. 321. ETIOLOGY OF SCURVY. 287 Foul air has no influence in determining the occurrence of scurvy, except in a general way by lessoning the vital resistance, and thus hastening and in- tensifying the symptoms of this, as of any other disease depending upon a specific cause. Personal tilth and foulness of the surroundings Lave also been erroneously held responsible for a share in its production. Even the pure air of the sea was at one time thought to be influential in exciting the disease, though little reflection was necessary to dispel this absurd notion. Scurvy has raged in inland towns and on fresh water courses, far away from the in- fluences of a marine atmosphere. The opinion was even held that the cir- cumstance of locality determined a difference in the nature of the disease, and hence the origin of the terms land scurvy and sea scurvy; whereas the fact is that there is no more pathological difference in these cases than there is in cases of pneumonia or typhoid fever occurring on shore and at sea. This view has been well nigh abandoned, though, as late as 1856, Dr. Crawford 1 emitted the same notion in relating his experience in the Crimea. He states that scurvy seldom exhibited there the characteristic features so often ob- served at sea, viz., the ulcerated and gangrenous gums, tailing out of the teeth, abscesses and sloughing ulcers, contraction of the limbs, visceral effusions, syncope, and sudden death ; and adds that it would seem probable that the difference between land and sea scurvy was physiologically connected with the existence of diarrhoea and dysentery in the one case, and their absence in the other ; the affection as observed at sea being usually attended with a torpid or at least irregular state of the bowels. This opinion is erroneous. In certain instances, the occurrence of scurvy has been supposed to be due to the use of impure water, as in the case of Ranke's expedition to the interior of Australia. There were two parties: one, thoroughly ecpiipped and pro- visioned, suffered for the want of abundant potable water, and was attacked with the disease; the other, less advantageously placed as regarded food and provisions, got all the pure water that they needed, and escaped. Other parallel cases are recorded, but they are entirely negative from the lack of certainty as to the exact nature of the food consumed. The more fortunate of Ranke's party may have partaken of succulent plants or esculent roots picked up on the journey. The various above-mentioned influences, whether ashore or afloat, are capable of deteriorating the nutrition of the body, and may in this way with truth be chargeable with promoting, under peculiar dietetic irregularities, the advent of an outbreak ; but neither singly nor com- binedly can they determine it without this concomitant. Individual peculiarities as to constitutional power and vital activity, exert a marked influence ; those of a weakly habit of body, either original or pro- duced by accidental attacks of disease, are more liable than those in robust, vigorous health. Persons also who have been overworked or exhausted by excessive climatic influences, whether of heat or cold, more readily succumb. This was seen in the case of two ships of the United States, serving in the Gulf of Mexico : the " Raritan," coming from the coast of Brazil, had a crew enfeebled by long service in a hot climate, while that of the "Falmouth"' was worn out by exposure to the cold, wet and boisterous weather of the northern coast of America, on which she had been serving. Both of these vessels suffered severely. In the same way, the deterioration of the vital powers brought about by an arctic voyage and a winter's residence in high latitudes, renders the men exceedingly liable in presence of the exciting cause of scurvy, and more so than those who are freshly arrived. There is no such tiling as inuring the system to the unnatural surroundings of the arctic regions ; the longer the residence there, the more likely the disease is to occur. This state- 1 Med. and Surg. History of the British Army, 1S54-56. 288 scurvy. ment is based upon experience, and readily commends itself to the judgment when the immense importance of sunlight upon the nutrition of the entire organic world is considered. One attack of scurvy confers upon its victim no exemption ; on the contrary, it renders a second more probable, other circum- stances being equal. The frequent association of the scorbutic, with other pathological con- ditions, is well known, and doubtless forms one of the chief reasons why the early descriptions of the disease were so inaccurate, the complicating affections having being included in them. A frequent combination is with malarial disease, and it is easily appreciated that the slow and profound alterations induced in the blood by this miasm are well calculated to hasten the develop- ment of scurvy. The same influence is exerted by diarrhoea, dysentery, syphilis, hemorrhages, exhausting discharges, and the debility arising from prolonged suffering from wounds and injuries. In fact, any cause whatever that lowers the tone of the system and impairs nutrition, may be considered among the category of predisposing causes. It will be only necessary, in passing, to notice the fanciful idea of Travis, 1 that the use of copper vessels in the navy was a principal cause of scurvy ; or that of Harvey, 2 who attributed it to gluttony or debauchery ; or that of Maynwaringe, 3 that it was due to tobacco and excessive venery ; or that of "Willis, 4 who found its cause in the increasing consumption of sugar. The evident connection between the character of the food supply and the occurrence of scurvy, attracted the attention of early observers, particularly Wierus and Echthius, who placed the cause entirely in errors of diet. This was the opinion also of Bachstrom, who published an essay on scurvy in 1734, in which he took the ground that abstinence from fresh vegetables was abso- lutely the cause of the disease, an opinion which was shared by other writers of experience, such as Eouppe 5 and Trotter. 6 This view has largely prevailed, and is now that which is accepted by most physicians. In 1847, Dr. Christi- son, 7 of Edinburgh, in a paper on the subject, attributed the prevalence of scurvy at Perth to deficiency in the quantity of azotized aliment and conse- quent insufficient nourishment of the body, and asserted his belief that milk, which supplied this deficiency, was an antidote for the disease. This theory, though ingeniously argued, is unsupported by facts ; thus, for instance, in the north of Wales, where fresh meats and milk are abundant, and where the cottagers raise little or no garden produce, cases of scurvy appear every year; and, indeed, the whole history of the disease is at variance with this theory. The habitual use of salted meats on ship-board, drew attention, naturally enough, to the causative relation of this sort of food, and not a few of the earlier observers have recorded their belief that it was the chief, if not the only, cause of scorbutic outbreaks. This statement has no foundation, how- ever, for the very worst epidemics of the disease have occurred at sea, when fresh animal food has been abundant, and in communities on shore who never employ salt provisions of any sort in their diet. The disease will undoubtedly appear more speedily in those living on salt, than in those living on fresh, animal food ; but from the mere fact that the nourishing power of the latter has been Impaired by the removal to a greater or less extent of its albuminoid constituents in the salting process, and that, as a consequence, it possesses less power in sustaining the body. The withdrawal of both sorts of animal food would still more speedily, for the same reason, lead to the appearance of the disease. That sail in itself is impotent as a causative influence, is further 1 Mill. Obs. and Inquiries. London, vol. ii., 1762. 2 Tlio Diseases of London. 3 Morbus polyrrhizos. 4 Tractatus de scorlmto. 6 D« nii'il. is navigantium, 1704. 6 Observations on the Scurvy, 1792. ' Monthly Journal of Medical Science, 1847. ETIOLOGY OF SCURVY. 289 shown by the fact that large quantities of it may be given, as was done by Sir G. Blane, in scorbutic cases, without apparent deleterious effects. Simple deficiency in the quantity of the food also, it has been alleged, plays the most important role in the causation of the disease, and its prevalence during famines has been cited in evidence of the truth of this assertion. The fact is quite familiar, however, that scurvy is far from being an invariable accompani- ment of famine, nor does it affect men on long cruises, or those shut up in besieged towns, when simply on short rations. The quality of the food has as little influence as lack of quantity in pro- ducing the disease. Mouldy biscuit, and spoiled or even putrid meats, have been subsisted upon for long periods, and though the health has been thereby greatly impaired, no scorbutic condition has been produced. From all the facts, both positive and negative, we may reasonably assume that the essential dietetic error leading to the development of scurvy, in the immense majority if not in all cases, consists in a deficiency in the variety of food ; that is to say, that there is not the requisite proportion of animal mat- ter with a diversity of vegetable substances. No single natural order contains plants that supply all the substances essential to the nutrition of the body and right composition of the blood; the graminaceous and leguminous articles of food, for instance, are numerous but not various; they all afford the same or analogous albuminous elements which have about the same nutrient value aa the corresponding substances in animal food ; and hence health and vigor cannot be sustained on a diet of animal flesh, combined with wheat, rice., and oat-meal, or with beans and peas, or with all of these together. Outbreaks of scurvy have occurred on ship-board where the ration is made up princi- pally of these articles, as on Anson's ships when supplied with an abundance of fresh animal, farinaceous, and leguminous foods. In the epidemic that occurred at Carlisle and its vicinity, according to Dr. Lonsdale, 1 some of the railway excavators were affected, though they breakfasted off of beefsteaks or mutton chops, and partook of dinners composed of bread, boiled beef or bacon, pea-soup or broth, and suet puddings containing currants ; but there were no potatoes nor fresh vegetables. It is clear therefore, that, in order to obtain the proper variety of materials required in nutrition, we must resort to several of the natural groups — those particularly which comprise the succu- lent vegetables and fruits. What is the precise nature of the materials furnished by these latter, yet remains to be determined. Acid fruits, such as oranges, lemons, limes, etc., stand pre-eminent as antiscorbutics, and this fact led to the conclusion that their utility depended upon the vegetable acids which they contained, and the use of the latter in scurvy has been followed with a certain degree of success. Experience has shown, however, that the fresh juices and pulp of these arti- cles, particularly when green, are more decidedly antiscorbutic than the same materials when prepared by the various methods of drying, cooking, and preserving, or than their vegetable acids. The influence of these agents in warding off or curing scurvy, may be of a catalytic nature, fitting by their presence the organic matter otherwise injurious or defective, for nutrition, in the same manner for instance as sodium chloride, which does not participate essentially by its elements in the formation of the solids and semi-solids of the body, yet is indispensable in the fixation of new proximate principles in those tissues. Dr. Aldridge 2 held that the cause of scurvy was a deficiency in the supply of mineral matter, phosphorus, sulphur, lime, potassa, and soda ; the daily 1 Monthly Journal of Medical Science, Aug. 1847. s Value of Food, Dublin, 1847. VOL. I. — 19 290 SCURVY. waste of sulphur is calculated to be about 20 grains, and that of potassa and soda 80 grains in an adult of 150 lbs. (10 stone) weight. The quantity of cereals that would supply the waste of other elements of the body during a single day, can supply only 17 grains of sulphur and 43 grains of the alkalies; and a similar amount of leguminous material would give only 11 grains of sulphur and 55 of the alkalies. Succulent vegetables, on the other hand, while deficient in nitrogen and the other elements, contain mineral matter in abundance. The potato contains both organic and inorganic principles in just proportion to compensate for the necessary waste. Dr. Garrod, 1 of Edin- burgh, upon the strength of one inconclusive blood analysis, declared that scurvy was caused by the use of food deficient in the potassium salts, the essen- tial change in the blood in that disease being brought about by the insufficient supply of these salts. Neither of these views, though ingenious and plausible, has received the confirmation of scientific research. Some of the old writers, Sennertus, 2 Charleton, 3 and Hoffmann, 4 from observ- ing the wide-spread character of the disease, its destructive effects and exten- sion in communities and aggregations of individuals, and its seizure of nursing infants, adopted the idea that it was contagious, or of a miasmatic character, depending upon a specific poison, just as syphilis, smallpox, or malarial diseases. M. Villemin, 5 in August, 1874, presented to the Academy of Medi- cine at Paris, a memoir in which he endeavored to sustain the theory that scurvy was "une maladie endemo-epidemique, contagieuse, analogue au typhus, a la peste, et resultant d'un miasme particulier." Rottwil 6 has also expressed similar views. Morbid Anatomy of Scurvy. After death, the body of a patient dead of scurvy presents slight evidence of rigor mortis, and is generally emaciated, especially when little food has been attainable, or when from the condition of the gums and teeth it could not be masticated and swallowed. Under reverse circumstances the body may retain its rotundity and fulness. It is prone to rapid decomposition, and the skin is of a dirty-yellowish or clay color, dry and parchment-like, more or less scaly and rough, and marked by bluish or livid spots of the most varying size and figure. The small and round spots located at the roots of the hair, from one to two lines in diameter, are caused by blood extravasated from the vascular network around the hair follicles, beneath the cuticle. The larger and more irregular discolorations are located in the deeper layers of the cutis. The subcutaneous connective tissue is more or less ocdematous and infiltrated with blood, or fibrinous material tinged with blood. The bloody extravasations form swellings of a doughy feel, without well-defined limita- tions, unless circumscribed by resisting fasciae ; the fibrinous effusions, on the other hand, present themselves as layers from one to two lines in thickness, at first gelatinous and of a pale yellow color, but subsequently assuming a higher organization, becoming vascular, of a bright yellowish-red color, firm and even elastic to the led, and with clearly defined outlines. The material be- comes so intimately Mended with the connective tissue as to destroy all appearance of its fibrillary structure. These appearances also occur in the connective t issue of the muscles, and beneath the fascia? forming their sheaths, lacerating their fibres or softening them to such a degree that they easily 1 Monthly Journal of Med. Science, 1848. 2 Med. pract., lit), iii. pars v. sec. ii. cap. Hi. * De scorbato, L672. * Medicina rationalis systematica, 1739. 6 Archives Gun. de Medecine, t. ii. 1874. 6 Nassauischen Jahrbucher, Bd. xvi. s. 740. MORBID ANATOMY OF SCURVY. 291 break down between the fingers. These deposits most commonly show them- selves about the muscles of the hams, but are occasionally found in the recti and pectoral muscles of the trunk, or about the elbows, and beneath the pterygoid muscles of the face. In the severest forms of the disease, effusions occur beneath the periosteum, forming nodes of more or less firmness, which may lead to necrosis of the bone. The joints are the seat of serous, and occasionally of sanguineous, effusions; the synovial membranes have been found eroded, the articular cartilages soft- ened and separated from their subjacent connections, and even, in extreme cases, the bone itself may be softened and infiltrated with blood. The joints may also be secondarily involved by changes going on in the surrounding con- nective tissue. Morbid changes frequently occur in the serous membranes^ The pericardium usually contains a little clear serosity ; not infrequently its surface is softened, and its tissue easily lacerable, or, as in some cases, inflamed and the seat of considerable hemorrhagic effusion. The pleural cavities often contain serous fluid, and are sometimes the seat of copious bloody effusions ; their walls are tinged with ecchymotic discoloration, and show indications of inflammatory action. The most constant, indeed ever-present, changes, are found in the mouth, and constitute what is known as scorbutic stomatitis. The gums are livid and swollen, and separated from the teeth, which they wholly or partially conceal in their fungoid exuberance; they display an advanced stage of fatty degene- ration, the tissue under the microscope presenting an abundant epithelial proliferation, and an enormous production of fatty globules. The teeth them- selves are either loosened, or have already fallen out. The nasal, pharyngeal, laryngeal and bronchial mucous membranes are generally pale, and marked with flecks of dark red color, and there is present more or less bloody, turbid fluid. (Edema of the glottis is occasionally met with. The nervous system is perhaps least frequently affected, yet, occasionally, the ventricles of the brain, when opened, reveal the presence of serous or sanguino- serous fluid, and similar fluids are more often found in the arachnoid. The brain itself is usually pale in color, and its vessels collapsed and empty. On the other hand, some cases display a different state of things ; the brain is engorged with blood, and is the seat of extravasation, and in rare cases of softening. The heart is found relaxed and flabby ; its tissue lacerable and atrophied ; its cavities quite empty in some cases, and in others filled with dark fluid blood. The semilunar valves lose their elasticity and fail to close the orifices accurately, so that water injected by the aorta runs freeh* into the left ventri- cle. The cardiac walls present a yellowish tint on section, and are often the seat of effusions. In cases in which the disease has been of short duration, the blood is of a dark color, sometimes fluid or loosely coagulated, while at other times it is very firmly clotted; in prolonged cases, on the other hand, the blood is usually of a lighter color, and more uniformly fluid, yet firm coagula are by no means uncommon in these cases, as noticed by Rouppe, Audral, 1 Fauvel, and others. The older coagula are thick, elastic, and closely adherent to the inner surface of the heart, but gradually merge into more recent, looser, and reddish depositions. The tissue of the heart becomes altered, the muscular fibres undergoing granular and fatty degeneration, so that at points the sarcous elements are entirely replaced by the new material. The endocardium and the inner surface of the great vessels show the evidences of sanguineous imbibition. The arterial and 'capillary walls exhibit no signs of marked change ; Lasegue and Le G-roux examined the capillaries in several 1 Archives Geuerales de Medecine, 1847. 292 scurvy. cases of scurvy which proved fatal in the siege of Paris in 1871, and found nothing, with the exception of scattered fatty granulations in their walls. 1 Analogous changes to those found in the cardiac muscles, also occur in the muscular structures of other localities. According to Leven, 2 the first muscles to undergo fatty degeneration are those of the loins ; in one of his cases, the fibres of the sacro-lumbar muscles had completely lost their striation, and the sarcolemma had in great part disappeared ; there remained widely separated, longitudinal lines, with the intervals crowded with granular and fatty matter. The muscles of the calf of the leg showed the same advanced changes, while those of the thigh were less altered. The lungs present as varying changes as those in the heart, They may be collapsed and bloodless, but as a rule are infiltrated with bloody serosity, particularly in those cases which during life showed large amounts of albumen in the urine ; ecchymoses on the surface of the lungs are not uncommon, and they are usually quite superficial. The posterior portions of these organs often show indications of hypostatic congestion or hepatization, and occasion- ally of gangrene. In the latter case, the gangrenous tissue breaks down easily under the linger into a pulp which emits an offensive odor. A fibrinous and bloody exudation is also found in various parts of the lungs, chiefly interiorly and posteriorly. The bronchial mucous membrane is more or less maculated, and contains a bloody mucosity ; and the same is true of the trachea, and larynx. The digestive system is seldom or never free from post-mortem changes. The mucous membrane of the stomach and small intestine is often softened and thickened ; in places ulcerated, even to the depth of the muscular layers, the edges of the ulcers being everted and infiltrated with blood ; and Dr. Ritchie finds the solitary glands in the lower part of the ileum enlarged. Similar lesions are found in the large intestines, and in some places, beneath a dark- red, pulpy material, easily removable by wiping, the subjacent tissues are found softened, infiltrated, or even destroyed. In other cases extensive folli- cular ulceration is seen, of a rounded shape, and with infiltrated borders. The entire length of the gastro-intestinal mucous membrane is more or less stippled with sanguineous effusions, varying from a pink to a blackish-green tinge, and blood in greater or less quantity is poured out into the canal. The liver always presents more or less evidence of fatty degeneration ; it is sometimes enlarged, gorged with dark blood, and softened, with its surface marked with spots of hemorrhagic infiltrations. The spleen is occasionally found of greater magnitude than natural, filled with grumous blood, its surface discolored, and its structure lacerable. Or it may be the seat of wedge-shaped infarctions. Vernette found the spleen enlarged in only 8 out of 500 cases of scurvy. The pancreas presents also occasional evidence of hemorrhagic effusion and softening. The kidneys, although there may have been albumen in the urine during life, are usually found unaltered. Dr. Ilimmelstiern has observed, in a few cases, a yellowish-red layer upon the mucous membrane of the pelves and ureters,and Heyfelder reports Laving found the kidneys engorged with blood, and the lining' membrane of the pelves, ureters, and bladder, here and there covered with bloody mums. In those eases in which the urine during life had contained large quantities of albumen, and which had been complicated with dropsy, the kidneys presented the ordinary parenchymatous degenera- tions found' in Bright's disease. Opitz, in prolonged eases of scurvy ,_ has seen atrophy of the kidneys. The renal capsule is ecchymosed at points, and Cajka has reported in some cases the presence of small infarctions in the cor- 1 Archives Gen. de MSdecine, Dec. 1871. 2 Leven, Une epidemic de Seorbut, 1862. PATHOLOGY OF SCURVY. 293 tical substance, and less often in the deeper structures. The pelvic, ureteric, and vesical mucous membranes present not infrequently spots of hemorrhagic discoloration, as well as of softening and erosion, and the contained urine is tinged with blood. Pathology of Scurvy. Hoffman, Boerhave, Huxham, Lind, and many others of the older obser- vers, recorded their opinion that in the blood were to be sought the essential changes upon which the scorbutic phenomena depended, and they generally considered the nature of these changes to consist in a breaking down of the blood-corpuscles, or a dissolved condition of the blood, which in turn led to the sanguineous effusions so common in scurvy ; a theory that had currency for many years, until chemical research finally dissipated the unfounded assertions on which it was based, and led to the establishment of more correct views. We still, however, have to deplore the fact that though much error has thus been removed, yet few new truths have been established by these investigations. The analyses are, as yet, too discrepant and too few in num- ber to determine with precision the exact nature of the chemical alterations in the blood. The disease has happily become so infrequent that few oppor- tunities now present themselves for chemical examination, and rarely can the quantity of blood necessary for the purpose be obtained, with safety, by venesection, in this class of patients. The want of uniformity, and the diffi- culties inherent to the process, as well as the varying conditions under which the analyses have been made, have contributed in no small degree to the dis- crepant results which have hitherto been obtained. The frequent effusions of blood in scurvy led Andral to suspect that the chief factor in scorbutic blood was the decrease of fibrin^ which was in per- fect accord with a theory that he had formed that this change was the uniform cause of passive hemorrhage. Magendie had already given experimental support to this conjecture, by inducing in animals phenomena analogous to those of scurvy, by the injection into the veins of defibrinated blood, or alkaline solutions. Andral 1 believed his views confirmed when in 1841 he analyzed on two occasions the blood of scorbutic patients, and found the fibrin reduced to 1.6 parts per thousand. Similar results were obtained by Eckstein and Fremy. On the other hand, the blood was analyzed by Mr. Busk, about the same time, in three well- marked cases of scurvy that occurred on the "Dreadnought" Hospital-ship, and in all of them the fibrin was in excess of the normal amount, the least being 4.5, and the greatest 6.5 parts per thousand. In perfect accord with Busk's results, were the analyses of the blood of five scorbutic females, communicated in a note to the Academy of Sciences, in 1847, by Becquerel and Rodier. In no ease was the fibrin diminished, but in some it was sensibly increased. In a subsequent case, Andral found that the fibrin, instead of being less, exceeded the physiological mean, reaching 4.4 parts, and he concluded that a diminu- tion of this element was not a necessary and constant occurrence, but only an effect, a result of prior morbid modifications, and a consequence which was produced more or less frequently according to the severity and duration of the disease. Parmentier and Deyeux found the blood of three scorbutics to resemble inflammatory blood, in respect to fibrin, while Frick obtained in one analysis 7.6 parts of fibrin, and Leven 4.3 parts. In mild cases of scurvy, neither the color, the alkalinity, nor the coagula- Essai d'hematologie pathologique. 294 scurvy. bility of the blood differs from that of blood in health, though "Wood alleges that the clot is loose and cotton-like, and Canstatt that its coagulability, in consequence of the large proportion of saline matters, is diminished. In Busk's cases, the separation of the clot and serum was as perfect, and took place as rapidly, as in healthy blood, and in two of them the blood was both buffed and cupped, as it was also in Leven's cases. In two of the most severe of Becquerel's cases the blood coagulated firmly, and in a slight case the clot was dark and loose. The albumen of the blood shows no marked change as regards its quantity. The five analyses of Becquerel and Rodier showed the average amount of organic matters of the serum to be 64.3 parts in a thousand, the smallest being 56.2 and the largest 69.2 parts. One thousand parts of the serum of the same cases gave an average of 72.1 parts of organic matter. Trick's single case gave 87.045 parts per thousand, and the average of Busk's was 78.2 parts, while Chotin and Bouvier obtained only 62.3 parts. The last-mentioned writers have recorded a fact in connection with the physical characters of scorbutic blood that deserves notice: the blood in one case did not coagulate at the usual temperature— about 158° F. — but required a tem- perature some degrees higher for that purpose. The red corpuscles in all the foregoing cases were notably diminished, the largest amount given being 117.078 parts per thousand, while the lowest was 47.8 parts. In Andral's second case the globules had decreased to 44.4 parts per thousand, the lowest amount yet recorded. The alkalinity of the blood seems not to be changed, although Chotin and Bouvier notice a slight increase. The saline constituents do not vary greatly from the normal standard. The average amount in Becquerel and Rodier's, and Busk's, cases was 8.1 parts per thousand, the smallest being 5.5 parts and the largest 11.5. In Dr. Ritchie's two analyses, the proportion of saline matters is given as 6.44 and 6.82 parts per thousand. Opitz and Schneider have found less than the physiological mean. In Frick's case the amount was 8.8, the iron being 0.721 parts per thousand, and 0.782 to 127 parts of globules ; lime 0.110, chlorides 6.846, and phosphates 1.116 parts per thou- sand. The iron was in excess of that in the normal blood, but in Becquerel's cases the mean was 0.381 — less than the normal. The proportion of iron in Duchek's cases was respectively 0.393, 0.402, and 0.476 parts, giving a mean of 0.423 parts per thousand, which nearly approximates the normal. Garrod in one analysis of the blood found a deficiency of the potassium salts, upon which he erected his well-known theory of the etiology of the disease. It is an interesting fact that in the physiological state the quantity of sodium chloride is not subject to variation, any excess introduced with the food being thrown off by the kidneys. The quantity in the urine bears a relation to the amount introduced as food, but the proportion in the blood is constant. The quantity of water in the blood has been found to be increased in all the analyses which have been made. Chotin and Bouvier estimated water and loss at 831.1 ; in Frick's case it was 791.69 parts per thousand ; and in Becquerel's five cases it was put at 807.7, 810.9, 811, 813.7, and 854.0 parts per thousand respectively. In Busk's three cases the lowest amount Avas 835.9, and the highest S49.9 parts per thousand. The specific gravity of the defibrinated blood was in all cases low in comparison with the normal stan- dard, 1057, the average in Becquerel and Rodier's cases being 1047.2, the lowesl 1038.8, and the highest 1051.7. In the single observation of Chotin ainl Bouvier it Avas 1060. The specific gravity of the serum was also less than normal d 027), the average of lour of Becquerel's analyst's giving 1023.8, the lowesl 102H. s and the highest 1025.5. Busk gives 1025 in one case and 1028 in another. The results of the most recent analyses, those of Chalvet, are shown in the SYMPTOMS OF SCURVY. 295 following table, in which scorbutic blood is contrasted with that of a healthy robust female : — Scorbutic Blood. Healthy Blood. Water 848.492 779.225 Solid matters 151.508 220.775 Dry clot 140.194 209.000 Albumen 72.304 68.717 Fibrin 4.342 2.162 Globules 63.548 138.121 Extractive matter — by absolute alcohol . 10.312 8.013 by ether . . . 1.002 1.300 Ashes of clot 3.000 5.691 Peroxide of iron of globules . . 1.060 2.259 Potassium of globules . 0.329 0.625 From the conflicting statements of the various observers, the following conclusions may be formed : That in scorbutic blood, water is in excess ; that there is on the one hand a marked increase of the fibrin, and in a less degree of the albumen and extractive matters, while on the other hand there is a marked decrease of the globules, and in a less degree of the mineral matters. On the authority of Chalvet, it may also be stated that demineralization of the muscular tissue is a notable chemical feature in scurvy. So far, microscopic examination has been entirely negative. Hay em 1 found no appreciable alteration from healthy blood, and in this view Leven 2 concurs ; while Laboulbene 3 notes the occurrence of an unusual number of white globules. Symptoms of Scurvy. The symptoms of scurvy are insidiously, and usually slowly, developed under the influence of the efficient causes, and it runs a chronic course, often extending over six or seven months, especially in cases in which the hygienic surroundings of the patient have been imperfectly or not at all rectified. In lighter cases this course is much shorter. A gradual alteration of the nutri- tive processes first occurs, until what might be called a scorbutic cachexia is established, in a period varying from a few weeks to several months. The initial symptoms consist in the skin losing its color and tone, and assuming a yellowish or earthy hue; it is relaxed, dry, unperspiring, and rough; in the legs, particularly, this roughness is very marked, and the skin, when rubbed, sheds an abundance of furfuraceous scales. The cutaneous follicles, markedly on the extensor aspect of the lower extremity, are prominent, similar in ap- pearance and feel to the condition known as "goose flesh." Kouppe 4 calls this the signum primum pathognomonicum. Dark-red or brownish flecks, of a circular outline, and of varying but small size, not unlike flea-bites, appear on the face and limbs. The cutaneous circulation is feeble, and the superfi- cial warmth less than natural; slight depression of the atmospheric tempera- ture produces a sensation of chilliness, and the feet and hands are cold. On assuming the erect posture, the patient complains of headache and dizziness. The muscles are relaxed, and soft to the feel, and a corresponding loss of vigor and strength is experienced by the patient, who is indisposed to exert himself in the performance of his customary duties, and seeks repose and freedom from feelings of fatigue and languor in recumbency. This prostration is occasionally so extreme that the slightest efforts in attempting to stand or walk are attended with rapid action of the heart, accelerated respiratory 1 Mem. de la Societe de Biologie. « Epidemie de Scorbut. 8 Communication to the Academie des Sciences, 1871. 4 De morbis navigantium. 296 scurvy. movements, and a sense of suffocation or breathlessness. The general circula- tion is impaired; the heart acts feebly; the arteries are contracted ; and the pulse is slow, small, and compressible. The mental powers are equally impaired. The face wears a haggard and depressed expression; gloomy forebodings of the future, and disinclination to turn the attention to the usual mental pursuits, are markedly present — a dis- inclination that subsequently merges into complete apathy or indifference to passing events, or even into somnolency. Pains in the legs, joints, and loins, are early manifestations; they closely resemble those of rheumatism, for which they are often mistaken. The pains are not exacerbated at night, but, on the contrary, are often more severe by day. Not unfrequently, lancinating pains in the muscles of the chest are complained of. The sleep is not disturbed until the disease has made some advance, when it becomes broken, and no longer refreshing. The appetite is usually unimpaired in the early periods of the disease, and even throughout its course, the condition of the mouth alone preventing the patient from in- dulging his desire for food, even, as is occasionally noticed, to voracity. There may be a yearning for certain articles of diet, principally those of an acid character; but, on the other hand, some cases present exactly the reverse condition — a disgust for food in general, or for particular varieties ; or the appetite may be vacillating, at one time craving, and at another repelling nourishment. There is no noticeable change in the normal thirst,* unless on the occurrence of febrile complications, when it is increased. The gums do not, at this stage of the disease, present the livid, swollen appearance of fully- developed scurvy, but, on the contrary, are generally paler than usual, with a slightly tumid or everted line on their free margins, and are slightly tender on pressure. The breath is commonly offensive, and the patient complains of a bad taste in the mouth. The tongue is flabby and large, though clean and pale, and the bowels are inclined to be sluggish. This preliminary state is followed, after varying intervals of time, by cer- tain local phenomena which are quite characteristic of the disease. There is a marked tendency to extravasation of blood into the tissues, either sponta- neously or upon the infliction of slight injuries or wounds. Fibrinous exuda- tions occur sooner or later into the gums, which become darkened in color, inflamed, swollen, spongy, and which bleed upon the slightest touch, finally separating from the teeth. These results are due in part to the considerable amount of pressure to which these parts are subject in mastication, and it is a conspicuous fact that the gums of edentulous jaws remain free from these changes. In a few cases the gums are but slightly altered, perhaps oedema- tons only, or jutting upon pressure ; or they become the site of bloody extra- vasations. In severer examples, in later stages of the disease, these various alterations progress to an extreme degree, and the extravasation is so volumi- nous that the gums present great, fungous, lacerable excrescences, which may finally break down into a suppurating, brownish, and very fetid mass, which communicates to the breath an odor of a most offensive character. The rest of the mucous membrane of the mouth remains unaltered, or at most slightly ecehymotic. Samson and Charpentier, 1 in a large number of cases saw this but once, and in one of Leven's 2 cases the fungous growth invaded the palatal mucous membrane, extending to the anterior pillars of the fauces. The sali- vary glands are enlarged and swollen; the tongue is imprinted with the form of I lie teeth, while (he latter become encrusted with tartar, and more or less concealed by the exuberant gums, or, becoming gradually loosened from the alveoli, finally drop out. The morbid process may even extend to the bone 1 Eturle sur le Scorbut, 1871. 2 Une 6pid£mie de Scorbut, p. 28, 1872. SYMPTOMS OF SCURVY. 297 itself, and necrosis and extensive exfoliation may follow. Mastication is more or less painful, and often impossible, so that the patient is reduced to the necessity of prolonging life by the use of fluid or semi-solid food. Under the influence of appropriate treatment, it is remarkable how rapidly (in from two to four weeks) these marked changes recede, and the parts resume their normal condition; yet it occasionally occurs that permanent, callous thicken- ing of the gums results. In the progress of the disease, effusions of blood under the skin are of early occurrence. They are at first located in the superficial stratum of the cutis, or just beneath the epidermis, especially around the roots of the hair; and present themselves as roundish, bluish-red fleeks, varying in size from that of a pin's-head to that of a split pea, not effaceable by pressure with the tip of the finger, but slightly, if at all, elevated above the surface, and enduring for weeks together. The nutrition of the hair-follicles is impaired, so that the hairs are often either lost, broken, or distorted. These petechias fade in color with progressive improvement in the case, and finally disappear, leaving behind brownish-yellow discolorations. They first appear in the extremities, particularly the lower limbs, then in the face, and lastly in the trunk. At a later period, extravasations of a larger size and more irregular form occur in the deeper layers of the derma. They vary in size from that of a finger-nail to blotches two or three inches in diameter; at first reddish in color, and subsequently of a bluish-red. When recession occurs, under appropriate treatment, the color passes through various shades of violet, blue, green, and yellow, as in ordinary traumatic ecchymoses. Outpourings of blood also occur into the subcutaneous connective tissue, notably that of the legs, and in localities where connective tissue is particularly abundant and loose, as in the ham and axilla. The dispersion of blood in this tissue may be so considerable as to cause the legs from the knees down to present a uniform, dark-blue coloration, that in form may not inaptly be compared to a stocking. The upper extremities also suffer, usually on their inner side, from the arm- pit down, the extravasation rarely reaching, however, to the hand. These extravasations take place also after the infliction of very slight injuries, as from blows, or the pressure of hard bodies, or even from the mechanical effects of prolonged dependency of the limbs, as in riding on horseback. Ex- travasations of a similar nature are occasionally present in the connect ive tissues of the muscles themselves, or between them, giving rise to swellings of various forms and dimensions. Nearly always, along with the sanguineous effusions, there is more or less oedema, usually beginning at the ankles, and gradually extending upwards ; in some cases, there are puffiness of the face and general anasarca, so that deep pits remain on pressure. This profound impairment of nutrition of the skin continuing, in the worst cases blood is effused beneath the cuticle, forming blebs of varying size, which finally break and leave superficial, ulcerated surfaces, which ultimately be- come covered with flabby, exuberant granulations, pouring out a purulent, often offensive sanies, and bleeding upon the slightest touch. In some cases the ulceration begins in the petechias at the hair-roots, and a number of these running together form a large ulcer. The destruction of tissue by ulceration is disposed to spread more widely and deeply, and is often of a most intractable character. Old cicatrices are the first tissues in these cases to take on the ulcerative action. Certain muscles, chiefly those of the legs, and notably the gastrocnemii, the abdominal and pectoral muscles, the psoas magnus, and the pterygoids, may become the seat of fibrinous extravasations, which finally change, by lapse of time, into hard, firm tumors, impairing the functions of those parts, and leading to contractions of the limbs. The symptoms in certain epidemics of extraordinary severity, have dis- 298 scurvy. played alterations in still deeper structures. Effusions occur between the ]n riosteum and the bone, forming painful, hard, and resisting nodes of vary- ing dimensions, especially along the course of the tibiae, upon the scapulae, and upon the maxillie. In young persons the epiphyses are separated from the shafts of the long bones, and in other cases the ribs become necrosed and disarticulated from the sternum, producing a creaking noise during respira- tory movements, as related by Poupart. 1 This occurs mostly on one side and about the middle of the series, yet it has been noted to occur on both sides, so that the sternum and attached cartilages, deprived of support, were perceptibly sunken. Recently repaired fractures have been known to recur under the influence of scurvy, from destruction of the callus. 2 The articula- tions as well as the bones in very severe cases of scurvy present evidences of disease, consisting in periarticular effusions which involve the surrounding soft parts, producing impairment of motion, enlargement, and false anchylosis, and even destroying the normal anatomical relation of the osseous surfaces so as to determine deformities. These changes are usually attended with severe pain, and most commonly occur in the ankle, knee, shoulder and hip joints, and disappear tardily, requiring perhaps months for their recession, if indeed this takes place at all. The symptoms manifested by the circulatory organs are prominent from an early period of the disease. The pulsations of the heart are slower, feebler, irregular, and often intermittent ; its impulse is decreased, or becomes quite imperceptible ; and when the associated anaemia has progressed to a certain extent, a systolic murmur may be audible. The arterial and venous channels are of diminished calibre ; the pulse becomes soft, of less volume, and tardier ; and a venous murmur may sometimes be heard in the cervical veins. The remarkable nutritive changes in the capillary walls, in part account for the numerous hemorrhages which occur both by rhexis and diapedesis. The most frequent is epistaxis ; the slightest blows, sneezing, or blowing the nose, will often determine it, or it may occur spontaneously, and in severer cases with such profuseness as to threaten impending dissolution, requiring nothing less than timeous introduction of the tampon to rescue the victim. Hemorrhage from the lungs is of rare occurrence, and when it does occur is rather indicative of pre-existing pulmonary disease, such as phthisis, or of the approach of a complication such as an infarction or gangrene, than a constituent feature of scurvy. ILematemesis is less uncommon, but is by no means frequent; the blood ejected from the stomach is usually limited in quantity, but in isolated examples the bleeding is profuse, producing great exhaustion and a sense of cardiac depression which preludes speedy death. Hemorrhage from the bowels is also an ill-omened feature, completely blanching the patient, and presaging early exhaustion and death. Blood may also appear as a product of a complicating dysentery which determines abundant, offensive discharges that may run on tor several weeks before the patient is finally exhausted. Hsematuria sometimes occurs, especially in broken-down and cachectic sub- jects, and in an advanced stage of scurvy. All of these forms of hemorrhagic effusion, now mentioned as localized in the mucous membranes, are to be deprecated as exercisinga pernicious influence, seriously aggravating ordinary cases, and fatally jeopardizing the issue of severe ones. Effusiveand inflammatory complications are also encountered in the serous Structures, and usually in eases of great severity, though they occasionally present themselves when the more common localized phenomena of scurvy are not particularly prominent. These complications may be marked by a 1 Memoires de L'Acadernie dee Sciences, p. 237, 1(500 ; and Philosophical Transactions, vol. xv. 2 Anson's Voyage around the World, edited by Walter. SYMPTOMS OF SCURVY. 299 gradual accession, or they may rapidly arise and involve the patient, just before in apparent security, in the greatest peril. These incursions are almost always attended by febrile exacerbations, and the usual grouping of clinical characters denotive of the same pathological conditions arising under ordi- nary circumstances. The local complications may cither affect the pleura or pericardium, or both. In Dr. Karawajew's 1 sixty antopsic examinations, pericardial effusions were noticed in thirty, pleural in thirty, pericardial and pleural in six, peritoneal in seven, and arachnoideal in only one. The exu- dations are sero-sanguinolent or fibrinous in character, and sometimes reach the inordinate quantity of four or five pounds, occasioning the patient the utmost distress, and embarrassing the respiratory and circulatory functions. Although these augment in a high degree the risk to life, yet under prompt and appropriate treatment recovery may take place, and the effusions vanish with surprising rapidity. Hemorrhagic extravasation into the nervous centres is a very rare occurrence. It has not been as yet recorded as having occurred in the brain-substance itself, but has in several instances been noted between the meninges, producing headache, dizziness, vertigo and finally somnolence, delirium, and coma. Opitz'" relates an interesting case in which convulsions suddenly occurred with unconsciousness, followed by hemiplegia of the left side of the body and the corresponding side of the face. After twenty -four hours, consciousness returned and the paralysis had disappeared. There were however headache and hyper- esthesia of the upper extremities present; twelve days later these also receded, and the patient finally recovered. The same author records paralysis as occurring in one case from extravasation into the spinal meninges. Dr. Sam- son observed an instance in which a fibrinous effusion formed upon the sciatic nerve, with consequent pain. In the circulatory system, symptoms always of threatening and often of fatal import arise ; embolism may occur at various points, particularly in the lungs and spleen, occasioning hemorrhagic infarc-' tions which have undoubtedly been the occasion of the sudden deaths some- times observed in scorbutic cases not apparently of a very dangerous form, nor attended with an excessive degree of exhaustion. The urinary system supplies no prominent symptoms ; the statements as to the condition of the kidneys and the composition of the urine are contradic- tory. The urine not unfrequently contains albumen, particularly in severe cases, but this is by no means indicative of corresponding changes in the renal structure; on the contrary, this may be found after death to be appa- rently free from disease. Simon 3 examined the urine in three well-marked cases of scurvy occurring in Schonlein's w T ards ; two were men between thirty and forty years of age, and the third a woman who had been delivered a few days previously. In its physical characters the urine was very similar in the three cases ; at first it was very scanty (8 to 12 oz.), and of a dark-brown color, as if bile pigment or decomposed blood were present, which, however, was not the case. It was devoid of the peculiar sweetish odor of typhus urine, but, after standing a few hours, developed a disagreeable ammoniacal odor. There was a deficiency of the phosphates, and the amount of urea was much less than in normal urine, not exceeding 20-30 per cent, of the solid residue. The fixed salts were diminished in the urine of the men, forming 14-18 per cent, of the solid residue, while in the woman they amounted to 27 per cent,, a little above the normal average (25 per cent.). The uric acid was slightly above the healthy standard in all the cases, forming 1-3 per cent, of the solid residue. 1 Himmelstiern, Beohachtungen iiber den Scorbut, S. 50. Berlin, 1S43. * Prag. Vierteljahrsschrift, S. 153, 1861. 3 Chemistry of Man, p. 320. 300 SCURVY. Krebel 1 states that the urine is at first cloudy and brown, afterwards becoming decomposed and offensive, and an oily scum forming upon it. Duchek 2 dissents from this statement, and asserts that in slight cases the urine in its physical properties is unaltered ; and that in aggravated cases it is generally of a deeper color, somewhat decreased in quantity, as happens usually in fevers, and always of an acid reaction. The quantity is diminished to from 1200 to 1500 cubic centimetres, and in very severe eases is as low as 830 cubic centimetres ; the specific gravity runs as low as 1015 to 1009, and the quantity of all the solid constituents is diminished, with the exception of phosphoric acid and potassa, the latter being in proportion to the soda as 1 to 1.9, while in health it bears the proportion of 1 to 12. As recovery pro- gresses, the quantity of both urine and its solid constituents increases, with the exception of the potassa which, on the contrary, decreases. Chalvet's analysis of the urine, from a well-developed scorbutic subject, furnished the following result : — Water 950.50 Solid matters 49.50 Urea . 9. (JO Extractive 12.60 Albuminoid matter ........ 7.50 Mineral matter 19.50 ( Matter soluble in absolute alcohol . . . < The conclusions that would seem to be authorized by the statements of these various authorities, are that the quantity of urine passed is decreased, as well as that of the urea, while the amounts of the albuminoid and mineral matters are increased. Physical examination will reveal the frequent occurrence of enlargement of the spleen, independent of malarial influences, and Krebel has encountered one case in which the liver was involved in inflammation. Some derangement of the visual organs is present in numerous cases. Dr. Foltz, in the epi- demic on the Raritan, reported four cases of nyctalopia and two of hemera- lopia, and other affections of the eye, such as conjunctivitis, induration and irritation of the ciliary margins of the lids, with a copious and acrimonious discharge, these conditions being obviously due to the scorbutic diathesis. Hemorrhage may occur under the conjunctiva, raising it into small pouches ; into the anterior chamber, causing iritis and adhesions ; and finally into the choroid and vitreous humor, exciting a general inflammation of the entire organ. Dulness of hearing and buzzing in the ears have also been signalized as occasional symptoms of scurvy. The phenomena of fever are always absent during the course of uncompli- cated scurvy, the temperature of the mouth sometimes falling as low as 92° F. ; and being always one or two degrees lower than normal. It is only in th<' later periods of the disease, when pathological processes most often super- vene in the internal organs, that an elevated temperature and the other ordi- nary symptoms of fever arc manifested. The lowered vital resistance of scorbutic subjects particularly disposes them to the incursions of other fevers, especially those of malarial and typhoid types; hence in the low, marshy districts of northern Europe, and in seel ions of country afflicted by famine and overcrowded dwellings, these complications are very common. ' TVr Scorbnt, S. 150. 2 Zeitschrift der k. k. Gesellscliaft der Aerzte zu. Wien, Bd. i. S. 56. DIAGNOSIS AND PROGNOSIS OF SCURVY. 301 Diagnosis of Scurvy. The recognition of scurvy is not surrounded by any embarrassing difficul- ties, as its exclusive etiological character, the altogether special circumstance's of its occurrence, the peculiar location of the disease in the various tissues, and the establishment of the preliminary cachexia, with the peculiar dull, earthy hue which subsequently merges as it advances into a deeper and cya- notic tint, point with unerring certainty to its identification. It is rarely re- stricted to isolated cases, but invades groups of individuals, or communities living under similar or identical hygienic conditions, as occurs on board ships, in prisons, in armies, in places closed by siege, or in districts of country afflicted with common calamities. Single cases are, however, occasionally met with, and I have myself observed one, in the person of a man who from penu- rious motives had abstained from all but the cheapest and coarsest articles of diet, subsisting chiefly on refuse food of an animal character, purchased in the markets and made up into soups. The disease was at first supposed to be purpura hemorrhagica, until the above mentioned facts were discovered and a closer inspection made of the variously colored spots ; the persistent and severe pains in the limbs and back, the swollen joints, ulcerated gums and fetid breath, then led to a correct conclusion, and the man soon recovered under dietetic treatment. The same conditions, in individual cases, will enable the observer to make a correct discrimination of scurvy from other pathological states involving hemorrhagic extravasations into the tissues, such as occa- sionally occur in ansemia, chlorosis, leucocythaunia, pseudo-leucremia, perni- cious anaemia, and hemophilia. These never occur except in isolated instances, while scurvy, as stated before, is rarely seen except as afflicting numerous persons at the same time. In the former diseases, also, the gums never pre- sent, although they may be tender' and disposed to bleed, the peculiar color and sponginess characteristic of scurvy. An error might, however, creep in here if we were to depend solely upon this phenomenon, for cases of scurvy have been reported in which this condition did not exist, and it does not occur, as already remarked, in edentulous persons. The state of the gums in leucocythoemia, it has been said, occasionally approximates this condition, but the other associated symptoms would suffice to differentiate that disease from scurvy. The rapid improvement of scurvy under fresh vegetable diet, will also pre- sent a striking feature not encountered in anaemic and purpuric cases. In the commencement of an outbreak, the rheumatoid pains, so common in the back and Jimbs in the severe cases, have caused them to be confounded with rheu- matism ; inquiries into the condition of the gums and skin will readily dispel this error. Finally, in none of the diseases with which it is possible to confound scurvy, do we meet with the same complications of vital organs : fibrinous and bloody effusions among the muscles, and into the pleura^ pericardium, peritoneum, and synovial sacs of the joints; deformities of the limbs from contraction of tendons; and distorted joints from the plastic outpourings about them. All of these features are special to scurvy, and serve to complete a clinical picture altogether characteristic and distinctive. Prognosis of Scurvy. The prognosis of scurvy will depend upon the stage of the disease, its grade of intensity, its complications, the constitutional power of the patient, and the 302 SCURVY. nature of the attendant circumstances — particularly the possibility or not of changing or ameliorating the hygienic surroundings. In the earlier stage of the disease, recovery under proper treatment is assured; and it is remarkable how soon the spongy gums and discolorations of the surface will recede, and the patient regain strength and cheerfulness. Even in cases of notable in- tensity, unaccompanied by involvement of the internal organs or serious com- plication with other maladies, the prognosis is very hopeful when the patient can be put under favorable influences. Yet it must be said that often appa- rently slight cases do not recover as rapidly as others which are seemingly, from external appearances, much more severe. Complicated cases, with im- plication of the thoracic or abdominal viscera, where these conditions have entailed no considerable effusions, though more unfavorable than the preceding groups, are still amenable to well-directed therapeutic measures. The same conditions, however, linked with abundant outpourings of serum and blood into the pleural, pericardial, and abdominal cavities, are exceedingly unfavor- able, and bode a mortal issue. Excessive and frequent hemorrhages are liable to bring on speedy death by syncope ; epistaxis was at an early period con- sidered a mortal sign, and one necessarily fatal. Colliquative diarrhoea and dysentery exhaust the strength rapidly, and induce a fatal issue by causing early and profound prostration, or by their continuance lead to the same result through gradual asthenia. Persons weak and feeble, either constitutionally or from the inroads of prolonged disease, especially of a malarial character, from a previous attack of scurvy, or from other cachectic complaints, are less apt to recover than those of an opposite character. The attendant circum- stances have also an important influence on the prognosis. On shore it is easier to secure good accommodations, with dry, well-ventilated, and clean apartments, and abundant supplies of fresh vegetable food and other desirable forms of nourishment, than on the sea; in long voyages, or in exploring par- tics into the interior of unknown countries or in high latitudes, it may be impossible to control to any considerable degree these indispensable require- ments for the recovery of the sick, and the outlook will be gloomy indeed for successful treatment of even the mildest cases. Treatment of Scurvy. There is no disease within the whole range of pathology which yields such satisfactory results to well-directed and judicious treatment as does scurvy ; and this is all the more gratifying when it is remembered that, during its period of rifeness from the 14th to the 18th century, it did more destruction t<» armies and fleets than the sword of the enemy and the other dangers of warfare combined. Equally as remarkable results in warding oft' the disease attend the intelligent adoption of the prophylactic, hygienic measures which experience has shown in multitudinous instances, through a long period of time and almost everywhere, to be indispensable to the maintenance of health. A cursory consideration of tliese measures will be a fitting prelude to a dis- cussion of the means which should be had recourse to in the actual invasion of the disease. Prophylaxis. — Groat ameliorations have been effected during the last cen- tury, and particularly within the last thirty years, in the physical conditions under which the sea-rarer and the poor in northern climates live. I3oth house and ship hygiene have made advances, and the people everywhere enjoy the fruits resulting therefrom, in possessing better lodgings, greater variety of food, purer air, more comfortable clothing, and, as a necessary corollary of this, a TREATMENT OF SCURVY. 303 higher moral life and increased happiness. These circumstances have limited scurvy to a restricted prevalence on board of badly-equipped merchant vessels, in long passages ; among exploring parties in high latitudes ; in armies during time of war, cursed with an incompetent commissariat ; and occasionally among the inhabitants of besieged towns. It has been attempted by legislation, with more or less success, to enforce on board merchant ships the adoption of the proper hygienic measures. Such laws are in force in the United States, in Great Britain, and in other countries, and require that all ships shall carry certain articles of acknowledged anti-scorbutic power, and that the quarters of the men shall possess a requisite amplitude. In the equipment of arc-tic vessels, proper prevision is always displayed to avert the invasion of scurvy during such service. The greatest import attaches to an unsparing storing up of fresh vegetable and animal food, which should always be provided at the commencement of any voyage likely to be prolonged for several months. It is often possible to carry live animals for days together, and the stock may often be replenished at the different ports touched at. By the various processes of canning, pre- serving, drying, etc., fresh provisions of all sorts can be obtained, that may be relied on as capable of supplying good, wholesome animal food. Eggs form a most desirable article of diet, and may be kept good for months by simple methods of packing ; and their nutritive value will be appreciated when it is considered that a single egg contains as much nourishment as two ounces of fresh beef. Another excellent animal food, on account of its nutri- tive qualities and reported efficiency as an anti-scorbutic, is milk, which, when properly prepared, can be preserved in its original purity and with undimin- ished nutritive value, indefinitely. Vegetable food of the most varied cha- racter can now be obtained almost anywhere, and a ship should not leave port without laying in a stock of potatoes, beets, carrots, cabbages, and fruits, which should be regularly served out as part of the ration. With a very simple contrivance, quickly growing vegetables may be successfull} 7 cultivated on shipboard. The plants most suitable for this purpose are the mustard, cress, radish, turnip, etc. ; cresses and mustard are the most rapid growers. Almost as efficient representatives of these fresh products of the garden are the same articles prepared in various ways, and put up in tin and glass vessels, and when the former are not procurable these should be substituted in the ration. Sauerkraut can be kept indefinitely in any climate, and has deserv- edly enjoyed reputation as a good anti-scorbutic, while it is cheerfully received by the sailor in his ration. Desiccated potatoes have been found, after several years' trial in the navy, to possess neither much food value, nor to be at all palatable, and, when served out, have as a rule been thrown away, so that other preparations should be preferred. Canned tomatoes are, on the other hand, eagerly accepted, and are much esteemed by the men. Cheese and oat- meal would also be desirable additions to the ordinary allowance. The value of lime-juice as a preventive of scurvy was long since known, yet it was not made a part of the English navy ration until 1795, when it was regularly served out. The merchant shipping act of England requires a supply to be carried by all merchant vessels, and it is ordered to be served out daily after the crew has been ten days on salt food. The juice readily under- goes change, if not prepared with the greatest caution, and particularly on exposure to the air; on this account it ought to be carried in glass receivers of from one to two gallons each, instead of casks or large vessels, so that one or two servings may exhaust the contents. Ordinarily the juice is mixed with 10 per cent, of spirit. These circumstances have rendered it desirable to have a preparation of the juice in some more concentrated and permanent form. Dr. 304 SCURVY. Lind 1 recommended a preparation of this sort, many years ago, under the name of "Rob." The very concentrated juice may also be preserved in gly- cerine, or in a solid form as a lozenge or biscuit. Malt, originally proposed by Dr. MacBride, on theoretic grounds, was highly esteemed by Captain Cook as a preventive, under the form of sweet wort. So, too, did he think well of the Scotch dish called " sowens," prepared by concentrating the liquid result- ing from the fermentation of oatmeal. Cider is also possessed of acknowl- edged anti-scorbutic power. It is a matter of importance not to fail in issuing good potable water to the crew, and fortunately this desideratum is now fully secured on war vessels by the distilling apparatus with which they are supplied. In the mercantile marine, the dependence is chiefly upon the shore supply, which should be in- spected as to quality before being received. The general qualities of water as to potability may be roughly tested by an intelligent person by simple chemical means. An important adjunct in preserving health in long voyages, is a good wardrobe of clothes suitable to the sudden and severe atmospheric vicissitudes ; warm woollen underclothing and stout cloth suits, for stormy weather and the cold of high latitudes. The greatest care should be exer- cised to avoid sleeping in wet garments, and when these have been removed, they should be dried without delay. The sleeping apartments of the crew should always be kept scrupulously clean and dry, and at the same time sup- plied with the requisite quantity of pure respirable air, and, if possible, abund- ant sunlight. It is unnecessary to do more than cursorily remark that all possible means should be adopted to sustain a cheerful disposition among the crew, encouraging the use of musical instruments, games, and social gatherings on proper occasions. Attention to the foregoing circumstances : varied diet, wholesome water, suitable clothing, and comfortable, well-ventilated quarters, will assure the utmost security against the occurrence of scurvy, either on shipboard or on the land. There is really no difference in this respect, as the same hygienic provisions apply equally to the soldier and sailor, and to the occupants of crowded eleemosynary and penal establishments. Curative Treatment. — In the management of the disease therapeutically, the first consideration is to amend the diet, if possible, supplying fresh meats, soups, or other nitrogenous food in a readily assimilable form, and recent vegetables ; the chief of the domesticated varieties of these are cabbages, beets, radishes, turnips, carrots, and potatoes ; others, growing wild, are sorrel, cresses, taraxacum, nasturtium, mushrooms, garlic, mustard, scurvy and com- m< >n grass, and the tops of the spruce. These are attainable almost everywhere, and some even in the hyperborean regions. The ancient Celt used the com- mon shamrock as food. The useful fruits are those of an acescent character, and the juices of the lime, lemon, and orange, hold deservedly the first rank. When these are not attainable, apples, pears, grapes, cherries, and currants will be of decided advantage. The vegetable acids, citric, tartaric, and acetic, their combinations with potassium, and the acescent wines will be of service. ] >r. 1 Vrin 2 found in his experience the expressed juice of the Maguey, or Agave Americana, superior to all other anti-scorbutic remedies, not excepting lime- juice. Nitrate of potassium, either alone or mixed with vinegar, has been lauded as an anti-scorbutic. It is remarkable how rapidly the most painful and even threatening symptoms melt away, as it were by magic, under this dietetic treatment alone. In cases associated with debility, or tardy in con- valescence, the bitter and aromatic tonics, quinine, gentian, etc., either alone (■I- combined with ferruginous preparations, and the mineral acids, will be 1 Treatise on the Scurvy. « Medical Statistics, U. S. Army, 1839-54, p. 362. CURATIVE TREATMENT. 305 indicated, as well as beer and wine. Derblich 1 records his belief that the tinc- ture of cantharides exercises almost specific effects in the treatment of scurvy. In meeting complications, appropriate remedies will be found for the scor- butic stomatitis in the mineral and vegetable astringents, washes containing carbolic acid, and solutions of chlorinated lime or permanganate of potassium"; a solution of nitrate of silver also yields good results. These various reme- dies will afford relief, but no permanent improvement will ensue without the consentaneous adoption of vegetable food. The alterations in the skin demand no particular treatment, unless ulceration has occurred, when the use of sooth- ing applications, and protection from sources of external irritation, will be indicated ; while at the same time the parts must be kept perfectly clean and free from offensive odor by the use of chlorinated or carbolated washes. In the hemorrhagic complications, the same treatment will be indicated as in simi- lar conditions unaccompanied by scurvy. Epistaxis may be checked by cold applications to the head, and by making the patient snuff astringent powders, such as tannin, powdered rhatany, etc. In serious cases, plugging of the nares must be promptly adopted. Hemorrhage from the stomach or bowels is to be checked by the external use of cold cloths, or ice, to the abdomen, and by the internal administration of ergot, tincture of the chloride of iron, gallic acid, acetate of lead and opium, or other agents of the haemostatic class. Effusions of blood or sero-sanguinolent fluid into the pericardium or pleura, if not excessive, will generally recede as the general condition improves under the treatment already indicated. Should the quantity, however, increase to such a degree as to embarrass the circulation and respiration, there is no alternative left but paracentesis, which at most affords slender chances for recovery. In the management of this disease, an important indication is to have the patient so watched that he may not be permitted to perform any movement likely to throw an additional burthen upon an already overtaxed heart ; it has happened, time and again, that assuming the erect posture suddenly, or ascending a few steps, has resulted in immediate death. The strength must be taxed neither by active catharsis nor by bloodletting ; should the bowels need moving, the gentlest laxatives will suffice to secure the desired effect. All preparations of mercury should be avoided, as they exercise the most pernicious effects, especially when carried to the extent of salivation. The evil results of these remedies were lamentably shown in the wholesale slaughter of four hundred men as reported by Kramer. 1 Wiener medizinische Wochenscrift, 1S61, S. 827. VOL. I.— 20 THE RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. BY A. YERNEUIL, M.D., PROFESSOR OF CLINICAL SURGERY IN THE FACULTY OF MEDICINE, PARIS. It is yet very difficult to establish in an exact and complete manner the relations existing between constitutional conditions and traumatic lesions, but even now, by the aid of the literature hitherto collected, we have (1) acquired very useful ideas in regard to the diagnosis, prognosis, and treatment of inju- ries which occur as the results of surgical or accidental wounds, and (2) for- mulated much more distinctly the indications and contra-indications for operation in individuals affected by previously existing constitutional states. If we consider how, much has already been done in this direction, despite the short time since these studies have been begun, and the very small number of authors who have investigated them, we may be assured that they will render, before the end of the present century, considerable service to medical science and to the art of surgery. Before entering directly into this question, it will be useful to define what I mean by constitutional diseases, and to indicate their number and their classification. A constitutional disease, clearly represented by the old expression morbus totias substantia?, and which may be more concisely termed panpathy ; a con- stitutional disease, I say, affects at the same time all the organic fluids and solids, altering the latter more than the former, or vice versa ; modifying by preference this fluid, or affecting this system, rather than others ; but at a given moment involving the entire economy. The number of these diseases has been sometimes too much restricted, sometimes too much extended, and a reform must be attempted in this respect. I shall content myself with drawing up a list into which may enter all those which are already known, or which are yet to be recognized. _ (1) Diseases of nutrition, usually hereditary, but also acquired : arthritism (including gout and rheumatism) ; undoubtedly cancer ; scrofula (including the large majority of cases of tuberculosis). (2) Poisons of external origin : syphilis, malaria, alcoholism, morphinism, saturnism [lead poisoning], glanders, heterochthonous septicaemias; or of in-\ ternal origin : diabetes, leukaemia, autochthonous septicaemias. (3) General conditions following sooner or later on a permanent lesion of an important viscus, such as the lungs, heart, liver, kidneys, brain, spinal cord, etc. Although presenting the fundamental characteristics of constitutional diseases, these conditions have not yet received a special name. It is only (307 ) 308 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. recently that those suffering from them have been called cardiac, hepatic, nephritic subjects, etc. Old age, as a permanent general condition character- ized by various degenerations of the viscera (steatosis, sclerosis), pregnancy, the puerperal state, and acute anosmia, being temporary extra-physiological con- ditions, may enter into this category. On the Reciprocal Influence of Constitutional Conditions and Injuries. Pre-existing or propathic general conditions may exercise an influence upon injuries in various ways : — Primarily, by favoring the development of certain complications which are situated at the site of injury, or start from it ; inflammation, circumscribed or diffuse ; lymphangeitis ; erysipelas ; hemorrhage ; neuralgia ; alteration of the granular membrane, etc. Secondarily, by modifying, arresting, and disturbing the reparative pro- cess ; by destroying what has already been accomplished (ulceration of cica- trices, softening of callus); by replacing an affection of a determinate and calculable duration, the trauma, by another affection the length of which we are unable to foresee. Finally, by fixing themselves upon the point already wounded and become the place of least resistance (locus minoris rcsistcntia?), in order to develop there a more or less obstinate diathetic manifestation. On the other hand, traumatism may exercise an evident action upon pre- existing constitutional states ; it may call them to the wounded spot, awaken or reawaken them, make them pass from a latent to an active condition, and cause their manifestations to appear at the site of injury itself, or in distant regions, if not throughout the entire economy. It usually hastens the course of the diathesis, and more especially aggravates the lesions which that has already produced, and which may have been more or less stationary before the injury. But this is not true of all cases. The constitutional affection and the in- jury may at first run parallel to each other, without influencing each other in the least; the subject of the diathesis supports the shock as if he were per- fectly healthy, while the wound on the other hand runs a regular and classical course. These fortunate cases are not very rare; we are beginning to be able to foresee them, and we shall undoubtedly soon succeed in increasing their proportion. In the second place, the influence of the trauma upon the con- stitutional disease is not always unfavorable, but rather the contrary ; for the local affection may perhaps be the cause as well as the effect of the general malady, in which event, its suppression exercises the most prompt and deci- sive action up< m the re-establishment of health. It is in this way, for example, that our operations act so effectually against chronic septicaemias. Finally, even when the simple or reciprocal influence of the injury upon the primary disease is exercised in an unfavorable manner, the resulting morbid actions are not always very disastrous. On the other hand, diatheses only have a limited pathogenic influence; accidental causes, including injury, can only make them produce a certain number of determinate local manifestations, which cannot differ, and in reality do not essentially differ, whether they have been produced by main force,and as it were unseasonably, or whether they have been developed spontaneously in consequence of the natural evolution of the malady. From a clinical point of view, constitutional diseases present numberless differences: they are active or latent; of recent date or of long standing; of slow or of rapid course; with a constant tendency towards aggravation or RECIPROCAL INFLUENCE OF CONSTITUTIONAL CONDITIONS AND INJURIES. 309 towards recovery; capable of yielding to treatment or of obstinately resisting it ; still compatible with a moderate degree of health, or impairing more or less deeply the more important functions ; sometimes single, sometimes com- bined or associated with one another in such a manner as to create hybrid forms, which are very little known despite their extreme frequency and great interest. It is hardly necessary to add that each constitutional disease pre- sents mild and grave, acute and chronic varieties ; and that for some of them, syphilis and scrofula for example, stages and periods are properly recognized. All these considerations enable us to understand, a priori, that operative and accidental traumata cannot have a uniform action upon dissimilar subjects, and that, on the other hand, different diseases cannot react in the same man- ner upon the traumatic process. But observation will show even better that the prognosis of operations varies infinitely in one or another panpathy, because each constitutional dis- ease interferes with the reparative process in its own way, and because the same surgical wound reacts in a peculiar manner upon each particular subject of a diathesis. I do not know how many observations would have to be made, nor how much time devoted to their analysis, before making a gener- alization and obtaining exact indications for practice ; but, in the mean time, I can enunciate certain synthetic remarks which I believe to be already suf- ficiently firmly established. They are not based on clinical history, but on pathological anatomy. Without underestimating the large gaps which this important branch of medicine still presents with reference to general diseases (and it is known that this reproach is emphasized by the latest representatives of the purely clini- cal school), we may nevertheless recognize in these affections three distinct phases: (1) that of dyscrasia, usually opening the scene, continuing perhaps permanently, and representing alone the morbid condition; characterized essentially by a change in the fluids, which, unfortunately, we are still far from understanding even with regard to the most frequent diathesis ; (2) that of peripheral lesions, appeciable to the chemist or pathological anatomist, but slight, or affecting organs of secondary importance ; and finally (3) that of visce- ral lesions, with two varieties which must be distinguished according as the organs are affected by a common or general pathological process — phlogosis, sclerosis, cirrhosis, steatosis, amylosis; or are the site of a heteromorphous deposit peculiar to certain general diseases — tubercles, gummata, lithiasis, various neoplasms. The following is the result of experience derived from a large number of cases taken from my own practice or that of others : in the purely dyserasic •period, the patients tolerate operations almost as well as healthy subjects ; the manifestations of constitutional disease, when they make their appear- ance, are usually of little gravity and but temporary ; and, if the changes of the fluids are still slight, the reparative process proceeds with sufficient regu- larity. During the period of -peripheral lesions, the reaction of the trauma may be more grave, because it finds, in the more or less seriously affected tis- sues, systems or organs, places of least resistance, thoroughly prepared for fresh diathetic manifestations or an aggravation of the pre-existing disorders. Anomalies in the local process are to be so much the more dreaded, as the concomitant dyscrasia is the more pronounced. During the period of visceral lesions, the dangers are greatly increased, because the morbid process is pecu- liarly complicated. In the first place, the sites (loci) of least resistance being situated in organs essential to life, the reaction of the traumatism upon them gives rise to, or aggravates, affections regarded as serious at all times and in every case, and in which there is great danger to life. The dyscrasia too, in its turn, reaches its height, fostered as it is by two causes : (1) the humoral 310 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. changes due to the constitutional disease, and (2) that other adulteration of the fluids which inevitably results from imperfect or perverted function of an important viscus ; hence conditions which are extremely unfavorable for the progress of the trauma towards recovery. I believe also that I can point out a third source of danger which has, I think, hitherto passed unnoticed. The injured region, it is commonly believed, is capable of developing an organic poison, the entrance of which into the economy produces a true intoxication, viz., traumatic septicaemia. The latter is of variable intensity, according to the quality or quantity of the poison, its accumulation or elimi- nation. Under ordinary conditions and in healthy subjects, the large viscera serve as emunctories for this poison as for so many others. But if this vent be closed on account of a profound lesion of the glandular parenchymata, elimination is rendered impossible, and those acute septicaemias are found to be developed which so rapidly lead to death. All these propositions would gain in clearness by being sufficiently de- veloped or illustrated by examples, and I greatly fear that they will not be understood in the concise shape under which I present them ; but I am limited as to space, and cannot dilate further upon this part of the subject. The conduct of the surgeon follows naturally from what has gone before. Since the subjects of diatheses cannot be deprived of the benefits of surgical interference, even though this be particularly dangerous to them, the surgeon should strive to lessen the gravity of the prognosis, and to insure at least operative success, that is, the immediate result of his operation. In cases in which he cannot do this, he had better abstain, unless indeed he does not seek the cure of the disease, and is content with merely checking its progress. Fortunately, he will often succeed in averting the accidents which arise from the constitutional condition, by the aid of a series of readily executed measures. In the first place, he will carefully choose his time. If this is impractica- ble in urgent cases, the rule of occasio prcccej)s is, on the contrary, easily fol- lowed when, life not being immediately threatened, we can hasten or delay the time of action. As regards the majority of morbid states, we should ope- rate quickly, during the dyscrasic period, before the onset, of the histological, and especially of the visceral lesions. In the two chief constitutional dis- eases, arthritism and scrofula, the latent period is preferable to that in which fresh manifestations occur. We may allow certain diatheses, like syphilis, to wear themselves out ; but, on the other hand, we should attack at the onset those neoplasms which are still local, and the extension and generalization of which are imminent. Great care should be taken with regard to the operative procedure. We must be very sparing of blood in exhausted or poisoned subjects; must save neuropathic individuals as much pain as possible ; and must prevent, as much as we can, traumatic fever in those whose viscera are affected. An excep- tional and little used method may become the plan of election in a particular instance. Diabetic phlegmons and carbuncles should be incised by the thermo- cautery and hot iron, not with the bistoury. Methods of slow and progressive division would, on the contrary, be injurious in irritable subjects, whom pain exhausts and irritates. The choice <>!' a dressing also merits special attention. I may remark, in the firsl place, thai diathetic' patients, like all others, owe thanks to the antisep- tic method. Whenever possible, the judicious employment of various forms of this method: the wadding dressing of Alphonse Guerin, Lister's dressing, the open antiseptic dressing, etc., counterbalance to a considerable extent the unfavorable influences of constitutional diseases. Under the wadding bandage, 1 have seen alcoholics and diabetics recover, who would almost un- doubtedly have succumbed ten years ago with the old-fashioned dressings. I ARTHRITISM. oil bare obtained wonderful results with tbe permanent antiseptic bath and with open dressings. Lister and his disciples daily perform similar miracles which throw into relief the great part played by the traumatic centre in the produc- tion of complications. AVe must not, however, run into extremes ; and in considering how very favorable is the suppression of traumatic fever in dia- thetic individuals, we must not imagine that all danger ceases from merely treating the wounds antiseptically. If this were so, the influence of constitu- tional conditions would be entirely neutralized to-da} T , and these pages would be unnecessary. I know not whether in the future affairs will run such a course that we need not fear the deterioration of the economy by antecedent diseases, hut unfortunately we have not arrived at that stage at present. With the anti- septic method we lose indeed fewer, many fewer patients ; but we still lose some, and a careful examination of the causes of death clearly shows us that they consist almost exclusively in bad constitutional conditions of the injured persons. We may add, moreover, that antiseptic dressings, in order to be really efficacious, should be applied rigorously, and that such applications cannot always be effected in the actual condition of science. In order to prove this, it is only necessary to refer to the extensive class of operations in cavities, that we may remind the surgeon that, under many circumstances, he must still combat- the evil influence of general disease. But the point which must be insisted on most strongly, is the necessity of instituting during, after, and especially before the operation, if there be no urgency, a plan of treatment in which are associated hygiene, diet, the use of drugs — medical treatment par excellence — designed to combat the constitu- tional disease, as would be done were no surgical complication present. Not only, by such a plan, will the chances of the immediate success of the opera- tion be increased, but we will often have the good fortune of indefinitely delaying the injurious relapses of the diathesis. It may even happen that, while merely attempting a preparation which shall be favorable to the final result, there may be obtained, by medical treatment alone, a recovery as bril- liant and much less onerous than that which was expected from the knife. After these general considerations upon the reciprocal influence of consti- tutional diseases and traumatic lesions, we will now begin the study of the relations of each panpathy to w T ounds. Arthritism. {Rheumatism, Gout, Herpctism.) Eheumatism. — (1) Influence of Rheumatism upon the Seat of Injury. — The rheumatic diathesis has not, like syphilis and scrofula, the property of im- pressing a peculiar stamp upon the traumatic lesion ; it does not even modify to an appreciable extent the reparative process as do alcoholism and diabetes. Neither favoring the production of pus, nor counting among its morbid pro- cesses either ulceration, gangrene, or diffuse inflammation, it has hardly any tendency to modify surgical wounds unfavorably, to increase or alter the sup- puration, to prevent the formation and transformation of the granular mem- brane. Open wounds, therefore, have commonly a good appearance in rheu- matic patients, and run their course in the usual manner. Certain specific complications may, however, occur at the wounded point, which are observed not unfrequently and are easily recognized. It is known that even a slight articular lesion in a rheumatic patient readily gives rise to a hydrarthrosis, a more or les.« obstinate synovitis, or even loose bodies ; and that a luxation, a 312 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. sprain, a penetrating or even epiphyseal fracture, may prematurely give rise to the characteristic lesions of dry arthritis, and sometimes even to true or false anchylosis. The rheumatic diathesis, in the various places in which its spontaneous manifestations arise, very readily and rapidly causes serous effu- sions, cedema, plastic exudations, temporary or permanent (under the form of various neoplasms — fibroma, cancer, etc.), simple or hemorrhagic congestions, all accompanied hy severe pains, fixed or wandering, temporary, intermittent, remittent or continuous, assuming the form of local hyperesthesia or irra- diated neuralgia; and, on carefully watching an injured rheumatic, it is easy to recognize at the seat of injury, or in its immediate neighborhood, an entire series of anatomical lesions of functional disorders, having the greatest resem- blance with those which have been mentioned — lesions and disorders which, to my mind, constitute the arthritic complications of wounds. Among these, for example, I include serous effusions in cavities or connective tissue, marked cellular proliferation, pseudo-phlegmons, active hemorrhages, erythema and other severe eruptions in the neighborhood of the wound, neuralgia, and, at a later period, neoplasms and certain affections of the cicatrix. (2) Influence of Injuries upon Rheumatism. — It w T ould be undoubtedly proper to distinguish cases according as the injury occurred before, during, or after the rheumatic attack ; but the facts are wanting for the carrying out of this programme. There are scarcely any observations on record of wounds contracted during an attack of articular rheumatism ; those of wounds prior to the first rheumatic manifestations, and which produce the unexpected and premature appearance of the diathesis, are equally rare. ^Nothing is more common, on the contrary, than the renewal of rheumatic symptoms of older or more recent date. This fact, equally well known to the physician and surgeon, has been recognized in a summary manner for a long time. The wounds which may excite the diathesis are extremely varied ; strains, frac- tures, slight or serious contusions, the most varied surgical operations, the removal of tumors, incision of fistula?, lithotomy and lithotrity, etc. In their turn, the manifestations of the diathesis thus reawakened, are no less variable ; sometimes the entire economy is disturbed by a fresh attack of acute, general- ized rheumatism, sometimes there is only a local affection, striking a part which had been previously involved, without this predisposing condition being however necessary. We find recorded cases of acute or chronic arthritis, certain cutaneous eruptions (herpes among others), neuralgic pains, muscular spasms, contractions, pericarditis, cystitis, pulmonary congestion, hepatic or nephritic colic, changes in the urine, profuse sweats, etc. Chronic rheumatism affecting important organs, such as the heart, lungs, kidneys, and walls of vessels, may at length affect their structure more or less profoundly, and convert them into weak points which will feel the effects of the traumatism. But the complications which then arise have only distant relations with rheumatism, and may be more conveniently studied when we come to the special consideration of the constitutional conditions developed by affections of the great viscera. Gout. — Like rheumatism, gout generally respects the reparative process, and usually does no1 interfere with the cicatrization of wounds. Neverthe- Li - it is sometimes manifested at the site of injury by fluxions with acute pains, which are capable of simulating frank inflammation, but which are cnly congestions, usually of a temporary character. The pain also occurs without any apparent lesion, and under the form of neuralgia. In these cases, indeed, the curative process is temporarily suspended or at least retarded. At a later period, chalk stones may appear around wounded joints, and in of fracture exuberant callus has been observed. Repeated slight injuries CANCER. 31-3 in the gouty may probably have for their effect the development of certain neo- plasms, especially epithelioma. Subcutaneous lesions and sprains are more liable to be followed by manifestations of the diathesis than open wounds. The traumatism in its turn, has an effect upon the disease. There is hardly any example known of an injury contracted during an attack of gout, or which has excited the first attack of a previously latent gout. In the cases observed, the injury occurred in the interval between two attacks, in a gouty patient who had previously suffered more or less often. As a rule, the attacks thus provoked by main force develop quickly (from the first to the fourth day for example), are of but moderate intensity and brief duration, and appear to be excited preferably by slight injuries. I have, for instance, twice seen gout follow puncture of a hydrocele with a very fine trocar. In one case in which an injection of iodine had been made, the attack appeared to act as a derivative, for the inflammation of the tunica vaginalis was to a great extent wanting, causing extreme slowness of recovery. In cases of chronic gout or gouty cachexia in gouty subjects affected with renal or he- patic lesions, the prognosis is rendered grave. More or less serious compli- cations may invade the seat of traumatism, but must be especially attributed to the visceral changes, rather than to the gouty dyscrasia. Herpetism. — I give this condition a place here, although I do not consider it either a distinct diathesis, or a separate constitutional disease. To my mind herpetics are simply arthritic subjects in whom the predominant manifesta- tions are on the part of the mucous membrane and the skin. Herpetism then acts . upon injuries only after the manner of rheumatism, and especially of gout, by producing at the site of the injury early or late neuralgias, either intermittent, remittent, or continuous ; and, in the integument near the seat of traumatism, congestions, fluxions, and, finally, various cutaneous affections, among which herpes occupies the first rank, as shown by the numerous observations of traumatic herpes which have already been recorded. Trau- matism is undoubtedly a determining cause of herpetic manifestations ; it produces cutaneous eruptions at places in which they have never appeared before, brings back with the greatest facility those which have disappeared, and prolongs the existence of those which are already present in the wounded region. Wounds, properly speaking, act much more effectually in this respect than deep-seated injuries, whether or not involving the great cavities. Cancer. Surgical operations are so frequent in cancerous individuals, that it is natu- ral to inquire whether or not cancer influences injuries, and in the event of an affirmative answer, what changes it produces in the reparative process. ]Sow it must be remembered in the first place that cancer, in spite of what has been said on the subject, is not a distinct constitutional disease ; that it is included in a much more extensive diathesis, the neoplastic diathesis, or the tendency to produce neoplasms spontaneously, or under the action of a deter- mining- cause ; that the neoplastic diathesis itself is strictly dependent upon arthritism — which is equivalent to saying that neoplastic and cancerous sub- jects are merely arthritic patients suffering from a special manifestation of the constitutional disease. v\ r e might therefore simply refer to the preceding paragraphs ; but a few special remarks will perhaps not be useless. Cancerous subjects belong to various categories. In some, the disease is latent, in a condition of predisposition ; in others, it already exists in well- defined manifestations. Some present only a single tumor, others have seve- 314 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. ral cancerous deposits scattered over various parts of the body ; sometimes the morbid masses are situated in the external parts, the limbs or walls of the splanchnic cavities, sometimes they occupy the viscera or deep parenchymata ; often they are observed both externally and internally. Finally, certain can- cerous patients present no other lesions than the single or multiple tumors with which they are affected, while in others we find humoral changes, or more or less serious disorders in organs which are free from all neoplastic deposits. In certain predisposed subjects, injuries, and almost exclusively contusions, appear to invite the manifestations of the disease. Before com- plete recovery, or a longer or shorter time after apparent recovery, the centre of traumatism is invaded by the neoplasm, and the cancer appears at the seat of injury. Cancerous patients who are affected by single tumors situated in organs not essential to life, and whose viscera are healthy, tolerate injuries well ; the reparative process pursues a normal course. The only complications to be feared are those which are observed in arthritics, and which usually present but slight gravity ; such are traumatic herpes, early secondary neuralgias, recur- rent attacks of rheumatism or gouty paroxysms, etc. I know of no authentic example of an open wound in a cancerous subject, in a region exempt from cancer, which has itself undergone the cancerous metamorphosis. In cases of removal of tumors, when the ablation has been early and free, the cicatrices are healthy, firm, and usually not liable to relapses, which readily occur, on the other hand, in distant localities. Cancerous patients affected by multiple deposits, and especially by visceral tumors, tolerate accidental wounds and surgical operations very badly. A large proportion succumb in consequence of even slight injuries, such as sim- ple fractures, the removal of small tumors, palliative operations, tracheotomy, formation of artificial anus, etc. The seat of injury may become the site of the ordinary complications of wounds: inflammation, hemorrhage, ery- sipelas, pyaemia, etc., but more frequently still we notice merely an almost entire absence of the reparative process ; immediate union, cleansing of the wound, formation of the granular membrane— all are wanting. At the same time, there are high fever and profound adynamia ; and death often occurs very rapidly without its being possible to ascribe it to any of the recognized complications of wounds. The same termination is usual in cachectic can- cerous patients, in whom the large viscera (liver, kidneys, heart) are affected by fatty degeneration. The complications which cause the fatal result are always better characterized in them, and we find the classical causes of opera- tive failure, diffuse inflammation, severe erysipelas, septicaemia, pyaemia, secondary hemorrhage, etc. Such a case as the following, which is unfortunately very common, cannot be explained with our present knowledge. An operation is performed upon a readily accessible, external tumor, in a cancerous subject who is apparently free from all internal lesions, and who presents the appearances of satisfactory health. The wound does not advance towards recovery, general symptoms appeal-, death occurs with or without local complications, and nothing is found at the autopsy except a few, small, cancerous nodules scattered through the lungs, liver, or other viscera, and the existence of which had not been suspected. Though the traumatism may produce the premature appearance of cancer by making the injured part the port of entry and place of election, it reacts even more frequently upon pre-existing cancerous tumors. Itusually accelerates their course, and causes an active increase of the proliferation. This is especially observed in cases of wounds of the tumor itself, such as con- tusions, exploratory punctures, incomplete operations, etc. But this irritating action is exercised equally at a distance. Many times we find that small, SCROFULA. 315 indolent, stationary glands, which it was not thought necessary to remove when operating upon the principal tumor, rapidly attain a considerable size, soften, and ulcerate. Before performing castration, the iliac and perineal regions may have been examined with the greatest care, and nothing suspicious have been discovered ; but the cicatrization of the scrotal wound is scarcely effected before the patient complains of lumbar and abdominal pains, and pal- pation discloses, deep in the abdomen, tumors which grow with extreme rapidity. Injuries not due to operations have the same stimulating power; those which are least severe, such as simple fractures or contusions of the limbs (very remote, therefore, from visceral cancers), may aggravate the latter to such a degree as to produce an entirely unexpected death within a few days. In some exceptional cases, the injury, especially if it is of an operative nature, appears to cause a temporary revulsion and to arrest the general progress of the disease. This respite is usually temporary ; the wound has scarcely cica- trized before the cancerous deposits assume or resume their destructive course. Surgical operations for cancer, when accompanied by profuse loss of blood, or followed by profuse or prolonged suppuration, manifestly hasten the progress of the cachexia. Scrofula. Bearing in mind the morbid processes habitually met with in the scrofu- lous : inflammation, not severe but obstinate, of slow course, and often chronic from the beginning ; abundant connective-tissue proliferation, readily set up by local irritation, but remaining stationary and able neither to disappear nor to complete its organization ; suppuration without inflammatory reaction of the surrounding parts, often profuse and kept with difficulty within bounds ; indolent, atonic, interminable ulcers, which return on the slightest occasions, etc. — we can readily understand what modifications this constitu- tional disease can produce on the various acts of the reparative process. At first, this process appears to progress as well as could be wished ; the traumatic irritation and local inflammation are moderate, circumscribed, without tendency to diffusion, accompanied by scarcely any pain ; immediate union is often attained, and, in cases of open wounds, the granular membrane is rapidly formed. After this first effort, however, everything seems to have come to a stop ; the suppuration becomes thin and serous ; the granulations grow pale, swell up, and soften ; the edges of the ulcer, which have ap- proached one another, separate, gape open, and grow thin ; the wound is replaced by an ulceration which, after a short period, differs but little from a scrofulous ulcer that has developed spontaneously. In case of interstitial injur} r , the connective-tissue proliferation appears under the form of diffuse swelling, fungous growths of the synovial membranes, and thickening of the periosteum ; suppuration commonly occurs in this centre of induration, in which, without doubt, tubercles are sometimes developed. These abscesses are followed by inevitable and interminable fistulne, with blind pouches, sup- purating tracts, and separations of tissue, whence stagnation and alteration of pus, almost inevitably giving rise to chronic septicaemia and its conse- quences, especially if various parts of the skeleton are involved. Recovery, however, sometimes occurs after a longer or shorter period, but it is not rare to find a relapse of the local complications, either on account of fresh vio- lence, even slight, affecting the parts formerly injured ; or under the influence of an intercurrent disease ; or from the progress of the scrofula as regards the viscera; or, finally, from the onset of tuberculosis. There is nothing 316 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. more common in such cases than the relapse of osteitis or arthritis, the return of abscesses, reopening of fistulae, etc. Scrofula has so great an influence on the reparative process that it im- presses its seal even upon the cutaneous cicatrices, which remain indelible and perfectly characteristic throughout life. On the other hand, scrofula possesses to such a high degree the vexatious power of indefinitely prolonging traumatic lesions, that it must always be looked for, even in individuals of very healthy appearance, whenever recovery from a wound is much delayed. Wounds inflicted by the surgeon act in precisely the same manner as acci- dental injuries. Their early phases are almost exempt from dangers, and very rarely attended by wound-complications, such as phlegmon, gangrene, hemorrhage, pyaemia, etc. The lymphangeitis and erysipelas which some- times start from them are transient, and without violent reaction. Accord- ingly, every one declares the mildness of operations in the scrofulous. This opinion should, however, be combated, or at least modified. It is true that rapid death is exceptional, but complete and permanent recovery is not much more common. If we trace the results of operations on scrofulous subjects with sufficient perseverance, we will notice the extreme frequency of half- successes, of incomplete results, of unfinished cures, of relapses at an earlier or later period ; so that it is exceptional to find a scrofulous patient upon whom resection or amputation has been performed, who is sound and healthy ten years after the operation. Traumatism possesses to a high degree the power of awakening, reawaken- ing, and aggravating scrofula, whether latent or already declared. In slight cases, it causes from time to time the first manifestation, in children of tine appearance, of the superficial and slight symptoms of the diathesis: rashes; cutaneous eruptions, impetiginous or otherwise; subacute or indolent adeno- pathies. More frequently still it stimulates extinct or languishing centres of disease, and restores to local affections their original severity. Cures which were believed to be radical, or, at least, near at hand, are thus again rendered doubtful. Finally, when there are visceral lesions derived directly from scrofula, such as tubercle of the lungs, intestines, mesentery, or nervous cen- tres ; or which are but consequent upon prolonged suppuration and chronic septicaemia, such as fatty and waxy degenerations of the liver, kidneys, spleen, and intestines; the injury almost always proves fatal by the more or less sud- den aggravation of affections which no doubt rendered life precarious, but which nevertheless, except for the traumatic shock, would have permitted the patient to live for some months, or perhaps even for some years, longer. At this stage of scrofula, the subjects of wounds or operations may un- doubtedly succumb to local complications, but much more frequently die of marasmus and exhaustion — that is to say, of phthisis, albuminuria, anasarca, uncontrollable diarrhoua and inanition — or of cerebral complications. Tuberculosis. If pulmonary tuberculosis may, without hereditary antecedents or evident predisposition, appear in the last stages of almost all constitutional diseases, such as arthritism, syphilis, diabetes, alcoholism, etc., and even of affections which have only involved the digestive functions, such as simple stricture or carcinoma of the oesophagus or rectum, epithelioma of the tongue, etc., it is none the less true that, in the immense majority of cases, tuberculosis is an appendant of scrofula, or that, in other words, tuberculous subjects are merely scrofulous siiltjerts <»f;i certain variety. The statements made in the preceding paragraph might therefore be applied SCURVY. 317 to the reciprocal relations of tuberculosis and traumatism. It must be re- marked, however, that as the mere presence of tubercles in any organ what- ever indicates at once a serious condition of the economy — a dangerous form of scrofula — we must expect to find the reparative process hindered, and recovery retarded or indefinitely delayed, in wounded persons who are tuber- culous. This fact has been amply demonstrated. The observations are numerous in which amputations, in tuberculous patients, have been followed by acute atrophy of the flaps, by inflammation, by conicity of the stump, etc. This influence of tuberculosis upon the course and termination of operations has been known for a long time; for we find the question discussed in old books whether it is wise or not to amputate in phthisical cases, or even to operate upon simple anal fistula?. The advocates of abstention find no diffi- culty in making evident, in the large majority of cases, not only the dangers but also the uselessness of surgical procedures which merely substitute for one chronic lesion another almost identical in character. Other authors, indeed, furnish facts which are favorable to intervention. The affirmative and nega- tive conclusions of our predecessors are much too general, and do not reflect sufficiently the extreme diversity of cases presented in practice. In fact, the unfavorable chances are singularly increased or diminished according as the tubercles are deep or superficial ; abundant, generalized and large, or rare, discrete and small ; as they are in course of genesis or rapid evolution, or stationary and in course of fatty or calcareous degeneration ; or, finally, as they have more or less disorganized the organ which they occupy. "Writers, again, have had too exclusively in view pulmonary tuberculosis, and have left out of sight tuberculization of the brain, mesentery, genital organs, bones, glands, etc. Even in respect to pulmonary phthisis itself, in considering the indications and contra-indications for operation, the surgeon should have regard to its extent, its degree, its' forms, its origin, and its causes. Finally, we must not accept or reject indiscriminately all operations, but consider each one separately. Thus, if resections must be avoided in tuber- culous individuals, we may sometimes, if only for the purpose of prolonging life and rendering it more comfortable, perform amputation, and, generally speaking, may employ the whole series of urgent, and a certain number of palliative operations. Scurvy. Essentially characterized by a change in the blood, by friability of the vascular walls, and by fatty degeneration of the tissues and especially of the liver, scurvy oft'ers all the conditions necessary for the production of various complications at the seat of injury. The most important is naturally hemor- rhage, so easily provoked by the least violence exercised upon the vessels and tissues, that it is almost always of traumatic origin, even when appearing to be spontaneous. The discharge of blood occurs at all parts: externally, into the cavities, into the interstices of the tissues; and gives rise not only to hemorrhage properly so called, but to all the possible varieties of blood- extravasation — extensive ecehymoses, suffusions, infiltrations, eftusions, blood- tumors, etc. To this first cause of delay in the local reparative process, must be added the more or less complete absence of the neoplastic junction; definitive histological regenerations are especially defective. Hence atonic, obstinate ulcerations of bad appearance ; interminable suppuration ; delay in the con- solidation of fractures; or production of permanent pseudarthrosis. The callus already formed may soften a longer or shorter time after the fracture; cases are even cited in which callus, that had been solid for several years, softened in consequence of an attack of scurvy. 318 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. Nothing justifies the belief that injury may produce scurvy. Cases have been reported in which a wound, occurring in a subject of healthy appearance,' assumed a scorbutic aspect, after which the other symptoms of the disease soon showed themselves; but this can be explained as well by saying that, at the period of injury, the scurvy did not exist, and that it was developed as an intercurrent disease ; or that it was yet latent and ill-defined, and that, after the maimer of other diatheses, it first showed itself at the seat of injury as at the place of least resistance. In confirmed scorbutics, wounds sensibly aggravate the general condition, and contribute to the decay of the .organism, by primary or secondary loss of blood, and by prolonged suppuration. Leucocttilemia. The number of cases hitherto collected is still very small, but is already sufficient to prove the disastrous influence exercised by leucocythsemia upon accidental or operative wounds. The most frequently observed complication, at the site of injury, is rapid or slow hemorrhage, which is almost always uncontrollable, and almost inevitably leads to death. This hemorrhage does not appear after capital operations only, but follows also insignificant wounds, such as biting the tongue, paracentesis abdominis, the application of leeches, lancing the gums, etc. The few patients operated upon who do not perish from loss of blood, die of phlegmon, phlebitis, pyaemia, or peritonitis, espe- cially after splenotomy — an operation, which has now been practised at least fifteen times upon leucocythaeihic patients, and which has, under these cir- cumstances, always been followed by death. Certain more or less conclusive observations lead to the belief that injuries may by themselves engender leucocythaemia. Splenic contusions have been cited in the first place — cases in which the hypothesis is acceptable; then a fracture of the thigh, a sprain, the extirpation of tonsils in a state of chronic inflammation; in a word, injuries not primarily affecting the spleen. With regard to the latter cases, at least, it appears more probable that the leuco- cythaemia pre-existed, but in a mild and latent condition, and that the injury aggravated and rendered it evident, This stimulating action is moreover demonstrated by a case in wmich a wound of the leg gave rise to peritonitis starting from the diseased spleen. Injuries sometimes shake the organism of leucocythaemic patients to such a degree that they immediately sink into a rapidly fatal collapse. HAEMOPHILIA. It would certainly be surprising not to find in the list of constitutional conditions bearing a relation to traumatism, this condition, peculiar to cer- tain individuals, in whom the blood tends to escape by every channel, and in whom there is no tendency to the production of spontaneous haemostasia. However, before recalling what is contained in the books, I experience a certain embarrassment, because, in my tolerably large experience, I have never seen a case of haemophilia; because the subjects in whom I have myself observed this tendency to bleed, and this difficulty of haemostasis, have been merely patients suffering from hepatic disease, malaria, diabetes, scurvy, leucocytnaemia, etc.; because among the published observations the majority are very incomplete from a clinical point of view as well as in reference to pathological anatomy; because, moreover, these observations become more and moire rare in proportion as we become better acquainted with diathetic hemorrhages; because, to express my meaning in one word, 1 am in no SYPHILIS. 319 decree convinced that there is such a special condition, deserving a special place in nosology and a special name, and because, if haemophilia really has an existence, I shall wait for it to be a little better demonstrated. Syphilis. During its always prolonged, if not indefinite, duration, syphilis may show itself or disappear several times, or be, in other words, alternately manifest or latent. The first condition is common in the beginning of the disease, during the first two or three years or even later, when treatment has been wanting or imperfect. In the opposite condition, the syphilitic may enjoy excellent health for a long term of years without any apparent symptoms. Syphilis may, therefore, be recent or old, evident or masked, when the injury occurs. In the immense majority of cases, the wound progresses naturally without appearing to be influenced by the constitutional disease, but the reverse sometimes occurs, so that the work of repair is more or less interfered with. It will not be useless,, in order that the modifications undergone may be appreciated, to recall the circumstance that the pathological processes of syphilis strongly resemble those of scrofula. In fact, we find here the same proliferation and connective-tissue new formation- — abundant, but useless, superfluous, even hurtful, as the new tissue strangles the old and finally replaces it by fibrous or cicatricial products. "We also observe the tendency to obstinate ulceration and indefinitely delayed repair. It is to be remarked that the two constitutional diseases attack the same systems : the external or internal tegument, osseous system, lymphatic system, etc. ; and that, finally, in their last stages or their grave forms, they generate products which are to a certain extent special and closely related, the tubercle on the one hand and the gumma on the other. We should, however, remember to the credit of syphilis, the much more pronounced tendency of its local manifestations to disappear spontaneously, or to yield to treatment, though ready to return on the slightest occasion, under the same form, or even under a different aspect. These facts enable us to understand what sometimes occurs at the seat of injury: in cases of fracture — delay or complete absence of consolidation, the repair being restricted to the formation of fibrous callus which does not undergo ossification; in cases of simple contusion of bone — osteitis, periostitis, exostosis, periostosis, suppurating gummata, subperiosteal abscesses, osseous denudations, necroses which are interminable on account of the non-forma- tion of natural sequestra. A contusion, even if confined to the soft parts, sometimes gives rise to indolent phlegmons which pursue a chronic course, with scarcely any suppuration, and which leave behind them either fistulas, or indurations, or ulcerating wounds. If the contusion be severe and circum- scribed, the skin may become gangrenous, and, upon the separation of the eschar, Ave find a wound which "possesses all the characteristics of an ulcer- ating syphilide or gumma. t Wounds made by cutting instruments may also suffer the influence of the diathesis, although this is of rarer occurrence. A failure of immediate union has m the first place been noticed, and, as a consequence, an unsuccessful result of autoplastics ; then again there may be early or lafe ■■modifications in the course of the cicatrization. Sometimes the wound assumes the appear- ance of an ulcerating or perhaps even of a serpiginous syphirme; sometimes it ulcerates without assuming a specific appearance, and does not heal ; finally, it may retain the appearances of an ordinary wound, but persist indefinitely, or it may cicatrize after a certain time only to break open again in a short 320 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. period. As for the rest, there is complete uncertainty as to the period at which the diathesis will disturb the curative process. This disturbance, in fact, may occur immediately after the injury, a few days afterwards, or even some weeks or months subsequently. It is common to find that the wound at first follows a normal course, then remains stationary, and finally assumes a syphilitic aspect. Syphilis seldom attacks wounds during the first months of its existence ; it affects them more readily when it is of older date ; when it has, as it were, impregnated the economy more intimately. However, we can formulate no distinct rule in this respect, since, in a very large number of cases, wounds have been found to undergo the specific metamorphosis in patients who have been free from all syphilitic manifestations for ten, fifteen, or twenty years, or even longer. The chances of the occurrence of this metamorphosis appear moreover to be the greatest when the injury affects tissues already changed, even though from other than syphilitic causes. Furthermore, other examples equally prove the predilection with which syphilis takes hold of places of least resistance which have become such a longer or shorter period before its invasion. Thus it has more than once been found to select as the site of its local manifestations some old seat of traumatism which had become entirely extinct, and the cure of which would otherwise have remained permanent. If the quality of the wounded tissues establishes an evident predisposition ; if the quality of the poison is also probably a factor in the determination of the mild, moderate, or grave forms of the disease ; surely we are permitted to believe a priori that the character of the constitution, that is to say the ante- rior constitutional condition of the wounded syphilitic, will react upon the injury, aid in modifying its course and termination, and recall, in certain cases, the diathetic manifestation. But we must remember that, however probable this may be, it has not been demonstrated. In syphilitics who are in a con- dition of cachexia, or who suffer from grave visceral lesions of the liver, lungs, kidneys, or nerve-centres, the reparative process goes on no better than in other subjects whose health is ruined, and may be complicated by disorders common to all cachexias, such as gangrene, hemorrhage, difFuse inflammations, etc. In these disorders, the part played by syphilis, properly speaking, is relatively small, or at least very indirect. Let us now speak of the reciprocal action. It is absent much more fre- quently than it is present ; we will here consider only those cases in which it is manifest. Of course, an injury cannot produce syphilis; but it may introduce it into the economy, attract it to the wounded point, aggravate it, and make it pass from the latent to the active stage. In the immense majority of cases, the infection is produced through the medium of an injury, though very slight and almost microscopical, We have already said that old wounds are some- times attacked by syphilitic complications in preference to healthy tissues, but the most common cases are those in which the injury affects syphilitics who have been infected for a longer or shorter period. At this point two facts appear: either evident syphilitic manifestations are present, or the dis- ease is entirely latent. In the first event, the lesions receive a more or less active impetus, and become more or less grave; in the second, they appear to originate full-blown, and to attack organs or regions which had previously escaped. They occur under the form of secondary or tertiary complications, according to the stage to which the intoxication has advanced in the wounded subject. The tertiary stage predominates when the syphilis dates back some years, even when it has never produced any secondary symptoms. These complications appear at the point of injury in the centre of trauma- tism, or in its neighborhood: they arc local manifestations excited by the MALARIA. 321 trauma ; or at a distance, but in a single organ or in a circumscribed region ; or finally in several parts of the economy at once, as it* there was a recent infection which had become generalized. The diathetic manifestations thus forcibly provoked by the stimulating action of an injury, are a valuable means of diagnosis, revealing the exist- ence of a syphilitic taint of which the patients themselves are ignorant, or which they believe to have been long since extinct. They usually present no exceptional gravity, and yield quite readily to well directed treatment. Malaria. Of all constitutional conditions, malaria is perhaps that which reacts most upon the centre of traumatism, and which reciprocally experiences most fre- quently the counter-stroke of the injury. Accordingly, in countries in which malarial poisoning is endemic, it is expected that the reparative process should be constantly disturbed by various complications, while wounds, on the other hand, excite or renew attacks of intermittent fever. In our temperate climate, and in large cities, these facts, though of rarer occurrence, are nevertheless met with. Malaria may give rise, at the site of injury, to various complica- tions, such as hemorrhage, neuralgia, erysipelas, spasms, and even tetanus ; com- plications which assume an intermittent type, and which yield to the employ- ment of sulphate of quinia. But the influence of the poison is not always shown by periodical disturbances. We find in fact that certain wounds assume a bad appearance, or at least remain stationary, until, the cause being suspected, preparations of quinine, which act like a charm, are adminis- tered. It is especially in cases of malarial cachexia that are observed that slowness and insufficiency of repair which terminate in serious diffuse in- flammations, or even in gangrene, and which are not always subdued by anti- periodic remedies. The injury may occur under the following various circumstances: (1) In a patient actually affected by intermittent fever. In this case the wound, especially if it is followed by hemorrhage, rapidly and markedly aggra- vates the disease. (2) In a patient who has previously been subject to inter- mittent fever, but who appears to have entirely recovered. The injury, even when of slight importance, such as a contusion, subcutaneous fracture, punc- ture, slight wound or operation, and although the recovery from the fever may have occurred many years previously (five, ten, or fifteen years, and even more), reawakens the latter or itself experiences its influence, which shows itself under the form of local intermittent complications. It may even hap- pen that these complications (hemorrhage, neuralgia, spasm), instead of choos- ing a site at the wounded point, appear in a totally different region of the body, not affected by the traumatism, and thus clearly indicate the return of the disease. (3) In a patient who has never had intermittent fever, and who lives in a healthy country, but who formerly resided in a malarial district. The wound, in such cases, may apparently give rise to intermittent fever or to intermittent complications. It is very clear that the injury, not being able of itself to produce a true intoxication, has merely provoked the explosion of a hitherto latent disease, and forced it to reveal itself by pathognomonic manifestations. These latter cases are not very rare, and are especially ol (served in large cities and in the healthiest regions. They must not be confounded with other cases in which intermittence is also evident, but which bear no relation to malaria. It appears astonishing at first sight that a dis- ease, which is generally so well characterized and so readily recognized, can remain so long and so completely latent. "We will be less surprised if we VOL. i.— 21 322 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. recall the fact that the fever is not the sole indication of the malarial poison- ing, and that, without having had a single attack in an infected district, the system may nevertheless be impregnated by the disease. Malarial anaemia and concealed neuralgias characterize malaria almost as well as tertian or quartan fever. Moreover, care must be taken, in whatever district it may be, not to con- fuse the fever which has been aroused with those quite numerous cases in which periodicity is present without the slightest relation to malarial infec- tion. I will mention, among others, those curious cases of wmmds of the spleen which give rise to traumatic splenitis, accompanied by distinctly peri- odical febrile seizures, and readily amenable to treatment by quinine; as also those equally periodical seizures, which are equally curable by sulphate of quinia, and which are due to affections of the urinary passages, in men suffer- ing from disease of the kidneys. Alcoholism. Acute and chronic intoxication must be studied separately. Simple drunk- enness, modifies certain primary phenomena of wounds, viz., pain and muscu- lar contraction ; it may obscure the diagnosis, especially in traumatic lesions of the head and spine ; it sometimes renders difficult the treatment of certain surgical affections, by interfering with the application of instruments and dressings; at other times, on the contrary, by causing muscular relaxation, it facilitates the reduction of luxations. Casual drunkenness has generally no marked action upon the course of a wound, and does not prevent the perform- ance of certain urgent operations, such as tracheotomy, catheterization, the arrest of hemorrhage, etc. It constitutes, however, a contra-indication to the employment of anaesthetics. Resort was had to it, in former times, as a therapeutic agent in various surgical affections, such as luxations, tetanus, septicaemia, etc. ; but the employment of other anaesthetics is far preferable if we wish to obtain muscular relaxation ; and if we desire to use alcohol as an antiseptic, it is useless to push it so far as to cause intoxication. Traumatism sometimes modifies the phenomena of drunkenness, the effects of which it increases or diminishes; now sobering one individual, and again rendering another even more violent. Chronic alcoholism is a predisposing cause of injury. The drunkard has hallucinations and a tendency to suicide; he readily loses the sense of self- preservation, and commits, even w T hen fasting, a host of extravagances. The keenness of his senses is diminished, as well as the promptness and precision of his protective and defensive acts. If hard drinking and drunkenness should disappear, we could dispense with one-third of the beds in our surgi- cal wards. Chronic alcoholism profoundly modities the reparative process, is singularly prejudicial to the healing of accidental or operative wounds, and greatly aggravates the prognosis of traumatism in general. In fact, every wound, although of itself of slight importance (contusions, subcutaneous frac- tures, punctures, excoriations), may be followed by death in drunkards. This termination is often due to complications starting from the wound, such as lymphangeitis, erysipelas, hemorrhage, diffuse phlegmon, gangrenous inflam- mation, or sphacelus, the whole accompanied or followed by grave traumatic fever or pyaemia, and the entire train of the adynamic and ataxic symptoms of severe blood-poisoning. These complications are the more alarming as the chenfical composition and structure of the humors and tissues have been more profoundly modified by the alcohol, and as these disorders affect organs more essential to life, such as the brain, or those more directly concerned with ALCOHOLISM. 323 nutrition, such as the lungs, liver, and kidneys. They do not always cause swift death, and may even disappear quite rapidly; then the curative process, which has been temporarily suspended, resumes its course with more or less activity and rapidity ; but it may also be subject to fresh periods of arrest, languish for an indefinite period, and even retrograde. We then observe pro- fuse suppuration, the absence of secondary union, and the formation of atonic wounds and callous ulcers. After various alternations, recovery may finally occur, but it is at least as common to find fresh complications supervene, rendering the local lesions manifestly incurable, and leaving no other alterna- tive than death from cachexia, or surgical interference of the most dangerous kind. The danger of wounds in drunkards is none the less serious when it comes reciprocally from the action of the traumatism on alcoholism. It is not rare to find that a wound recalls, with more or less violence, the manifestations of alcoholism which is latent, or which has been long believed to have disappeared. In the first rank stands Delirium Tremens. This serious complication may arise suddenly, a few hours after the injury, and by a true refiex action upon the previously affected cerebral organ; or it may appear at later periods, when the septic poison originating in the wound and produced by the local complications has more or less poisoned the blood. Be that as it may, this delirium tremens of traumatic origin is of considerable gravity, and often resists all the measures which are directed against it. Delirium is not the only neuropathy which injury may produce or awaken in the victims of alcohol ; there must also be noted, epileptiform convulsions, tetanic spasms, hyperesthesia and anaesthesia, hallucinations, and other psychical disturb- ances. The reaction of the traumatism upon the other viscera affected prior to the wound, though less sudden and violent, is none the less very threatening. On the part of the digestive tract appear vomiting, anorexia — sometimes complete — and the malnutrition which results therefrom. When the liver is cirrhotic or fatty, secondary hemorrhages are greatly to be dreaded, as are also albuminuria and uremic phenomena when the kidneys are affected. In case of fatty degeneration of the heart, we must have in our minds the liability to residual Overdistension (asystolie), which has been already several times observed in drunkards, and which explains the sudden or very rapid death sometimes observed in their cases. In other words, when we remem- ber that alcohol produces three principal lesions, to wit, fatty degeneration and cirrhosis in the parenchymatous organs, and atheroma in the vessels; and that in inveterate drinkers all the tissues and organs are more or less deterio- rated, and all the functions more or less compromised, we may understand that death may occur in several ways, and, in some manner, through all the more important organs. To certain lesions, however, correspond certain disorders which destroy life by a constant mechanism. In crushes of the limbs and compound fractures for instance, death occurs from acute septicemia. The centre of traumatism rapidly becomes the site ot an intense phlegmonous inflammation, which extends step by step, and soon involves the entire limb; the connective tissue is infiltrated with gas and putrid fluids; sphacelus at once attacks the contused parts, and cadaveric decomposition appears to commence before death. Surgical interference is almost useless; amputation and resection are unavailing. Antiseptic dress- ings applied immediately after the accident have saved some wounded alco- holics, but still permit the death of the larger number. 324 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. Morphinism. In regard to morphinism, we possess but few records, and those unaccom- panied with many details. Opium administered continuously, and in moderate doses, is rather favorable to the cure of wounds, and more than one surgeon has extolled its use in severe injuries. But, as in the case of alcohol, there is a great difference between use and abuse, and in the same way that there is an acute and a chronic alcoholism, there are also acute and chronic forms of poisoning by opium. The latter variety, which was formerly known only in the Orient, has in its turn invaded the Western world since the extensive employment of narcotics by subcutaneous injection. Chronic morphinism is the only variety with the effects of which upon the course of injuries we are somewhat acquainted. Thus at the locality of hypodermic injections have been noticed phlegmons, abscesses, and spots of gangrene ; at the site of operative wounds, erysipelas, bronzed inflammation, orange-colored suppura- tion ; in a word, complications which are very analogous to those observed in alcoholics, and in diabetic and albuminuric patients. While waiting for carefully made autopsies to show the nature of the histological lesions produced by slow morphia poisoning, experimentation and clinical study enable us to compare morphinism to the constitutional conditions described above. In fact, by injecting toxic doses of morphia in animals, we produce albuminuria, glycosuria, and ocular lesions which are comparable to those caused by these two diseases; and furthermore, examina- tion after death reveals intense congestion of the nerve centres, and of the liver and kidneys. Moreover, this albuminuria and this glycosuria have been already noticed in morphiomaniacs. Charcot, for his part, has observed the development of furious delirium in morphiomaniacs, and in a case of pneumonia this latter affection terminated in gangrene. It is easy to under- stand that opium-eaters should present at the seat of injury complications with which they might be affected at any point whatever, without its direct implication, and simply in consequence of the poisoning itself or of the visceral lesions which it produces. We know nothing of the reciprocal influence which traumatism may exercise upon morphinism. We will merely mention as a fact which is interesting to surgeons, that the use of chloroform demands special precau- tions in individuals who habitually make excessive use of morphia. Though relaxation is usually produced in them with readiness, the narcosis may be prolonged for an extremely long time, and may be accompanied by a depres- sion of temperature which, in some cases, has awakened well-founded a] •pre- hensions. As a sequel to these remarks on morphinism, we should no doubt speak of the more or less analogous intoxications caused by belladonna, tobacco, haschish, and some other narcotic substances. But, unfortunately, we must for the present, in absence of the necessary information, leave blank a space which the future will certainly fill. Saturnism or Lead-Poisoning. Animal and vegetable matters do not alone possess the baleful privilege of poisoning the organism, and of giving rise, like general diseases, to permanent constitutional conditions; the metalloids and metals also have the same property. We are in the possession of valuable knowledge with regard to this class of poisonings, several of which have even received special names. HEPATISM — NEPHRISM — CARDISM. 325 Thus we speak of iodism, mcrcurialism, and saturnism, and we shall soon speak of phosphorism, arsenicism, etc. The list will become very markedly extended as soon as shall be included in the pathology of artisans all the special morbid conditions produced by the constant employment of this or that toxic substance. These poisons naturally bring into the chemical composition of our fluids, and into the histological constitution of our tissues and organs, modifications, some of which have already been well described. Naturally, also, these dys- erasise and these peripheral or visceral lesions, modify the reparative process in cases of wounds. Unfortunately, we can here only form conjectures and hypotheses, surgeons not having hitherto concerned themselves with the manner in which injuries act in individuals poisoned by phosphorus, arsenic, mercury, etc. More anxious to mark a place for these investigations, than capable of illustrating the subject by my personal experience, I have made a short section on saturnism, as I have already collected some observations on wounds occurring in individuals suffering from lead-poisoning. In one, a contusion gave rise to a renewed attack of lead-colic; in another, an insignificant wound of the great toe was followed by lymphangeitis of rapid course; in a third, the onset of saturnism caused the reopening of a focus of suppuration which had been closed for ten years. Two amputations, one of the leg, the other of the arm, performed in patients of this class were not followed by any complications. No conclusions can be reached until we are in possession of a larger number of facts. Hepatism ; Nephrism ; Cardism. "We have already laid down the principle that every old or serious lesion of an important viscus, whatever may be its origin and causes, produces, after a longer or shorter interval, a change, first in the chemical composition of the fluids, and then in the anatomical constitution of the solids ; creating, in a word, a general morbid condition, imperfectly defined perhaps, but as dan- gerous to life as a well-determined disease. Such changes inevitably occur in patients suffering from affections of the liver, kidney's, heart, spleen, lungs, intestines, and doubtless also the brain. It is true that, in many of these individuals, the lesions of the liver, kidney, heart, etc., are neither primary nor isolated, and that they form part, on the contrary, of a pre-existing mor- bid entity — so that, for example, a patient suffering from hepatic disease is an alcoholic, one suffering from kidney disease is gouty, and one from heart disease rheumatic. Nevertheless, while taking the general disease into con- sideration, great interest attaches to an examination of the peculiar influence exerted upon it by the marked alteration of this or that viscus. In fact, constitutional diseases do not always implicate the same organs, and do not always affect them with the same intensity ; not all rheumatics suffer from cardiac disease ; not all alcoholics have a diseased liver ; and a patient may be gouty though the kidneys are in good condition. Clinically there is room for investigating (1) what differences would be presented by three rheumatic patients, one of whom had a mitral lesion, a second biliary lithiasis, and the third albuminuria ; and (2) the differences noticeable in three cases of hepatic disease, in which the causes of the lesions were alcoholism, syphilis, or pro- longed suppuration of bone. In the field of surgery these researches are no less important, experience having shown that injured persons are exposed to serious complications whenever one of the important viscera has been previously affected, and that 326 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. there are intimate relations between the nature of the complications and the lesion of this or that organ. 1 have thought it well to reproduce hero some of the information which we possess on this subject. It is necessary, how- ever, to remark that though the framework may be prepared, it cannot at this time be filled up. We possess somewhat precise information only in regard to those conditions which are produced by hepatic, by renal, and by cardiac affections ; in the future, the series will undoubtedly be made complete. Hepatism. — It is difficult to define this condition precisely, and to briefly indicate the general disturbances which characterize it, for the lesions of the liver are numerous; of very various kinds; often latent at the beginning, dur- ing their entire course, and even when they are in an advanced stage ; and finally are manifested by a sufficiently complex set of symptoms. Neverthe- less it is correct to say that they more especially affect the functions of the digestive and circulatory apparatus, and that they interfere with nutrition by the changes produced in the quantity and quality of the blood. Each distinct hepatic lesion (chronic congestion, atrophic or hypertrophic cirrhosis, fatty or amyloid degeneration, syphiloma, lithiasis, biliary reten- tion, cancer, cystic disease), evidently acts after its own manner and with more or less intensity upon nutrition, digestion, the peripheral or cardiac circulation,, and the composition and genesis of the blood. But from the point of view which we occupy, that is to say as far as concerns the relations of affections of the liver to injuries, the differences are not as marked as might be believed. In tact, in autopsies upon individuals suffering from hepatic disease, who have succumbed from the results of their wounds, the most varied changes have been found: fatty degeneration, cirrhosis, old perihepa- titis, amyloid degeneration, lithiasis, cancer, unrecognized hydatids, etc. Everything leads us to believe that when the number of cases shall be in- creased, less confused results will be obtained ; but, at the present time, we are compelled to satisfy ourselves with merely referring to the influence of hepatic affections, taken all together, upon traumatism, and vice versa. In the first place, we may declare, without fear of contradiction, that this influence is generally injurious ; that every wound is serious in a patient suf- fering from hepatic disease; that every such patient is in danger, and that in case of such coincidence, the prognosis is rendered gloomy by each of the two factors in the morbid association. After this statement, if we reflect upon the extreme frequency of secondary changes in the liver; upon its almost inevitable implication by toxic agents such as alcohol, arsenic, and malarial and septic poisons; upon its implication sooner or later when the kidneys, spleen, or heart are chronically affected; upon its almost certain participation in all cachexias (tuberculous, cancerous, purulent, etc.); we shall understand what weight hepatism possesses in the question of surgical indications and contra-hid ica- tions, ami we shall wonder that a fact of such gravity should have for so long a time remained unrecognized. The chief complications observed in these patients, at the region of the wound, are: inflammations of bad character; bronzed, erysipelatous, and dif- fuse phlegmons; sphacelus; wandering erysipelas, and, as a natural conse- quence of these local complications, grave traumatic fevers, septh-emia of an adynamic form, and pyaemia following a rapid course: secondary arte- rial, venous, or capillary hemorrhages are especially to be dreaded on account of their frequency and gravity, and the slight efficacy of ordinary hemostatic measures. The blood, moreover, does not How through the wounded vessels only, hut also escapes at a distance through the nasal and intestinal mucous membranes. Independently of these acute and serious accidents, we also find in these patients that the wound assumes a bad appearance, remains atonic HEPATISM — XEPHRISM CARDISM. 327 and languishing, furnishes an abundant but serous and fetid pus ; that, in a word, it presents no tendency to cicatrization. I have several times observed this torpid process in the anal region, even when there was no tuberculous lesion present in the lung. The wounds, however free they may themselves be from any unusual phe- nomena, may react directly upon the pre-existing hepatic! affection, causing, for example, the reappearance of jaundice, biliary colic, anasarca, ascites, ob- stinate vomiting, and anorexia, profuse diarrhoea, etc. Under this disastrous influence, a patient with hepatic disease who yet has been in a passable con- dition and threatened by no immediate danger, may soon enter into the period of cachexia, and finally succumb at the end of a few weeks or months. But the disturbing action of the traumatism may be still more rapid and terrible. Thus we may find a patient who suffers from cancer of the liver, cirrhosis, or biliary lithiasis, sinking, shortly after an injury, into a vague condition, bear- ing no name, and without any well-defined symptoms, and die in a few days, precisely as those do who are wounded while suffering from albuminuria or diabetes. The probabilities of the appearance of local complications, or of the recip- rocal action of the injury upon the hepatic condition, can in no wise be deter- mined from the nature or gravity of the injury. Life has been seriously threatened or even destroyed almost as often in consequence of slight injuries (leech bites, paracentesis abdominis, opening abscesses, simple fractures and dislocations), as after serious operations or grave wounds (compound fractures, severe contusions, herniotomy, castration, amputation, removal of tumors). ISTephrism. — This is the general condition observed in patients suffering from a grave renal affection, whether old or recent. This condition may be acute or chronic, temporary or prolonged, latent or revealed by more or less evident symptoms, among which the character of the urine occupies the chief rank. The part played by the urinary secretion in the depuration of the blood enables us readily to understand and, to a certain extent, foresee, the changes undergone by the nutrient fluid when the renal parenchyma does not fulfil its eliminating function. Xephrism is very like cases of blood-poisoning, with this difference, that the poison here does not come from without but from within, manifesting its effects as soon as it accumulates in the mass of blood > and making an effort to escape through complementary channels. At the same time that they prevent the necessary expulsion of superfluous and inju- rious matters, certain renal lesions also permit the spoliation of the blood by the untoward escape of useful substances, as is the case, for example, in albu- minuria. The blood, thus adulterated or impoverished, is ill-fitted for the nourishment of the tissues ; the poison, seeking unusual channels of escape, affects the various organs, so. that, at the end of a certain length of time, there is a true disease totius substantias; the digestive functions are lowered, the heart is affected, the peripheral circulation embarrassed ; the blood escapes from its channels, and serum accumulates, especially in serous or connective tissue spaces. Finally, the nervous centres themselves participate in the disorder. Renal affections, which are numerous, do not all produce nephrism with the same rapidity or intensity, but eventually, if persistent, they all end by ruin- ing the organism. Generalized, interstitial or parenchymatous nephritis, hydronephrosis, and cystic degeneration, are especially grave; then follow renal lithiasis and pyelonephritis; and finally fatty and amyloid degeneration. From a surgical point of view, however, we may repeat what has been said above with regard to affections of the liver, that is that we are not in a posi- tion to say which form of nephritis, for example, most seriously complicates 328 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. injuries, and, in its turn, receives from them the most disastrous aggravation. We must restrict ourselves to the statement that the coincidence of an injury and a renal affection (even if but slightly serious) gives occasion for a very unfavorable prognosis. The local complications of wounds in these cases are very similar to those which have been observed in patients suffering from hepatic diseases. Thus we note secondary hemorrhages, diffuse inflammations of the connective tissue or lymphatics, severe erysipelas, sphacelus, osteo-myelitis, pyaemia, and, as less serious complications, persistent oedema, extreme slowness of the reparative process, interminable serous suppuration, a puffy, bleeding, grayish appearance of the granulations, etc. The bad appearance of wounds is espe- cially noticeable when they affect tissues which have been already infiltrated, as occurs in cases of albuminuria. To these unfavorable conditions of the traumatic centre are naturally superadded general phenomena, and especially more or less active fever, often accompanied by chills. Such symptoms must not always be attributed to the existence of pyaemia. In fact, the attack which makes us fear the invasion of this terrible complication may be simply of renal origin ; that is to say, produced by the reaction of the injury upon the pre-existing disease of the kidneys. At the approach of death, it is not rare to find a very marked fall of temperature. If local complications of wounds carry off a certain number of patients with renal disease who have been wounded or operated upon, death occurs perhaps still more frequently from the inverse action ; that is to say, from the rapid or progressive aggravation produced by the traumatism in the pre- existing renal lesions. Among operations, we must particularly mention those performed on the urinary apparatus itself, such as lithotomy, lithotrity, and urethrotomy, and also the incisions rendered necessary by hemorrhagic or urinary infiltrations. If we suppose them to have been properly per- formed, and the after-treatment judiciously conducted, these operations are benign when the kidnej^s are sound or but slightly changed ; but things are very different when any form of nephritis is present. The mortality then becomes considerable ; those operated upon usually succumb in a few days with the general lesions which characterize the last stages of renal affections abandoned to themselves, to wit, diffuse inflammations, gangrene, serous effusion into the pleural and pericardial cavities, pulmonary oedema, and ursemic accidents, such as coma, dyspnoea, eclampsia, etc. Peripheral wounds and operations may also lead to rapid death, even though the seat of traumatism does not appear abnormal ; but the progress of the compli- cations is usually less violent ; a latent albuminuria becomes evident or is aggravated ; nephritis declares itself, with fever, dyspeptic disorders, vomit- ing, dryness of the tongue, etc.; anasarca appears or becomes more extensive. .Ml may then do well ; but it is not rare to find that the renal affection thus excited assumes a progressive course, and increases continually until it pro- duces death, a longer or shorter period after the healing of the wound. An injury bus mare than once given rise to the first appearance or sudden return of nephritic colic. Traumatisms affecting certain regions of the cen- tral nervous system bave produced albuminuria and polyuria, usually, how- ever, only temporary. AVounds of the kidneys themselves are serious when they give rise to oliguria, and especially to anuria; for these symptoms, though accidentally produced, imply a condition of the economy which is as serious as if tiny resulted from an old renal lesion. We shall not thoroughly understand flic reciprocal influence of injuries and of nephrism until it shall have been demonstrated that all wounds modify the composition of the urine, that every modification of the urine implies a corresponding change LOCOMOTOR ATAXIA AND VARIOUS NEUROSES. 329 in the composition of the blood, and that this modification may in certain cases act upon the reparative process. Cardism. — Even severe disturbances of the central circulation do not derange the course of the reparative process, if they are temporary. On the contrary, valvular lesions and degenerations of the muscular tissue of the heart may, by changing the static and dynamic conditions of the entire circulation, modify the chemical composition of the blood, cause impairment of important viscera like the liver or lungs, alter the connective tissue which is so necessary to cicatrization, and, in a word, create, locally as well as throughout the entire economy, conditions which are very unfavorable to the proper evolution of the process of cicatrization. Thus passive hemorrhages, either prolonged primary, or early or late secondary bleedings — difficult to check in all cases — have been observed in patients thus affected, together with considerable oedema of the wounded region, and, at the site of the swelling, patches of erythema, of erysipelas, and even of gangrene, such as are met with in all infiltrated tissues, whatever be the cause of the infiltra- tion ; and, finally, a local atony which readily metamorphoses the wound into an ulcer, and indefinitely delays cicatrization. The reaction of the injury upon pre-existing cardiopathies, is still more serious, without reference to the grave, even fatal, attacks of syncope which may follow immediately upon the injury. It is very frequently found, in cases of fatty degeneration of the heart, that the circulation and respiration become embarrassed, and that the wounded person rapidly succumbs, without anything having foretold this termination, and when everything has appeared to be doing well. The catastrophe has been more than once attributed to the efi'ect of chloroform, or to shock, though simply due to the sudden or slow stoppage of an already affected heart. In less severe cases, the traumatism merely reveals cardiopathies which had been hitherto misinterpreted or even ignored by the patients ; intensifies the symptoms, especially the anasarca and serous suffusions ; and increases the phenomena of oppression, of dyspnoea, by aggravating the secondary disturbances on the part of the lungs. We possess but little information in regard to wounds in individuals suf- fering from aneurisms of the aorta. I nevertheless know of the rupture of an aneurismal sac (the existence of the blood-tumor not having been previously suspected) in consequence of the simple puncture of a hydrocele. Operations are often performed upon limbs affected by arterial atheroma, and it is said that secondary hemorrhage is to be apprehended in such cases. This assertion does not appear to be well demonstrated, and there is much more reason to fear gangrene, in cases of contused wound, or complete or partial sloughing of the flaps of an amputation. There is also danger of a complication which is perhaps even more grave ; starting from the injured point, the vessels become inflamed, and an acute endarteritis descends towards the periphery and mounts to the endocardium, producing all those consequences which can readily be foreseen. Locomotor Ataxia and Various Neuroses. This disease, which affects the nutrition of certain tissues, chiefly the bones, predisposes on this account to fractures and to those peculiar atrophies of the epiphyses, the point of departure of which is sometimes found in external violence. Some facts also tend to prove that cicatrization progresses slowly or imperfectly in the wounds of ataxic patients. The reciprocal influence of traumatism upon ataxia is better established. 330 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. In the first place, wounds which involve the spine directly and the spinal cord indirectly, readily give rise to chronic myelitis, the symptomatology of which is very like that of ataxia, in certain cases. It has been asserted that wounds affecting the limbs, that is to say at a distance from the spinal cord, may also give rise to ataxia. This is doubtful, and it is much more probable that the violence merely plays the part of an exciting cause giving rise to the premature appearance of the phenomena in predisposed subjects. At all events, there is no doubt that ataxia is usually exaggerated and aggravated by injuries, whether or not they affect the region of the spine. It has been held that certain operations favorably modify or even cure ataxia. But this is a mistake; this affection has been confounded with nervous disorders of re- flex origin, which have been relieved by removing the point of peripheral departure. Injuries sometimes present, in neuropathic individuals, a defec- tive evolution and numerous local complications ; analgesia, hypera?sthesia, simple or hemorrhagic congestion, lesions of the granular membrane, delay in cicatrization, etc. As a result of wounds of nerves, and of limbs formerly affected by infantile or other forms of paralysis, superficial or deep ulcera- tions are found to occur, which are attributed to trophic disturbances, and which are at all events very painful and extremely difficult to heal, especially in winter. Reciprocally, in the same neuropathic patients, an injury may excite, revive, or exaggerate nervous manifestations which assume the strangest forms, and which attack the central and visceral nervous systems, as well as general motion and sensation. Among defined neuroses, hysteria and epilepsy present close relations to traumatism. In addition to the fact that they sometimes seem to be directly due to injuries, affecting especially the genital apparatus in woman, and the brain in both sexes, it is certain that wounds of the most diverse character as regards situation and extent, have the power of exciting hysterical or epilep- tic attacks, often indeed with extreme violence. On the other hand, we find mention made by authors of more than one case of epilepsy cured by an acci- dental wound or by premeditated operation. There has been considerable discussion as to whether insane persons tolerate wounds better or worse than other individuals, and the most contradictory facts have been adduced in re- gard to the matter. The fact is that it is impossible to class together the subjects of mania and those of dementia ; those who are excited, with the victims of general paralysis ; those whose brains are affected by alcoholism and those affected by old wounds. With such a variety, it is neither possible nor useful to attempt a generalization ; and a detailed investigation would not be in place in a work of this character. Diabetes Mellitus. All are agreed concerning the unfavorable course of wounds and the gravity of operations in diabetic patients. The reparative process is often absent, or at hast very slow, and interrupted by numerous complications. In open wounds are noticed primary capillary hemorrhages, which are difficult to arrest, and also secondary hemorrhages; in contused wounds, diffuse inflam- mation, bronzed phlegmons, and extensive sloughing. Insignificant wounds such as punctures and excoriations, become inflamed and provoke lymphan- geitis, erysipelas, and phlegmons which become complicated by gangrene en masse or in isolated patches, and the progress of which is with great diffi- culty arrested. Slight operations, followed by immediate union, have often presented similar complications. Even the moderate pressure of an apparatus hae produced circumscribed gangrene of the skin. Subcutaneous wounds are PHOSPHATURIA. 331 less serious, but fractures unite with great difficulty. Diabetic phlegmon and gangrene sometimes progress slowly and without provoking an}' very violent or grave general symptoms, but they none the less terminate in death, in the majority of cases, especially in old persons whose internal organs are in a bad condition, and when suitable treatment has not been employed in time. Traumatism affecting the region of the medulla oblongata, either directly or indirectly, may, as is well known, produce glycosuria which is usually of short duration, and which undergoes spontaneous cure. Wounds affecting a diabetic subject generally aggravate his condition. The sugar, which had disappeared, shows itself again, or becomes more abund- ant. This is espeeially observed in operations upon those who have been previously recognized as diabetic, and in whom the sugar has been made to disappear from the urine. This return of glycosuria may be temporary, but it may also hasten the development and natural termination of the disease. Wounded diabetics may recover, but they may die in several ways ; in the first place, from inflammatory or septic complications which have started in the wound ; then of complications on the part of the brain, heart, or lungs ; and finally they may rapidly die in a sort of adynamic condition which we cannot attribute to any well-defined local or general complications. The gravity of the prognosis is greater as the wound or operation is more serious, as the quantity of sugar is larger, and as the diabetes is accompanied with more advanced visceral lesions. The distinction established by modern writers between glycosuria and dia- betes is admissible to a certain extent, but we must not trust to it too much, and regard as benign those wounds which occur in individuals who pass but little sugar. It is equally incorrect to regard as favorable the substitution of albumen for sugar in certain diabetics. Except in urgent cases, we should never operate upon a diabetic patient, until we have made the sugar disap- pear as much as possible from the urine. Alcohol-diabetes. — Although it has not yet been referred to, the associa- tion of alcoholism and diabetes cannot be very rare, if we take into account, on the one hand, the polydypsia natural to diabetics, and, on the other, the advice given these patients to take stimulating drinks. As poisoning by alco- hol and poisoning by sugar both give rise to quite similar complications in the traumatic centre — diffuse inflammation, erysipelas, gangrene — it is not sur- prising to find that in the subjects of alcohol-diabetes, wounds, which were at first slight, are followed by serious and rapid complications. Thus, I have seen a puncture or contusion cause very extensive sloughing, and catheteriza- tion give rise to double, rapidly fatal nephritis. While an autopsy often gives negative results in cases of simple diabetes, in those cases of alcohol-diabetes which I have seen, grave visceral lesions have been noted — cirrhosis, old peri- nephritis, double nephritis — which were very probably the results of the alco- holism, and which would by themselves have given rise to the fatal termina- tion without the concurrence of the diabetes. More numerous observations will permit further study of this interesting variety of hybrid disease. Phosphaturia. Glycosuria is not the only form of diabetes ; in the same rank must be placed simple polyuria, or diabetes insipidus; phosphaturia, or phosphatic diabetes ; azoturia, and finally uric diabetes, which alternates so frequently with diabetes mellitus. Who knows indeed whether the list will not become more extensive, and whether it will not be necessary, at some future period, 332 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. to add the exaggerated elimination of the chlorides, or of any other sub- stances contained in the urine? For the present, I have but little to say in regard to the relations existing between injuries and these various forms of diabetes. In a very large and stout man a slight contused wound of the leg did not heal, and tended to become transformed into an ulcer. Examination of the urine showed that the patient was azoturic to a high degree. On the other hand, a young scrofulous individual passed daily from 12 to 15 litres [121 to 16 quarts] of urine as clear as water. Disarticulation of the first meta- tarsal bone had to be performed ; it was followed by no complication, and the wound healed without delay or difficulty. I have collated more abundant and more interesting material with regard to phosphaturia. It has, in the first place, appeared to me to play an im- portant part in fragilitas ossium, and in the spontaneous fractures which occur without previous circumscribed lesions. Certain facts would permit us even to establish relationships between organic affections of the bones and phos- phaturia, although it is impossible to decide whether the latter be cause or effect. We will often find an exaggerated elimination of phosphates in eases of polyuria in scrofulous children suffering from osteitis. I have several times observed the disastrous influence exercised by phosphaturia upon the local progress of injuries. I have noted, for example, a consecutive hemorrhage, a diffuse phlegmon, orange-colored suppuration, purulent destruction of the eye after the operation for cataract, marked delay in the union of fractures, etc. As a sequel to well-characterized maladies, it would be proper to study, in their relations to accidental or surgical injuries, certain temporary states which assuredly are not pathological in "the literal sense of the word, and yet during the duration of which, the organism finds itself under peculiar conditions. These states include dentition, puberty, menstruation, the menopause, pregnancy, the 'puerperal state, and lactation. In the opinion of the public, these con- ditions have a very manifest influence upon previously existing or inter- current diseases, and it would be very useful to know exactly whether it were the same in regard to wounds. The question of surgical interference, also, arises very frequently in the two extreme periods of life, infancy and old age. Opinions differ widely as to the course of injuries and the manner in which they are tolerated under these circumstances. Unfortunately we have not sufficient materials to clear up all these problems ; we barely possess a few facts in re- gard to pregnancy and the puerperal state, and to operations in childhood and old age. . I give here a brief summary of what is known to science upon these subjects. Pregnancy. This question was debated at length in the International Congress of Geneva, in 1877. It was established that pregnancy and traumatism may run their course parallel to each other in a normal manner, without influ- encing cadi other in the slightest degree, even when the injuries are extremely severe; thai pregnancy may disturb the reparative process by delaying or hindering healing, and by giving rise to various wound-complications at the injured poinl ; it may also aggravate certain non-traumatic affections in such a manner as to render necessary and even urgent, operations which, in the non-pregnan1 condition, could have been avoided or postponed. The delay or hindrance in the healine of wounds, which is produced by pregnancy, may cease immediately after delivery, which restores to the reparative tendency all its power. Accidental or operative wounds, even the slightest, may interfere with PREGNANCY. 333 gestation in several ways : by provoking abortion or premature delivery ; by causing the death of the mother with or without that of the child, and either before or after that of the child. The normal termination of the pregnancy, that is to say the reciprocal independence of the traumatism and of the pregnancy, may be foreseen and announced : when the wound is remote from the genital apparatus ; when it affects healthy tissues ; when it is slight, simple, and not complicated pri- marily or consecutively by any accident capable of transforming the wounded person into a sick one ; and when, on the other hand, the uterus, the foetus, and its annexes, are anatomically and physiologically normal, and when the ma- ternal organism, which has been suddenly subjected to the injury, is sound or nearly so, that is to say free from all constitutional disease existing either before or after fecundation, and when it remains so afterwards. The injurious influence of traumatism upon pregnancy and the various ter- minations which follow, may, in turn, be foreseen and declared : when the wound affects the foetus and its annexes, the uterus, and the other organs pertaining to the genital sphere, and when these parts are, in advance, altered in various ways ; when the wound is extensive or grave in itself, or when it affects organs essential to the life of the mother ; when the mother has suf- fered, before the reception of the wound, from a constitutional morbid condi- tion, or from a circumscribed affection which renders abortion possible and probable ; or when some complication starts from the wound or its immediate neighborhood, and is at all events capable of weakening, shattering, or poi- soning the maternal or foetal organisms. We may hope for and declare the favorable, though indirect, action of sur- gical traumatism upon pregnancy, when, by the aid of even a serious opera- tion, we can succeed in removing an affection which is still more dangerous to mother and child. The aggravation of certain morbid conditions in the pregnant woman is explained by the general or local modifications which pregnancy produces in the circulation, in nutrition, in the composition of the blood, and in the gene- sis of anatomical elements ; and in the same manner is explained the favor- able action of delivery, which suppresses various pathogenetic causes. We can understand the hurtful effect of the puerperal condition upon trauma- tism contracted after delivery, if we take into consideration the conditions then presented by the injuries which, in fact, often involve tissues that are altered, or profoundly modified in their structure and properties ; indi- viduals already wounded by the mere fact of the uterine trauma ; women already sick in consequence of pregnancy itself or of the constitutional condi- tions which may be associated with it. Whenever a woman, during the period of fecundity, is wounded accidentally or as the result of a surgical operation, we should always determine whether she is in a condition of preg- nancy or not. In the former event, we should note with extreme care, imme- diately after the injury or before the operation, the organic conditions of the mother, the state of her genital apparatus, and that of the product of concep- tion. In case of an accidental injury, the local and general treatment should be^ directed to moderating or preventing the direct or indirect, disastrous effects of the wound upon the genital apparatus ; to maintaining the patient in, or restoring her to, the condition of one who is simply wounded, and to prevent her from being changed into one who is sick ; to palliating or com- bating every injurious effect of pregnancy upon the reparative process ; in a word, to preventing abortion. When abortion occurs, we should watch the wound to ward off" any possible aggravation, and the uterus to prevent the septicaemia of which it is sometimes the starting-point and the seat. 334 RECIPROCAL EFFECTS OF CONSTITUTIONAL CONDITIONS AND INJURIES. Surgical interference is not interdicted during pregnancy, but is subject to special rules. We should operate upon a pregnant woman with the greatest reserve, and sometimes refuse absolutely; but it would be an equally grave fault to abstain systematically in all cases. The affections which are amenable to operation — more numerous during gestation than during the non-pregnant state — are divided into several categories which suggest the following rules of practice : — To operate at once in those affections which immediately endanger the life of the mother, and against which medical treatment would be certainly or almost certainly unavailing ; To operate also, at a suitable time, and after having tried palliative or curative remedies, in those diseases which, although not immediately com- promising life, endanger it by their progress, and tend to become incurable if not met with energetic treatment ; To operate also in those affections which, without disturbing pregnancy and without being aggravated by it, become, at its termination, causes of dystocia. In these cases, the surgeon may operate before or at the very period of delivery, upon the mother or upon the foetus, the premature expul- sion of which may be induced. An attempt should be made to save both the maternal and foetal lives, but, if this be impossible, the latter must be unhesitatingly sacrificed to the former ; To abstain, as far as possible, in those affections which are uninfluenced by pregnancy — and which, in turn, only compromise pregnancy and parturition indirectly — by, as far as possible, allowing nature to act, and by aiding her by mild measures ; To abstain absolutely from every operation for affections which compromise only the form or function of organs of secondary importance, or wdiich are susceptible of spontaneous cure after delivery ; To avoid, as far as possible, every operation during the puerperal state. In case of danger, to operate rather during pregnancy, and, under opposite circumstances, to postpone interference until a period sufficiently remote (two to four months) from delivery. Infancy. The benignity of wounds and surgical operations in children is universally admitted, and the explanation, moreover, is simple. In fact, at this period of life, constitutional diseases are not deeply rooted, but of recent date; the viscera are lor the most part healthy ; and connective-tissue proliferation and regeneration of tissues occur with promptness and energy, etc. We must not, however, regard this benignity as a rule without exceptions. Athrepsic children, poorly nourished, syphilitic, or tubercular, or who suffer from calculus with nephritis, readily fall a prey to the consequences of their wounds. In this long period of childhood, moreover, we should establish categories according to the age, and consider also the particular variety of operation which is in question. The new-horn, for example, support loss of blood and restricted diel very badly ; and the resulting contra-indieations continue at least until the twelfth or fifteenth month. It is for this latter reason that we postpone until the fourth or fifth year, if not later, complicated operations upon the mouth, lips, hard or soft palate, etc. The small size of the parts also relegates to the period of late childhood certain anaplastic operations upon the penis and lingers. Finally, we wait still longer before undertaking the cure of certain imperforations in the female sex. OLD AGE. 335 Old Age. Some old people, whom we should rather call aged than old, tolerate trau- matic lesions as well as adults. In others, on the contrary, the reparative process remains imperfect. Interstitial wounds suppurate ; immediate union fails ; local inflammations do not remain circumscribed ; gangrene attacks the detached and thinned integument ; simple fractures unite slowly ; severe contusions are complicated by diffuse phlegmon and sloughing. At other times, the seat of traumatism remains indolent, without tone, and languish- ing ; but threatening internal inflammations are set up ; pneumonia, nephritis, meningo-encephalitis declare themselves, followed by their train of general adynamic or ataxic symptoms, and death promptly ensues. The autopsy almost always reveals a previously existing bad condition of the great viscera, which entails the same consequences as in adults. In individuals who are apparently healthy despite advanced age, the organs have sufficed for the needs of a regulated and tranquil life; the traumatism occurs, gives a shock to the economy, stirs up old morbid susceptibilities, and destroys an organi- zation which has only maintained itself in equilibrium, as it were, by accident. GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. BY D. HAYES AGNEW, M.D., LL.D., BARTON PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. Operative Medicine must be based on exact knowledge. The cunning of the hand can be safely directed only by the wisdom of the head. To be able to discriminate, with accuracy, the various morbid conditions of the human body, is the highest qualification of a physician. Such knowledge can only be attained by large experience, by habits of close observation, by the ability to logically dispose of, or classify, phenomena, and by the possession of a sound judgment. In the formulation of phenomena gleaned from the domain of physics, the student is concerned with matter alone, the behavior of which is, under like circumstances, uniform. The physician also has to deal with material forms, but these forms are instinct with life and intelligence, factors which necessarily render the problem for study vastly more complex and more difficult of solution. It is, consequently, no easy task to accurately interpret the phenomena of disease, and to ascertain with absolute certainty its true nature; and yet it is only when such knowledge has been obtained that the physician or surgeon can safely venture to administer remedies or to counsel operations. The diagnostician, to be properly equipped, must have cultivated an exten- sive domain of study. Anatomy, Physiology, Pathology, Chemistry, Physics, and Mental and Moral Philosophy, constitute the foundations of diagnostic knowledge. In pursuing the investigation of surgical disease, two methods are practised, namely, the analytical and the synthetical. By the first, the surgeon com- mences his inquiries at the origin of the affection, and traces it down to the time of the investigation ; by the second plan, the examination commences with the present phenomena, and follows them back to the beginning of the disease. Generally the first or analytical method is pursued", although the latter, or synthetical, will, in certain instances, be found preferable. The examination will, in the largest number of cases, be most successful when it is introduced by eliciting a general history of the complaint, and afterwards obtaining particulars. Such a course is less embarrassing to the patient, and tends to establish the practitioner in his or her confidence. The obscurity which attends some cases may require that both the analytical and the synthetical methods shall be employed, and even then, it is not impossible that the secret of disease may defy and baffle the tactics of the wisest diag- nostician. Whenever the surgeon is compelled to abandon certitudes, and to base his opinion on probabilities, he is on dangerous ground, and should either advance cautiously or not advance at all; the latter course should, by all means, be adopted when there is no urgency for active measures to be taken. A few vol. i.— 22 ( 337 ) 338 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. hours' delay will often clear away all obscurity, and render perfectly plain problems which were before insoluble. Difficulties in Surgical Diagnosis. The difficulties which environ the investigation of disease, arise from several sources. Among these may be mentioned the reluctance with which many consent to communicate any information calculated to affect unfavorably the social or physical standing of themselves or those who may be related to them by consanguinity. This difficulty can be overcome only by the personal tact of the surgeon. In this matter there exist very great differences among practitioners. Some men, either from constitution or education, are unfor- tunate in never being able to secure the entire confidence of a patient, while others, more favored^ by a kind, sympathetic manner, an insinuating address, and other amenities which impart a loadstone attraction to character, will, in a few minutes, obtain such a mastery over the will and the affections of the patient, that nothing will be withheld. There are also constitutional pecu- liarities and idiosyncrasies, which impart to the phenomena excited by morbid impressions unusual characteristics, altogether dissimilar to those developed in most persons under the operation of like causes. The similarity of the morbid phenomena, which may result from diseases altogether unlike, con- stitutes another source of embarrassment, as do also the wide range of sym- pathy which prevails in the human body, and the reflex impressions which tend to disguise their original source, thus diverting the attention from the real to the unreal. The interrogation of a patient, like that of an unwilling witness in a court of justice, requires considerable skill. Sometimes it is desirable 'to allow the patient to narrate the history of his own case, provided that he adheres strictly to the subject of inquiry, and does not wander off into useless digres- sions, or matters altogether non-essential. A license of this kind will often disclose peculiarities "of character which will prove of value in the general estimation of the case. Questions should 'be put in plain words, free from all ambiguity and from technical terms. The answers of the patient should be as brief and concise as possible, or as may be consistent with furnishing the desired information. In order to secure exactness and brevity of statement, no leading or sugges- tive questions should be asked. Undue levity of manner, either in interroga- tion, or as excited by the language used by the patient, is to be deprecated. Such a manner is calculated to wound the sensibilities of the sufferer, and lays the profession open to the charge of being unfeeling. It is not to be expected, that the uneducated should describe their sensations in grammati- cally constructed sentences, or in the most fitting words. When it becomes necessary to question women on matters of a private nature, the inquiries should be framed in the most delicate language, and should never be pressed beyond the strict bounds of propriety, or from motives of curiosity. With young women, much embarrassment is avoided l»v addressing the questions, and obtaining the answers, through a mother or elderly friend, rather than directly to and from the patient. The influence of disease in changing the morale of the sick must never be forgotten. Under morbid influences, the most amiable character may be transformed into cue which is fretful, irascible, or morose; and hence the necessity on the part of the surgeon of making due allowance for deportment which, under other circumstances, would be regarded as uncivil and inexcus- able. GENERAL EXAMINATION: HISTORY OF THE CASE. 339 Unless absolutely necessary, no exposure of the person should be made in conducting examinations; nor should the use of instruments be repeated oftener than the nature of the case demands. In fine, the strictest formality and absence of familiarity ought to be maintained between the surgeon and his patient, alike with the poor and unlettered, as with the rich and cul- tured. In the examination of a case, whether medical or surgical, the inquiry will be both general and special. In the former, or general examination, the ques- tioner endeavors to obtain, from the patient or his friends, a history which will include the particulars of age, sex, social condition, habits, occupation, residence, family antecedents, etc. The special inquiry will be confined to obtaining such information as may be learned by a personal examination. General Examination: History of the Case. Aoe. — The influence of age in giving shape to surgical inquiries, and in solving the problem of disease, is very important. The notable irritability of the nervous system in childhood and adolescence, impresses a peculiar physiognomy on most of the affections belonging to infantile life. For ex- ample, the irritation of a resisting gum, in dentition, may be reflected to the remotest parts of the body, and may cause the most disorderly and spasmodic action of the entire muscular system. Such phenomena, when occurring in an adult, would be referred to an entirely different source, and would excite ap- prehension of a much graver state of things than when the subject is a child. A pain in the knee, in a child, would immediately direct attention to the hip-joint. Abdominal pains and grunting respiration would suggest the pos- sibility of disease of the vertebra?. Cervical enlargements, which in the adult probably would be regarded as cysts, carcinomata, or sarcomata, would in the child be construed as adenomata. Vesical irritation in children suggests the presence of urinary calculus, while in a person advanced in life, the same symptoms would be referred to cystitis or to an enlarged prostate. In lesions resulting from violence, affect- ing the extremities of bones in children, the probability of a separation of the epiphysis, an accident which could not occur in an adult, would necessarily enter into the consideration of the case. A force which in a young adult would cause a fracture at the upper end of the femur, external to the capsu- lar ligament, would be likely, in an individual over fifty or sixty years of age, to produce a similar lesion within the joint. Finally, the diseases pecu- liar to childhood are the different exanthemata, as scarlet fever, measles, etc.; inflammatory affections of the upper part of the alimentary and respiratory passages — as, for example, tonsillitis, diphtheria, laryngitis, and tracheitis — are also common in youth. In middle life, inflammatory attacks affecting the thoracic, abdominal, and cranial viscera, are most commonly met with ; while in advanced life, the characteristic maladies are such as affect the genito- urinary organs, or cause structural degenerations in the bloodvessel system. Sex. — There exists such a radical difference between the physical and psy- chical nature of the two sexes in health, that it is reasonable to expect that their peculiarities should be intensified under the perturbing operation of disease. In the moral constitution of women, the emotional element prepon- derates, and in the physical organization, the sexual system. The reaction of the latter on the former imparts a coloring to all morbid phenomena — hence the hysterical convulsions, hysterical joints, fictitious blindness, irritable bladder, etc., which are encountered during the active period of the uterine 340 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. and ovarian functions ; while after the climacteric has been passed, woman often becomes the prey of those horrid fibroid and carcinomatous neoplasms which attack the uterus and the mammary glands. Men, on the contrary, enjoy a singular exemption from hysteroidal attacks, as they also do from carcinoma. If a man complains of uneasiness or pain in a joint, it is gene- rally real — rheumatic, gouty, or symptomatic of some other form of inflam- mation — and not a mimicry of disease ; if a limb suddenly loses its power, the paralysis is real, and not a simulation ; if an irritable bladder is developed, there is a reasonable certainty that there is a true physical basis for the dis- turbance, such as stone, cystitis, or an enlarged prostate. Should he become the subject of cancer, the disease will most likely prove to be of the epithelial variety, and will probably be seated on the lip or in the rectum; and if he is seized by a convulsion, epileptic or otherwise, the idea of central or cerebro- spinal lesion will be naturally entertained. Both sexes furnish examples of cardiac derangement. In the male, they are not often present unless some structural change has taken place in the heart and bloodvessels, such as valvular disease, atheroma, or aneurism ; while in the female, they are quite as frequently the result of reflex irritation. Hernia is met with in both sexes ; but while inguinal hernia largely outnum- bers all other varieties in the male, in the female sex, the femoral variety is very common. AVhile, however, in the main, the portrait which has been drawn is a true one, yet the surgeon must never assume, without a most critical and exhaustive investigation having first been made, that, because the patient is a woman, certain symptoms have no real or substantial basis. Indifference to this caution has cost many women their lives, the disease having been unrecognized until too late to admit of a remedy. Occupation is not only a fruitful cause of disease, but determines in many instances the nature of the morbid process. The worker in a manufactory of lucifer matches, provided that a defective tooth exists in the jaw, is prone to suffer from phosphor-necrosis of the maxilla. The painter becomes the subject of lead colic ; the chimney-sweep, of soot-cancer of the scrotum. Persons who are employed in the manufacture of chemicals, who are constantly exposed to contact with irrespirable gases, or who are habitually engaged in sand-paper and glue establishments, not infrequently fall victims to serious disease of the air passages and lungs. The house-maid, some of whose duties require her to be much in the kneeling posture, is liable to have an enlarge- ment of the patellar bursa. Plumbers and other persons whose occupations call them to labor in damp or wet localities, such as ditches, drains, etc., are peculiarly predisposed to rheumatism. A particular occupation or trade may produce such alterations in the form or symmetry of the body as, if not understood, would be apt to create much unnecessary apprehension in the mind of the surgeon. Thus, the shoemaker or the tailor, toiling day after day over the lap-stone or the lap-board, becomes round-shouldered, and finally gets a curved spine, or changes the form of Ins breast; while the boy who is constantly engaged at the lathe, destroys, by the habitual use of the same foot, the bilateral symmetry of the lower extremities. Eabits. — The influence of habit not only constitutes a powerful element in the production of many of the affections of the body which become the sub- jecta of medical or surgical attention, but, when recognized, materially modi- lies prognosis, and explains phenomena which otherwise would be exceedingly obscure. Thus we have defects of vision which are induced by the excessive use of tobacco ; except for the knowledge of the existence of this practice, the appearances of the eye would excite serious apprehension for its future. The GENERAL EXAMINATION: HISTORY OF THE CASE. 341 same habit, not infrequently, is instrumental in producing follicular pharyn- gitis, but the prognosis will be very different in a case of this nature arising from smoking, and in one symptomatic of pulmonary disease. The surgeon's opinion in regard to a sore on, or a discharge from, the male or female geni- talia, will be influenced in no small degree by the known purity or depravity of the patient. But, on the other hand, a chaste and virtuous young woman, or an innocent wet-nurse, may suffer unjustly in character, the one having been infected by an impure kiss from a lover whose lip bears a syphilitic crack, and the other by suckling a syphilitic child. In childhood, a prepuce elongated by habitual traction with the fingers, at once excites the suspicion of either stone in the bladder or the existence of a tight phimosis. Sexual weakness, when ascertained to be the result of venereal excess, assumes a very different importance from that which it possesses when induced by the oxa- late of lime diathesis, or by spinal concussion. Antecedent History. — This embraces a history not only of the past life of the patient, but also of that of his ancestors. Nothing is better established than the transmissibility of disease. It is much more likely to abide with tlie children, than the wealth which they inherit. Singularly enough, it some- times happens that morbid legacies will skip a generation and appear in the succeeding one, although such cannot be said to be the rule. The value of a knowledge of antecedents in imparting certainty to diagnosis, is incalculable. A patient who in the past has been the victim of syphilis, and who, after probably the lapse of years, is attacked with pains in the course of certain bones, will demand a different kind of treatment from that proper to a case of idiopathic rheumatism ; and the same will be true of an iritis arisino- from a similar cause. There are many instances of persons who exhibit symptoms of pulmonary disease, but in whom no detectable lesion exists. The physi- cian may be in doubt as to the necessity of a change of climate, but if it be shown that a maternal or paternal ancestor has "died of tuberculosis, that doubt will be immediately solved and the change advised. A pain in the knee or in any other articulation of a child, awakens much more anxiety when it is known that there is an antecedent history of tubercular disease ; and so in the clinical investigation of obscure tumors, the diagnosis is influenced in no small degree by what can be learned with regard to the physical sound- ness or unsoundness of ancestors and other relatives. Personal History is no less important than a history of antecedents in interpreting morbid phenomena. In this is comprised acknowledge of con- stitutional peculiarities. An individual possessed of a sanguine temperament, as manifested by the possession of a strong and vigorous heart, a full and bounding pulse, a florid complexion, a warm surface, and the other signs of a dominating vascular system, is one predisposed to acute inflammation of different organs. Apprised of such a constitutional predisposition, the sur- geon will be ever on the alert, anticipating these complications, and pre} tared to combat them before they have gained strength or have become fully entrenched. The patient may possess a phlegmatic temperament, character- ized by a dark complexion, a lazy circulation, and obtuse sensibility, with the mental operations and bodily movements alike conducted sluggishly. Individuals so constituted are stolid, indifferent to suffering, and disposed to endure quietly rather than complain by word or other demonstration. Here the tendency, on the part of the medical attendant, is to undervalue the power or severity of the disease or injury, and to be betrayed into a false sense of security while the mischief is underrated or is not detected until too late for successful management. Allowance must also be made for persons 342 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. of a nervous temperament, those restless individuals with quick movements, whose circulation is easily excited, and who endure pain badly. Their excessive sensibility and easily extorted complaints must be largely discounted. There is another aspect in which personal, antecedent history should be considered, and which must influence diagnosis. Thus if a joint should suddenly become swollen and painful, the disorder, aside from any previous history, might be attributed to very different causes; but if it were ascertained that, immediately before the occurrence of the trouble, the patient had met with a fall or a violent wrench of the limb, all the phenomena would be referred to a sprain. If it should be known that an attack of epilepsy had been pre- ceded, at some interval, by violence applied to the head, it would not only be logical to refer the convulsion to a traumatic origin, but a knowledge of the fact would be of the utmost value in determining the propriety of operation. In a case of facial paralysis, both the diagnosis and the prognosis would be modified by learning that the loss of power had followed a blow below the ear. A person picked up in a state of coma, and with the smell of liquor on his breath, might be subjected to a damaging and unjust criticism; one which would be quickly recalled if it should afterwards appear that the patient had fallen or been precipitated headlong from his carriage or his horse. In certain cases of convulsions resembling those of tetanus, hysteria, or mania, how much light is shed on the disease, when it is known that the patient has been bitten by a rabid dog! Xot infrequently information on some of the above conditions can only be obtained from some person other than the patient himself. Mental and Moral States. — The influence of the mind and emotions over the functions of the body, is perhaps too often under-estimated. Such influences are notably concerned in causing disturbances of the various secre- tions. Under the feeling of fear, the action of the salivary and other glands of the mouth and pharynx may be for a time entirely suspended, and the throat rendered so dry that nothing solid can be swallowed. A marked suppression of urine will occasionally occur as a result of great mental anxiety or distress. Profound grief, which no formula of words can express, is often denied the relief of tears, from the operation of the lachrymal glands being completely arrested. The harass and worry of business cares will sometimes beget an irritable bladder. Permanent impotence has been produced by fright. The shock following the communication of unwelcome tidings has developed a heart murmur; and the effects of fear, of remorse, or of disappointment from the miscarriage of cherished plans at the moment of their expected consumma- tion, are always unfavorable to the reparation of surgical injuries. Then there is an anient temperament, which, when associated with a highly wrought imagination, tends to impart an unreal or fictitious coloring to the disease or injury of its possessor, and is well calculated to mislead the unsuspecting prac- titioner. Hope is a mighty element in the cure of disease, and it is the duty of the surgeon, whenever he can conscientiously do so, to avail himself of this powerful cordial and stimulus, which constitutes so efficient an antidote to the effects of sickness and injury. Social Condition. — This will also become a subject of investigation, which should include an inquiry into the state of the patient, whether single or mar- ried, active or idle; his sexual indulgences, whether occasional or frequent, lawful or illicit ; and, in the case of a woman, the number of her pregnancies, of her miscarriages, and of any irregularities or complications which may have taken place during or after parturition. KNOWLEDGE OBTAINED BY PERSONAL INVESTIGATION. 343 Residence. — The influence of local conditions in affecting surgical diseases must not be overlooked. Miasma contracted during- a temporary residence in some unhealthy distrk-t, will often lie dormant in the system until aroused into activity when the individual is overtaken by some accident. It is, accordingly, a great relief to the mind of the surgeon, if, on the occurrence of a rigor after an operation or injury, it be ascertained that the patient has previously been exposed to malarial inliuences. The effect of location in impressing certain characters on disease is well seen in the nature of many of the maladies which befall large 'numbers of our metropolitan populations, whose residences, situated in lanes and alleys, are often damp and badly sup- plied with either sunlight or air, and who subsist on food the quality and preparation of which render it unsuited to the purposes of nutrition. The propriety of referring to the effect of residence, the ophthalmic, glandular, and other diseases incident to defective nutrition which are usually encoun- tered in persons living in such dwellings and under such surroundings, will be apparent. Duration of Disease. — The period over which a disease extends, has no small influence in determining the question of its nature. Thus, as regards morbid growths, a tumor which has existed for several years without causing any marked uneasiness, either local or general, will probably be regarded as benignant, while one of a few months' duration, which has rapidly Increased in size, will be deemed malignant. There are, of course, some exceptions to this rule. Special Examination: Knowledge Obtained by Personal Investigation. Posture or Attitude. — The eye, when educated in the school of experi- ence, will often be able to detect the nature of a disease in the posture assumed by the patient. Incipient coxalgia is disclosed in a Hexed position of the limb, in eversion of the foot, and in obliteration of the gluteo-femoral groove ; dislocation of the head of the femur on the dorsum ilii will be recognized by the shortening of the limb, by inversion of the foot, and by the salient position of the trochanter major ; while in intracapsular fracture of the thigh bone, the nature of the accident will be strongly suspected on seeing the foot lie on its outer side. In acute peritonitis, the inflammation is revealed by the dorsal decubitus, flexed limbs, and distended belly ; while in colic, or spasm of the muscular walls of the intestines, the patient will often lie on the abdomen. A child, who, in walking, keeps the body rigidly straight and stiff (Fig. 21), the shoulders elevated and the arms abducted, and who moves with a shuffling gait, furnishes the evidence of spinal caries; as he does also when he squats down instead of bending in order to pick up an object from the ground (Fig. 22). A large, inflammatory effusion into the thorax or into the abdomen, generally necessitates a sitting instead of a recum- bent posture. A patient who carries an uninjured arm flexed and sup- ported by the opposite hand, with the head inclined to the damaged side, will probably be found to have a broken clavicle. Sliding down in the bed be- tokens extreme exhaustion. "In all cases in which persons are seen to fix the shoulders, either by resting the hands on the bed or by throwing an arm over the back of a chair, or any unyielding support, difficulty of respiration may be safely predicated. Indeed, almost every disease and injury will betray, to some extent, its nature in the posture assumed by the patient. External Expressions of Parts. — A correct knowledge of the normal appearance or form of different parts of the body, is of inestimable value to 344 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. the physician or the surgeon, as it is only by the possession of such knowledge that he is able to appreciate those deviations which are produced by disease or accident. A flattened shoulder, with a salient acromion process," suggests a luxation of the humerus ; a prominence of the spinous processes of one or Fig. 21. Fig. 22. Appearance of child suffering from caries of the vertebrae. Mode of stooping in a subject of spinal caries. more vertebras, indicates the existence of Pott's disease of the spine ; the obliteration of the gluteo-femoral fold raises a suspicion of coxalgia ; angular deformity in the continuity of a limb reveals a fracture of its bone or bones ; a joint, whose surface depressions and elevations have all been merged in a general swelling, is likely to be tilled with fluid ; and the obliteration of the intercostal depressions, by the bulging of the tissues between the ribs, indi- cates an empyema or hydrothorax. The form or shape of a swelling will often reveal its exact location. Thus, an enlargement situated under the jaw, the Limitations of which are the angle of the inferior maxilla posteriorly, the symphysis of the jaw anteriorly, and the digastric muscle below, will be found 1<> be seated in the submaxillary region ; and in like manner, a- swelling which is rigidly confined between the spine of the scapula and the upper border of the hone, will in all probability lie beneath the deep fascia and in the supraspinous fossa. As other illustrations under this head, may be men- tioned the acuminated form of an abscess, the pyriform scrotum in hydrocele, the convoluted appearance of varicocele, the frown which settles on the brows in peritonitis from the contraction of the corrugator muscle, the sardonic grin in tetanus, the pinched features of the Hippocratic face, presaging ap- proaching dissolution, and the notched teeth in transmitted syphilis, with many others which might be readily adduced. KNOWLEDGE OBTAINED BY PERSONAL INVESTIGATION. 3-15 Information Derived from Touch. — While in most instances the form of a swelling can be determined by the eye alone, yet occasionally it becomes necessary to call into requisition the sense of touch, in order to obtain a cor- rect idea of the exterior of an enlargement. Thus a tumor within the abdo- men, or in the neck, or in the groin, may present a uniform surface to the eye, but, when examined by the fingers, may be found to be irregular or lobu- lated. It is possible, in some cases of extra-uterine pregnancy, to trace the outline of the fetus through the abdominal walls or through the vagina, and thus to establish the diagnosis. In this way, also, the convoluted form of a varicocele, and the irregularity or knobbed surface of a mammary tumor, will be disclosed. The lenticular form of the inguinal glands, discoverable by the touch, serves to distinguish an adenitis from a hernia. Independent of the external configuration, we learn, from the touch, the density of tumors and other enlargements — whether liquid or solid, hard or soft, elastic or doughy, fluctuating or tremulous. By tact, also, we recognize the peculiar crepitation or crackling which indicates a collection of air in the subcutaneous connective tissue (emphysema). By the same sense, the crepitus of fractures and the crackling of inflamed bursas can often be distinguished when their sound cannot be heard ; and it is through the touch that the physician measures the force, frequency, and regularity of the arterial pulse. "Weight. — Closely related to the exercise of touch is the estimation of weight. The diagnosis of a tumor is influenced in no small decree by its weight. Disproportion between the weight and the bulk of a morbid growth located in the testis or mammary gland, affords considerable ground for re- garding the neoplasm as either a carcinoma or a fibroma. Mobility is also determined by an exertion of the sense of touch. External growths which admit of being extensively moved are usually superficial ; .while those which are fixed are, as a rule, deeply situated. In fracture there is preternatural mobility, while in luxation there is unnatural rigidity. Temperature, although only to be correctly measured by thermometry, may often be estimated by the touch with sufficient accuracy to enable the practitioner not only to form just deductions in regard to the nature of the disease, but to prescribe the proper line of treatment. Too much attention cannot be bestowed on the cultivation of the sense of touch. It is susceptible of being educated to a degree of extreme delicacy, as is witnessed in the readiness with which, in the blind, it is made to sup- plement the deficiencies of vision. Many fatal blunders in surgery have resulted from an untrustworthy touch. Color, also, is to be considered in forming a diagnosis. Thus we have the bright scarlet blush which belongs to acute inflammation ; the dusky red which accompanies low forms of erysipelas ; the dull red or mottled hue of chronic inflammation, indicating also venous obstruction ; the blue or livid color of the lips in some cases of croup, or in asphyxia ; and the purple and red intermingled which mark the skin overlying malignant growths. To these may be added the varying shades of color — blue, blue-black, olive, and yellow— which follow ecchymoses or extravasations of blood, generally venous, into the subcutaneous cellular tissues ; the black of mortification ; the^ unnatural white of anasarca ; and, finally, the sallow and waxy hues which attend advanced cases of carcinoma. Translucency. — The true nature of many swellings is ascertained by the translucency of their contents. The existence of this condition is revealed by 346 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. placing the patient in a darkened chamber, and by supporting the part to be examined between the surgeon and a lighted taper or candle, the hand at the same time being placed vertically above the tumor in order to intercept the upper rays of light, which otherwise would confuse the vision. A less satis- factory mode of demonstrating translueency, which may be practised by sun- light, consists in using a hollow cylinder of paper, one end of which is placed on the swelling while the eye of the surgeon is applied at the other end. It is in this way that, either by artificial illumination or by sunlight, we are enabled to recognize a hydrocele, a spina bifida, and various forms of cyst. Mensuration. — The measurement of parts also serves to enlighten diag- nosis, the standard of reference being, in the case of the extremities, the corresponding sound limb. The metallic or the linen tape-line, accurately graduated, is best adapted for obtaining measurements. In cases of fracture and of dislocation, a resort to mensuration is often necessary before any reli- able conclusion can be reached. Much care is required to render this mode of investigation valuable. For example, in applying the tape-line to the lower extremities, the patient should be laid on a level, unyielding surface ; the limbs placed side by side ; and the bod}' in an exact line with the ex- tremities, so that the pelvis shall not incline to the right or to the left. Any deviation from this position will so vitiate the measurements as to render them nugatory and unreliable. It is also necessary that the measurements shall be made between points of the skeleton which are stable and unvary- ing ; in the lower extremities, from the anterior superior spinous process of the ilium or the spine of the pubic bone above, to the internal malleolus below ; or, in case of dislocations of the coxo-femoral articulation, from the anterior superior spinous process of the ilium to the trochanter major and the tuberosity of the ischium. In the upper extremity, the points of reference, in fracture of the humerus, are the acromion process of the scapula and the condyles of the humerus ; and, in elbow dislocations, the condyles and the olecranon process of the ulna. By the tape-line, any irregularity between the two sides of the thorax, such as is likely to occur in effusions into the cavity of the pleura, can be determined, as can also the growth of an ovarian cyst or the enlargement^ of a dropsical joint. Deviations of form from the perpendicular can be easily determined by the plumb-line. When it is desired to obtain an exact trans- cript of the angles or curves of the vertebral column, this can be done either by laying over "the spine a malleable metallic ribbon, and pressing it into the irregularities, or by running up and down the vertebras two or three times a wet plaster-of-Paris roller, and, after it hardens, removing it from the back, when it will be found to retain the exact shape of the column. Sound. — Through the educated ear, the physician and the surgeon discover pathological conditions which are going on in parts and organs far out of sight. By the sense of hearing, the crepitation of a pneumonia, the friction sound of a pleurisy, the segophony of thoracic effusions, murmurs attending defects in the mitral and semilunar valves of the heart, the bruit of an aneu- rism, the fly-buzz of arterio-venous aneurism, the click elicited by the contact of a sound with a calculus, and the crepitus of fracture, can all be ascertained. Movements. — These may bo less or greater than normal, or they may be constrained, or eccentric. Examples of diminished mobility are seen in cases of fractured ribs, or of collapsed lung — where the walls of the chest, on the injured side, become almost quiescent. An inflamed joint immediately seeks rest, and a broken arm or leg enforces a suspension of voluntary muscular INTERROGATION OF THE INTERNAL ORGANS. 347 movements. Excessive, or exaggerated, or involuntary movements are witnessed in the walls of the chest in cases of difficult breathing, either from pulmonary or cardiac disease. There are excessive movements which attend the loss of the governing or inhibitory power of the nervous system which regulates muscular action, as is seen in chorea, paralysis agitans, nystagmus or oscillat- ing eyes, epilepsy, hysteria, and ataxia. Constrained movements often reveal serious structural disease. Incipient spinal caries may be detected by the mechanical, cautious, and shuffling walk of the child, before any external deformity can be noticed. Eccentric mover meats are seen in cases of infantile paralysis, in which the loss of power in the extensors of the thigh compels the child to advance the limb by the action of the muscles placed on the outer aspect of the pelvis, in doing which the extremity is swung around in the segment of a circle, instead of being car- ried directly forward. Smell. — The sense of olfaction is as quick to appreciate odors of an un- pleasant as of a pleasant nature. In this way dissolution of the tissues, necrosis of bone, steivoraeeous fistula, nasal catarrh, or incontinence of urine can be detected. The odor of hay, which often attends pyeemia, can frequently be so distinctly recognized, as to cause suspicion of the existence of this dis- ease, before anything is known about the history of the case. There is, also, a peculiar, earthy smell, which belongs to the soft parts when undergoing mortification, and which is detectable by the olfactories, in many instances, in advance of the exposure of the diseased tissues. As a final illustration under this head, I may mention the offensive odor discoverable on inhaling the breath of a patient laboring under obstruction of the follicles of the ton- sils, an odor which results from the decomposition of the retained secretion. Interrogation of the Internal Organs. In order to make a diagnosis thorough, the condition of the internal organs must be ascertained. This will include an examination of the organs of circulation, respiration, and digestion, as well as of those of the genito-urinary apparatus and the nervous system. Circulation. — Under this head, the attention of the practitioner will be directed to the state of the heart and of the bloodvessels, noting the strength, regularity of beat, and sounds of the former, all of which exercise no small influence in enabling the surgeon to decide as to the propriety of severe and tedious operations, and especially as to the administration of anaesthetics. When the inquiry extends to the bloodvessels, the relation of atheroma to aneurism, and to senile gangrene, must be considered, as must also the pres- ence of a varicose condition of the surface veins of the chest and abdomen, indicative of obstruction in the deep-seated venous trunks of those cavities; the pulsation of the jugular veins in anaemia; and the relation between phle- bitis and embolism, and between varicose veins of the lower extremities and leg ulcers. In like maimer, lividity of the surface is important, as revealing defective aeration of the blood from obstructive causes or from cardiac disease. The state of the circulation is usually determined by the pulse, and while the fingers rest on the artery, there should be observed the force of its beat, its regularity, its volume, and its compressibility. The influence of emo- tional causes, of age, and of sex, on the frequency of the pulse, must be noted. In the case of a person laboring under temporary excitement, or in that of a nervous woman, agitated perhaps by the visit of the surgeon, the pulse will 348 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. often vary as many as twenty or thirty beats in as many minutes. Even per- sons in health present variations in the rapidity of the circulation at different times ; and in women and children, the pulse is always more rapid than in men or in persons advanced in life. In view of the above peculiarities, the medical attendant who is familiar with the details of his profession, generally asks some preliminary or general questions, in order to place his patient at ease before proceeding formally to examine the state of the circulation. As a rule, in all inflammations seated below the diaphragm — for example in pe- ritonitis and enteritis — the pulse is bard, contracted, and cord-like; whilst in those which are supra-diaphragmatic, it is full and bounding. In compression of the brain, the beat of the artery is slow, full, and labored, while in concus- sion, it- is frequent, small, and feeble. In both of these conditions, a gradually increasing rapidity of the pulse presages a fatal termination. Gastric distur- bance through reflex agency, and cardiac disease from mechanical disability, will often give rise to an irregular, an intermittent, or a dicrotic pulse. Pro- fuse hemorrhage imparts to the arteries a peculiar, gaseous feel, with a tremu- lous and jerking movement. In grave injuries of the extremities, the absence of pulsation in the principal vessels of the part determines the question of amputation. Thermometry. — The relation which subsists between circulation, tissue me- tamorphosis, and the resulting evolution of heat, has rendered the use of the thermometer a valuable adjuvant both in diagnosis and prognosis. The nor- mal temperature of the body lies somewhere between 98° and 99° Fahrenheit. Before 1636, Sanctorius had drawn the attention Fig. 23. Fig. 2'4. of the profession to the importance of thermometri- cal observations as an index of morbid changes in the system ; yet the first experiments, made to ascer- tain the local temperature of an inflamed part, were those of John Hunter in a case of hydrocele. The instrument used, however, was the ordinary ther- mometer, and was consequently badly adapted for obtaining accurate results. Two forms of clinical thermometer, of which the first is the best, are illustrated in Figs. 23 and 24. Another excellent form is shown in Fig. 96, page 527. When used, the instrument should be placed either under the tongue or in the axilla. If in the latter region, the thermometer should be retained in position by placing the arm close to the side, and should be allowed to remain about ten minutes, when the mercury will have risen to the highest point it is likely to reach. It is customary to take two ob- servations each day; one about eight o'clock in the morning and the other at seven o'clock in the evening. These should be recorded upon a tem- perature sheet kept for the occasion, and placed either at the head of the bed or in some convenient place for reference. Between the elevation of temperature and the frequency of the pulse, there is some general cor- respondence; that is to say, for every degree of heat above 98 Q Fahr., there are about ten pulsa- tions of the heart more than when that organ is Clinical thermometers. beating with its normal frequency. Every degree INTERROGATION OF THE INTERNAL ORGANS. 349 above the normal temperature, is an evidence of increased tissue metamor- phosis, and when the thermometer records 105° or 106° Fahr., the danger to life becomes imminent. In fatal cases of disease or injury, the temperature rapidly falls on the approach of death ; an occasional exception to this is sometimes witnessed, however, in instances of fatal injury of the head or spinal column. Respiration. — The function of respiration may be disturbed from mechan- ical, from pathological, or from emotional causes, and the phenomena to be observed are the frequency, the ease, and the regularity with which the pro- cess of breathing is executed. Mechanical interruption of respiration may be caused by a tumor pressing on the trachea, by the presence of membranous formations in the larynx or windpipe, by tumors in the vicinity of the rima glottidis, or by foreign bodies within the oesophagus. In like manner hydro- thorax, empyema, and pneumothorax, by pressing the lung back towards the spine, will give rise to difficult and labored breathing. In pneumonia, the inflammatory infiltration which floods the parenchyma of the pulmonary tissue, not only presses the air out of the air-cells, but also prevents their ex- pansion. This necessitates abnormally frequent respiratory acts, the lung attempting in this way to compensate for the deficient aeration, incident to imperfect expansion. Tubercular infiltration produces similar phenomena. Cardiac disease will also induce hurried breathing, especially when the patient is compelled to walk, to climb an ascent, or, sometimes, even to change his position, the muscular efforts acting as a stimulus to the organ. The respiration may be slowed or quickened by disease of the medulla oblongata. The latter frequently suffers in cases where, in consequence of organic changes in the kidneys, these organs are unable to eliminate the redundant products of tissue waste, wlun their retention in the system soon begins to exert its toxic effects on the brain and other organs of the body. Blood thus loaded with meta- morphosed tissue becomes an anesthetic to the nerve-centres, producing stupor, with labored breathing, which may alternate with excitement and rapid respi- ration when the organs begin to feel an urgent need for better blood. The sluggish flow of the blood through vessels which have undergone atheroma- tous degeneration, will also explain similar phenomena so often witnessed in persons thus affected. In many instances, the two acts of respiration, inspi- ration and expiration, are not equally involved ; thus in croup, in oedema of the larynx, and in certain cases of laryngeal tumor, the inspiration is most embarrassed. There is a singular power of compensation resident in the human body, which under extraordinary conditions is exhibited in a very striking manner : thus when a rib is broken, in order that the process of repair may not be dis- turbed, the movements of the corresponding side of the chest are greatly diminished, while the deficiency is measurably supplemented by the dia- phragm and the muscles of the abdomen. In pleuritis, the inspiration is brought to a sudden check before the full expansion of the thoracic walls has been completed. There are significant sounds accompanying the respiration, which possess great diagnostic value. For example, the tremulous voice, which accompa- nies extreme weakness ; the hiccough, so often connected with grave disorders, or following upon the appearance of mortification; the grunting respiration which attends caries of the vertebras ; the stridulous sounds caused by the air passing between obstructions in the respiratory tube ; the obscure, mumbling articulation of words in cases of inflammatory swelling in the faucial and pharyngeal parts; the whisper or aphonia from swelling of the larynx or paralysis of the vocal cords ; and the tracheal rales which announce the near 350 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. approach of death. Emotional disturbances of respiration are characterized by full inspirations and expirations, following each other sometimes rapidly, then more slowly, and often executed in a jerking or tremulous manner. There must also be mentioned the slow, stertorous and puffing respiration from paralysis of the faucial and buccinator muscles, the result of cerebral compression. The respiratory movements of the thorax are often observed with a view to furnish the rational signs of disease. In pleuritis, any attempt at taking a full breath is not only followed by acute pain in the side, but the inspiratory act itself is suddenly arrested by the suffering induced. The same test will, in fracture of the ribs, develop crepitus, which may be either felt with the hand or heard with the ear, applied over the injured region. In swellings suspected to be hernise, the diagnosis is strengthened by noticing, in the tumor, a distinct impulse on coughing. Nervous System. — Much valuable information may be gleaned by testing the common sensibility of the skin, mucous membranes, and muscles. For the coarser examination of the cutaneous sensibility, an ordinary pin, or a pair of compasses will answer ; but, for nicer and more accurate results, the a?sthe- siometer, of which two forms are shown in the annexed cuts (Figs. 25 and 26), should be employed. Fig 25. Fig. 26. iEsthesiometera. This instrument has a length of four inches, divided into tenths. The aeuteness of the sensibility is determined by the greater or less nearness at which the touch of the two points can be recognized as separate impressiors. The presence of certain morbid poisons circulating in the blood, among which may be instanced that of syphilis, will lessen very much the aeuteness of sensibility of the skin, and the same is true of a number of nerve-lesions which are followed by numbness. The sensibility maybe excessively exalted (hypermstkesia), so much so, indeed, that the gentlest touch with a feather or the finger will be intolerable, and will give rise to signs of extraordinary suf- fering. Hyperesthesia is among the common phenomena of hysterical joints ;ni(l of mimicked disease of the spine. The qualities of sensibility, or its perversions, are seen under different phases ; sometimes as burning, an evidence of nerve-injury; sometimes as itching, as in poisoned ' wounds ; sometimes described as a feeling like that of ants crawling over the surface (formication) ; or of nettles bring brough.1 in contact with the skin (urtication) ; or of a current of air passing over the affected part. Such conditions of the peripheral INTERROGATION OF THE INTERNAL ORGANS. 351 nerves may be due to reflex impressions, or to organic changes in the spinal cord, or other ganglionic masses of neurine. The absence of certain reflex movements, as those proceeding from tapping the patellar tendon, the tendo Achillis, or the cremaster muscle over the spermatic cord, are supposed by some writers to indicate serious changes in the structure of the spinal marrow, though there are other authorities who attach little importance to such tests. Significance of Pain. — It is frequently found to be the case that parts which in their normal state exhibit little sensibility, become exquisitely sensi- tive when inflamed. The entire muscular system of a child is frequently thrown into violent paroxysms from an inflamed gum, which, in the healthy condition, is quite insensible. Inflammation of the hard, callous tissue of the heel, so admirably constructed to endure pressure, occasions intolerable suffer- ing. Pain, of which we are only conscious through certain impressions trans- mitted along special tracts of the medulla spinalis to the brain, thus pos- sesses diagnostic value. Pains differ in quality, location, and duration. (1) Quality of Pain. — Shooting, darting, or shuttle-like pains belong to carcinoma; burning pains to injury of the nerves and inflammation of the skin ; itching pains to poisoned wounds ; dull, heavy pains to rheumatism ; gnawing or boring pains to disease of the bones; throbbing pains to inflam- matory transudations occurring in and beneath dense or unyielding struc- tures, as in whitlow and palmar abscess ; and sickening pains to contusions of the testes. (2) Location of Pain. — Disease is not always situated at the point where pain is experienced. Pain is very commonly felt at the knee, in coxalgia ; at the extremity of the urethra, in vesical calculus ; along the ureters or down the thighs, in renal calculus ; and at the inferior angle of the scapula, in inflammatory disorders of the liver. Disease at the root of the fifth pair of nerves will excite pain in the jaw and face. Many serious errors have been committed in locating disease by the misleading influence of local pain. (3) Duration or Constancy of Pain. — Constant pain is usually inflammatory in its origin ; intermittent pain, neuralgic. In peritonitis, the extreme sen- sibility or pain continues without abatement ; in colic, it is paroxysmal ; the pain of peritonitis is aggravated by pressure, while that of colic is relieved by the same means. Fixed pain, that which never shifts its position and is con- tinuous for a long time, even though not severe, should never be treated as a light matter. Fugitive pains are usually rheumatic or neuralgic. The sud- den cessation of pain in an inflamed part often announces the commencement of gangrene. The importance to be attached to pain must be regulated in some degree by the temperament of the individual suffering it. There are persons whose nervous system and whose mental and emotional natures are so constructed, that the slightest pain is followed by extravagant or exaggerated manifesta- tions of suffering ; while there are othei\s, heavy and phlegmatic in their organization, or possessing an iron will, who either do not feel pain as much as others, or who endure it with singular fortitude and stolidity. Motility. — Many obscure morbid conditions are unravelled by studying the behavior of the muscles. There are three sources from which eccentric phenomena of the muscular system may be derived : (1) the cerebro-spinal centre ; (2) the nerves which supply the muscular fasciculi ; and (3) the sar- cous cells. Among the most common morbid disturbances of muscles are loss of power, tremors, spasms, twitch ings, contractions, choreic movements, and wasting or atrophy. Loss of power may affect one muscle or a number of muscles; one or both 352 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. extremities ; the half or the whole of the body. "When half of the body is affected, the cause is usually referable to the brain. When a single extremity or both lower extremities are paralyzed, the cause is to be sought for in the spinal marrow. A single muscle or group of muscles may be paralyzed from mechanical causes, such as the pressure of a morbid growth, or of a mass of exuberant callus. The nerve force may be suddenly exhausted by overtaxing the muscles, and this exhaustion may be followed by temporary or reflex paralysis. Spasms and twitchings of the muscles may be excited by the mechanical irritation from the spicule of a broken bone. Local irritations frequently provoke, through reflex agency, general spasms of the muscular system, as is witnessed in the convulsions which accompany difficult denti- tion, or which are brought on by a tight phimosis, by overloading of the stomach with crude ingesta, or by uterine disease. Permanent contractions of the muscles often occur, causing deformities of the limbs ; a class of cases exceedingly unpromising, as the contractions depend upon structural changes which are altogether irremediable, namely, sclerosis of the anterior columns of the spinal cord. In fracture of the vertebra?, the particular region of the spine involved is ascertained by observing which muscles are rendered help- less. Loss of power is also a result of fatty metamorphosis of the sarcous sub- stance, rendering its cells incapable of being affected by nerve force. Those neuroses which arise from peripheral causes, are, of course, most amenable to treatment, as the cause is in many instances a removable one. In these affec- tions of the nervo-muscular system, the use of the faradic and galvanic cur- rents becomes necessary, in order to test not only the pathological alterations of the muscles, but also to ascertain where the defect lies ; that is to say, whether in the centre of power, in the nerve of communication, or in degene- rated fibre. An instrument called the dynamometer (Fig. 27) is employed Fig. 27. Dynamometer, The outer scale represents kilogrammes, and the inner myriagrammes. to measure the degree of power. The movements of the pointer on the dial- plate, when grasped by the hand of the patient, indicate the force exerted, in kilogrammes, while the stretching of the spring in the longitudinal direction, by an arrangement of cords and rings, indicates the force of the lumbar muscles, or the lifting power, in myriagrammes. Digestive Apparatus. — The wide range of sympathies possessed b}^ the digestive organs confers upon them a notable distinction in the production of morbid phenomena. This fact is no matter of surprise to the anatomist, who is familiar with the rich supply of nerves derived from the sympathetic, and their intimate communication with those of the cerebrospinal system. Many disorders of the circulatory, respiratory, nervous, and gen ito-uri nary organs, though but reflected irritations from some portion of the intestinal tract, INTERROGATION OF THE INTERNAL ORGANS. 353 would, if their origin was not understood, assume the gravest significance in the mind of the practitioner. In studying the bearings of this division of the subject, the inquiry should commence at the mouth, and pass downward to the termination of the intestinal tube, including the different glandular organs contained in the abdominal cavity. In the tumid, fissured and pale lip, are to be seen the indications of struma, and of anaemia ; in the soft, spongy and bleeding gum, a scorbutic state of the blood, or the constitutional effects of mercury or of phosphorus. The inflamed and swollen gum satisfactorily explains the fretfulness, otalgia, startings and convulsions of the infant. The constitutional effects of silver, of lead, and not unfrequently of tubercular disease, are shown in charaet er- istic lines upon the gums. Among the multiform manifestations of syphilis are the notched incisor teeth of the permanent set. The failure of a tooth to appear in the dental arch, if associated with enlargement of the jaw, suggests the probability of a dental cyst ; while an inflammatory swelling and abscess of the face and neck, about the angle of the jaw in the adult, will direct the attention of the surgeon to the possible eruption of a wisdom tooth. The tongue constitutes an important index of both general and local dis- order. The dry tongue is a common attendant of febrile excitement, and is the result of arrested secretion. A similar appearance of the organ is seen in persons who sleep with the mouth open, and is due to evaporation of the natural moisture of the part. Habitual dryness of the tongue from this cause should lead the practitioner to examine the nasal cavities for polypi or other morbid growths. A dry tongue with rigidly prominent papillae, occurring in the course of traumatic and other fevers, is always a source of anxiety to the watchful physician. The dry, red, and glazed tongue is among the com- mon signs of gastro-intestinal inflammation, as is a similar condition of the fauces and pharynx. In anaemia the organ is pale, flabby, and soft. The tooting which encrusts the tongue when it is furred, is made up of epithelial cells, the debris of the various secretions of the mouth, altered blood-corpus- cles, etc. A thin white coat is an evidence of debility, and demands tonics. A heavy white coat, tinged with yellow, implies derangement of the biliary function. A dark, pasty crust, adhering in strips, and found also attached to the gums, constituting sordes, reveals blood disorganization, and is the atten- dant of low forms of fever. It should not be forgotten that a catarrh of the throat will often cause a coated tongue, when the alimentary tract in all other portions is not implicated. The form of the tongue is not without diagnostic significance. In intra-cranial inflammations, "when the brain is not subjected to too much pressure from transudations, the organ will be narrow and pointed ; in chronic derangements of the digestive organs, it will become broad, fissured, and rounded at the borders ; and in inflammations of the respiratory organs, it not infrequently is seen to be transversely con- cave, from depression of its centre and corresponding elevation of its sides. The motions of the tongue are well worthy of observation. A tremulous state of the organ, or difficulty in its protrusion, frequently witnessed in low fevers, betokens great danger. When thrust out to one side, there is probably a brain-lesion on the opposite side. Angeiomatous growths appear occasionally on the tongue, and cause, in the affected part, a blue, spongy enlargement. Mucous patches on the tongue disclose constitutional syphilis." The saUingual space, where the openings of the sublingual and submaxillary salivary ducts exist, should not escape inspection. Tumors occurring in this region are likely to be either ranulae or salivary calculi. Difficult deglutition, imperfect or guttural enunciation, cough, and stiff- ness of the neck, will demand a critical examination of the fauces and pha~ vol. i. — 23 354 GENERAL PRINCIPLES OF SURGICAL DIAGNOSIS. rynx — observing if there exist any elongation of the uvula, any hypertrophy of the tonsils, any enlargement of the pharyngeal glands, any post-palatine purulent secretion, or any swelling in front of the cervical vertebrae, the loca- tion of post-pharyngeal abscess from diseased bone. Inability to swallow solids, with return of the alimentary bolus, demands exploration of the oesophagus with appropriate bougies for the detection of stricture. Vomiting, when there has been a history of chronic dyspepsia, accompanied by loss of flesh, will suggest a careful examination of the abdomen for inter- nal carcinoma. Sudden attacks of vomiting, with pain and flatulence, attract the attention of the surgeon to the hernial passages. The appearance and the odor of the ejected matters must not escape observation, stercoraceous emesis always denoting intestinal obstruction from some cause. In determining the outline of the solid organs within the abdomen, and thus detecting alterations in their size, the surgeon resorts to manipulation and percussion. In the same way the form of the organ can be ascertained, as in displacement of the kidney, distension of the gait bladder or of the uri- nary bladder, and fibroma of the uterus. Accumulations of fluid within the abdomen, either cystic or peritoneal, are to be recognized by palpation, by use of the grooved needle, or by employment of the aspirating trocar. The differentiation of fluids taken from the abdomen, and their relation to special diseases, will be materially aided by observing their physical, chemical, and microscopical characteristics. The thin and light straw-colored liquids are generally peritoneal (ascites); the dark, thick, ropy, and gelatinous, ovarian ; and the clear, limpid, and spontaneously coagulating, fluids from the broad ligament. A characteristic cell is also said by l)rysdale to be found in ovarian fluids. The alvine discharges require to be scrutinized. Putty-colored dejections point to hepatic disorders, and are often found associated with an icteroid discoloration of the conjunctiva and the skin. The admixture of blood with the discharges will suggest ocular, instrumental, or digital exploration of the anus and rectum; since blood, and often mucus, may proceed from fissure, from hemorrhoids, from stricture, from carcinoma, or from syphilitic disease. The form of the feces may also reveal the existence of stricture, being in such cases small, flattened, angular, or round like pipe-stems. The character of pain (if present), and the period at which it is developed, will also aid in forming a diagnosis in cases of anal and rectal disease. For example, there is pain in defecation, both in hemorrhoids and in fissure; but in the former it is experienced chiefly at the time of evacuating the bowels, soon passing over and leaving only a sense of warmth for some time after, while in fissure the pain comes on at variable periods after defecation, and increases in se- ven 1y for several successive hours. Tenesmus is a common symptom of colitis, but may be equally urgent as the result of a foreign body being lodged in the lower extremity of the bowel. When tenesmus is accompanied by frequent and small watery passages, it is often significant of rectal impaction. < rENiTO-URiNART System. — The sexual systems of the two sexes play a very important part in the causation of both functional and organic disorders of the human body, [mpotency, the loss of the venereal appetite, and unnatu- ral excitement, in the male, are conditions which demand for their proper understanding a critical inquiry into the state of the brain and spinal marrow, the constitution of the urine, the condition of the organs themselves, and the habits of the patient. The connection between priapism and spinal or cerebro-spinal injuries; between spermatorrhoea and nervous restlessness, with palpitation, dyspepsia, and loss of strength and spirits, will not escape the not ire of the careful observer. Ketraction of the testicle, and pain along INTERROGATION OF THE INTERNAL ORGANS. 355 the course of the ureter, in renal colic ; pain at the meatus after urination, and elongation of the prepuce, in vesical calculus ; phimosis and its relation to urinary incontinence, convulsions, and eczema ; a diminished and twisted stream of water in stricture; urethral discharges and their connection with stricture; and frequent micturition as an indication of enlarged prostate and of cystitis, are all subjects which will demand investigation. The influence of sound kidneys on the success of operations is such that no prudent surgeon would willingly undertake an operation without previous examination of the urine, unless in cases where operative measures were un- avoidable. Examination of the urine should include an investigation of its quantity, specific gravity, color, reaction, and composition ; while the means for determining these points are measurement, the use of the urinometer, ocular inspection, the employment of chemical reagents, and examination with the microscope. The principal substances to be sought for are albumen, blood, pus, muco-pus, sugar, urates, phosphates, and oxalates ; and the pres- ence or absence of each of these has an important bearing on both diagnosis and prognosis. SHOCK. BY C. W. MANSELL-MOULLIN, M. A., M.D. Oxon., F.R.C.S., FELLOW OF PEMBROKE COLLEGE, OXFORD ; LATE RADCLIFFE'S TRAVELLING FELLOW, PNIV. OXON.J SURGICAL REGISTRAR TO THE LONDON HOSPITAL. LONDON. Originally employed in any case of sudden death or collapse following injury or mental emotion without discoverable lesion, the term Shock has, step by step with the increase in knowledge of physiology and the extension of experimental inquiry, become more and more definitely associated with the conception of a sudden check to the circulation brought about throuo-h the agency of the nervous system, and resulting either in a death so immedi- ate as scarcely to have a parallel, or in a condition of prolonged prostrat ion with or without a more or less successful reaction. Such a result can only take place through the direct influence of the nervous system. Long ago, Travers 1 pointed out that frequent instances of sudden death, consequent upon injuries which left no trace of their destructive operation upon the texture of the vital organs, and that other instances of death after the lapse of a few hours or days, and some even of weeks, from the injury, admitted of no other explanation according in any degree with the history and symptoms of the malady, than a suspension or failure of the nervous power. Isor is it less clearly proved by the spontaneous disappearance of all symptoms in cases of recovery, sometimes almost as rapid as their onset (for patients left pulseless and apparently moribund, without external injury, may be found on the succeeding day restored to the tone and tranquillity, comparatively speaking, of health), that there can be associated with it no serious structural lesion. Of course it must not be inferred that no change at all has taken place, but simply that it is not within range of perception by means of our present niethods of investigation ; and, indeed, it is to be expected that, with increas- ing knoweledge of the conditions under which the manifestation of that form of molecular motion known as nerve-force is possible, we shall some day be able to form an idea of the way in which its action may be modified or sus- pended, without the production of any visible alteration of structure. Causes of Shock. "Whatever may be the immediate cause of shock, whether it result from a purely mental source or from a serious bodily hurt (for probably either alone is sufficient, although in general each bears a share), everything denotes dimin- ished energy of circulation : the pallor and coldness of the skin, the weak- ness and small volume of the pulse, the difficulty of respiration, the languor Treatise on Constitutional Irritation, p. 431. (357) 358 shock. and general depression, all point to some failure among those forces that main- tain the circulating fluid at the necessary tension ; to some difficulty affecting the motive impulse of the heart, or the peripheral resistance of the capillaries, or the state of tone of the smaller vessels, arteries as well as veins; for these are the forces mainly concerned in keeping up the arterial pressure on which the circulation depends. That the first of these three, the heart, is affected, can have escaped the notice of none who have ever experienced emotion of any kind ; with regard to the others, there would be greater doubt if it had not been proved by experimental demonstration ; though it might reasonably have been surmised from the well-known occurrence of syncope, in failure of the heart's power from organic disease or other causes, that for the production of shock, unattended by loss of consciousness, some additional element must be present. With regard to the causes of shock, there can be no doubt that mental emotion, especially joy or fear, of itself, without bodily hurt of any kind, may be followed by the gravest form of shock, resulting in immediate death even where there is no probability of organic disease of the heart. Many years ago, the janitor of a college had rendered himself in some way obnox- ious to the students, and they determined to punish him. They accordingly prepared a block and axe, which they conveyed to a lonely place, and, having dressed themselves in black, some of them prepared to act as judges, and sent others of their company to bring him before them. When he saw the preparations that had been made, he at first affected to treat the whole thing as a joke, but was solemnly assured by the students that they meant it in real earnest. He was told to prepare for immediate death, for they were going to behead him then and there. The trembling janitor looked all around in the vain hope of seeing some indication that nothing was really meant, but stern looks everywhere met him, and one of the students proceeded to blindfold him. The poor man was made to kneel before the block, the executioner's axe was raised, but, instead of the sharp edge, a wet towel was brought smartly down on the back of the culprit's neck. This was all that the students meant to do, and, thinking that they had frightened the janitor sufficiently, they undid the bandage which covered his eyes. To their astonishment and horror, they found that he was dead. 1 And although this extreme effect may not be common, instances of cata- lepsy, hysteria, idiocy, and other morbid mental conditions are in plenty : nor can this be in any way a matter for astonishment, when the effects of mental impressions on the functions of the body are taken into consideration. A familiar instance of their influence is seen in women during lactation: the qualities of the milk are from this cause often suddenly changed so as to pro- duce very serious effects upon the infant : in some recorded cases the result has proved fatal. It is remarkable and characteristic that severe shocks to the system from mental emotion, after the more immediate effects have passed away, often leave some organ permanently impaired in its function. Sudden fright, for instance, has produced deafness. 2 There is, however, in individuals the greatest possible difference in this respect. No two persons are ever affected in the same way by mental emo- tion, or to the same degree: some are but slightly moved by that which influences others in a most serious manner; others again are greatly disturbed by slight accidents of some special kind, while they are altogether heedless altout troubles much more grave; and under different circumstances, at dif- fered times of life — nay, even at different times of the day — the same people may remain apparently unconcerned, or be quite overcome. Yet sometimes, when the temperament and nervous susceptibility of a patient are well known, a prediction may he hazarded as to the probable effect of an injury or opera- 1 Lauder Brunton, Shook and Syncope. 2 Savory, Collapse ; Holmes's System of Surgery. CASES ATTENDED BY SHOCK. 359 tion, and timely help be thus gained in the question of prognosis. Sex is not without its influence, though it is scarcely possible to estimate how far sus- ceptibility to shock is due to difference inhabits of life ami physical develop- ment, and how far to a quicker sympathy and more ready emotion. The effects of age on the production and course of shock are more certain, espe- cially if account be taken of the complete absence of anxiety in the young, and of the apathy so common in the old. It is generally said that the imme- diate results of an injury are worse at these two periods of life than at any other; but, in the case of the young, much allowance must be made for the relative amount of damage sustained, for the very serious effect of even, com- paratively speaking, a slight loss of blood, and for the great susceptibility to eold. In the aged, shock is more particularly characterized by uncertainty, both as to its course and persistence ; not unfrequently its intensity is dimin- ished and its duration prolonged ; and often, when all seems going on well, the heart's strength fails suddenly, and the patient dies when least expected. It must be mentioned, however, that Xussbaum and others will not admit cases of this kind as examples of death from shock, believing that hemor- rhage, by means of the effects that may follow it even after some time has elapsed, is much more likely to have been the cause of the fatal issue. Pain, when intense and unintermitting, has been known to prove fatal, but probably in the majority of cases by inducing syncope, though it has a dis- tinct effect upon the heart's action ; patients, while in a state of shock, whether arising from bodily or mental origin, seldom feel any but the most acute agony; and in many of the examples brought forward, protracted labors for instance, extreme muscular exhaustion has been of material help in causing death. It is more singular that, as Astlcy Cooper pointed out, the moment of transition from intense agony to perfect ease has been known to prove fatal. Deep mental ^re-occupation , generally met with under the form of extreme excitement, undoubtedly possesses the peculiar poAver of postponing the occur- rence of shock, perhaps in the same way that the will, or the violent irrita- tion of a sensory nerve, can for a time suspend perception. It is especially in military surgery that cases of this kind are recorded — where serious and painful wounds are not oven known of, till long after their infliction. It is only the onset of the shock, however, that is delayed: its intensity loses nothing from the combined effect of the injury, pain, commencing fever, exhaustion, fear, and perhaps even despair. Another mental condition that may lie mentioned as having a peculiar influence is that of intense and per- haps delayed expectation ; at least it would seem that this might assist in the explanation of those deaths, the most mysterious of all, which follow imme- diately on some trivial operation, while accidents seem to be without effect ; perhaps there may be a comparison between these cases and those already mentioned of sudden death on the cessation of pain; in each it seems to follow the breaking off of a condition of extreme mental tension. Cases attended by Shock. The majority of the cases of shock met with in surgical practice, follow accidents or operations, serious either from the actual extent of the injury inflicted, or from the fact that special organs or textures have been involved. Hums and scalds, especially when the area involved is extensive, even if the depth is insignificant, are among the most common causes of shock ; then come contused and lacerated wounds, such as are produced by the violent crushing ot a limb, and capital operations, though by care and attention in the case of 360 SHOCK. these, the severity of the resulting shock may be much reduced. In all, the danger is great in proportion to the proximity of the injury to the trunk, a fact that is conclusively shown by the results of amputations on the lower limbs; and it would seem as if the injury to the bone itself had some special influence, for Pirogoff 1 saw two men die on the table during amputation through the thigh (one for injury, the other for chronic disease of the knee- joint), at the instant that the bone was being sawn through ; a spasmodic contraction passed over the muscles of the body, the face became pale, the eyes lost their lustre, the pupils dilated, and death followed at once — in neither case was an anaesthetic administered. Furneaux Jordan 2 too, watch- ing a thermometer placed in the axilla, while an amputation was being per- formed, observed on several occasions a drop of as much as one-fifth of a degree during the application of the saw. There is a special gravity attached to those cases of shock which result from railway accidents, probably in no small measure owing to the part taken in their production by mental causes, and to the general concussion sustained by the body in its suddenly suspended motion ; for instances of severe and lasting shock, often assuming most insidious forms, are met with from time to time in occurrences of this kind, without there being any definite or marked bodily lesion, and, indeed, are often the more severe when this is quite absent, and there is no other expla- nation than a general or mental cause. Simple concussion of the brain would present a frequent and good example of shock, if it were possible to eliminate and set aside the symptoms that depend upon the injury inflicted on the brain-substance itself, probably presei it in all, even the slightest cases, and productive of indirect as well as of direct results, if any reliance is to be placed on experimentation. 3 As accidents involving the extremities are followed by shock, other things being equal, in proportion to their proximity to the trunk, so it might rea- sonably be supposed that injuries inflicted on the trunk itself would present cases of the greatest severity ; and this is true not only of accidents that involve considerable damage to organs or textures — damage that might of itself render difficult the continuance of functions necessary to the mainten- ance of life, — but also of slighter injuries, blows or contusions, that in other parts of the body would scarcely be noticed, but which here are often, and sometimes unexpectedly, followed by results of the gravest character. Few can have passed through school-life without having experienced the effect of a blow on the scrotum, or on the pit of the stomach : the intense collapse and complete prostration that supervene at once, and may even terminate fatally, as cricketing annals unhappily show. Fischer 4 relates a case of death with all the symptoms of the deepest shock, following a few hours after a testicle hud been crushed ; and Erichsen mentions as a frequent occurrence in castra- tion, the sinking of the pulse at the moment of division of the spermatic cord, even when the patient is fully under the influence of an anaesthetic. But it is not a little singular that, in spite of the generally received tradition on such matters, and of the undeniably grave symptoms which are so notori- ously produced, there should not be recorded one single case in which death has followed in a healthy man immediately upon a blow on the abdomen, without injury to any of the subjacent viscera. Even the classical instance given by Sir Astley Cooper, and always quoted as an example, of the laborer who while wheeling a harrow, received a. slight blow in the epigastrium and tell down (lead, eai 1 1 lot he admitted, 5 though it is siq (ported by such authority; lor it did not occur within his own practice, and in the account left of it 1 Kri< v Ksoliimrgie, S. 89. 2 Hastings Essay on Shock. 3 Goltz, Pfltiger's Archiv, 187fi. * Volkmanu's Saramlung klinischer Vortriige, No. 10. 6 Pollock, Holmes's System of Surgery. CASES ATTENDED BY SHOCK. 361 there is nothing that is inconsistent with the idea of sudden failure of the heart's action, from the combined effects of degenerated structure and over- exertion. Death may, however, occur at a later period; a boy after being crushed by the end of a costermonger's barrow against a wall, was admitted to hospital in a state of collapse, from which he partially rallied towards evening, only to sink again gradually before twenty-four hours had elapsed ; nor was there anything" found after death that could account for this; only a little redness and stickiness of the peritoneum in one small spot behind, 'against the vertebra?, as of commencing peritonitis, "it often happens that 'penetrating wounds of the abdomen, and still more frequently that injuries or operations involving the handling of the viscera, such as ovariotomy, are followed by results of this nature, though exceptions are more frequently met with in this class of injuries perhaps than elsewhere. Death within five minutes has occurred after such a simple operation as tap- ping the liver for hydatid disease. The patient, a, man id years of age, to all appearance perfectly healthy, and temper- ate, presented himself on account of an enlargement of the abdomen which had been noticed some ten months. It was plainly a case of hydatid disease of the liver ; and was of such inconvenience that the man wished something to be done. After some days in the ward, a fine aspirating trocar and canula were introduced without any anaesthetic, and a few drops of clear fluid evacuated ; as no more followed, a canula somewhat larger, about the size of a small goose-quill, was inserted through the same opening immedi- ately on withdrawal of the smaller one. A few drachms of blood-stained fluid came, and then all of a sudden the patient's face became pale and livid, his arms sank down by his side, and, with the exception of a few faint irregular beats, the pulse ceased. At the post-mortem examination, on the following day, the puncture was found on the convexity of the liver, and a probe was passed through it into a small cyst lying by the side of a much larger one ; there was no great distension of the abdominal veins, and the only sign of visceral degeneration was a slightly granular condition of the kidneys. Bryant 1 relates a very similar case, except that the amount of fluid removed was considerably greater, about nine ounces (though much more than this has frequently been withdrawn without damage), and that, while the inferior vena cava was considerably obstructed by the pressure of the tumor, a large branch of the portal vein had been perforated by the trocar. Injuries to other abdominal viscera offer examples no less frequent and quite as characteristic. The strangulation of a portion of small intestine, whether in a hernial sac or by some band within the abdominal cavity, is attended at once by symptoms of the most complete prostration, and may of itself, if left unreduced, be sufficient to occasion death, without the production of perito- nitis. Many more instances are on record of this result having followed the application of taxis, with or without the administration of chloroform, espe- cially in the case of umbilical or ventral hernia? in corpulent subjects reduced by long-continued vomiting. The same effects are produced by large doses of corrosive poisons, such as sulphuric and other mineral acids, or arsenic, the immediate effects of which are intense local pain, coldness and pallor of the surface, sighing respiration, and a weak, perhaps imperceptible pulse. Similar results follow when per- foration takes place in the stomach or intestines, and their contents escape into the peritoneal cavity. The occurrence of shock after parturition, espe- ciallyin the case of bearing twins, is probably partly due to nervous influence, and partly to the removal of pressure from the abdominal vessels by the loss of such a large portion of the abdominal contents, which must almost un- avoidably occasion more or less relaxation of the vessels. 2 1 Lancet, June 8, 1878. 8 Lauder Brunton, Shock and Syncope. 362 shock. Great loss of blood, especially if it has taken place suddenly, brings on all the symptoms of collapse, but usually accompanied by syncope ; and certain poisons (as nicotin and muscarin) which act directly on that part of the nervous system that is in immediate relation with the heart and vessels, produce the most intense prostration of mental and bodily vigor through the diminution of vascular tension, and these cases are of more than ordinary interest, for in this way the practical physiologist is able at will, by methods the working of which is fairly well understood, to produce a condition not to be distinguished by any of its symptoms from that consequence of injury or mental emotion which has been so long unintelligible. Indeed, so close is the resemblance presented by cases of this kind to the collapse caused by abdominal injury, for example, that Furneaux Jordan and others have included hemorrhage and this class of poisons among the causes of shock. But it would seem alto- gether more reasonable to restrict the definition, by retaining the idea of in- direct, perhaps reflex (whether traumatic or mental) origin, and to regard these cases in which the result is produced by some influence acting directly on the vascular tension, as a means of explaining those in which the same is brought about indirectly and refiexly as the consequence of some perhaps distant injury. Symptoms of Shock. Few conditions are more characteristic than that of a patient suffering from the graver effects of shock ; none resemble death itself more closely. lie lies perfectly quiet, giving no heed to anything that goes on around ; with limbs helpless and prostrate, as they may be placed, or as the chance of the moment may dictate ; conscious, yet seeing only in a mist, and hearing none but loud and repeated questions (though rare instances are met with in which the senses, especially the hearing, are acute beyond all measure); with no paralysis, yet replying with difficulty, in a syllabic, scarcely audible voice, and only executing with painful slowness some simple movements often left half finished. The expression of the face is quite changed ; all the features, especially the nose, are smaller and shrivelled ; the weary eyes have lost their lustre, and lie rolled upwards in deeply sunken sockets, surrounded by a dusky ring ; the pupils in general are dilated, and react very slowly to the stimulus of light. The skin, and such parts of the mucous membrane as are visible, are pale, but livid too; the fingers and nails blue, and the skin on the palmar aspect hanging in loose folds. Large drops of sweat hang on the forehead and eye- brows ; the whole body is cold; at times a shiver passes through all the limbs ; and the loss of temperature is often so great as to make the ther- mometer fall two or more degrees. Common sensibility and the sense of pain arc much blunted over the whole body ; only some paroxysm more sharp than ordinary can rouse to any movement, while the worst of news is heard with- out emotion, so great, is the already existing depression. The pulse is almost imperceptible, irregular, unequal, and very rapid; the arteries are small and the tension low; the ascent in a sphygmographie tracing is very short and sloping, but the apex fairly well marked ; the presence of dicrotism in these cuses probably depends upon the amount of hemorrhage. The respiratory movements are very irregular— abnormally deep, sighing inspirations break- ing suddenly into :i series of very superficial ones which are scarcely audible; sometimes, especially as the graver symptoms are passing oil' and reaction is beginning to se1 in, there is vomiting; the sphincters generally remain closed, but no rule can be laid down upon this point; retention of urine occurs per- haps more frequently than not, and sometimes, with this, there is partial sup- pression. SYMPTOMS OF SHOCK. 363 This death-like calm is, however, by no means invariable in cases of shock; indeed, in this respect they may present the greatest possible variety. There may be from the first a condition of the most extreme restlessness and excita- bility, that erethistic form which Travers has termed "prostration with ex- citement;" or this may follow on the former type as a kind of reaction. The patient then tosses wildly and vaguely from side to side, as if frantic, complaining of a fearful oppression and want of breath; with presentiments of death, and a feeling of total annihilation; often shouting again and again The same thing, perhaps utterly meaningless; with a countenance expressive of nothing but a nameless anxiety and excruciating agony. No encourage- ment is of any use; the consciousness is unclouded, but seems altogether pre- occupied by the frightful anguish ; no question is answered ; there is only the same constant moaning exclamation; no attention is paid to anything going on around; there is but one feeling, that of closely impending dissolu- tion. The respiration and pulse present the same general character as in the torpid form of shock, but it is seldom that the pallor and coldness are so great; sometimes even the face is flushed, and burning thirst is nearly always felt; fluids are swallowed with the greatest eagerness, and vomited as soon. Often the limbs or the whole body are convulsed by a sudden rigor. Sleep is unknown, or there is at best a fitful slumber which gives no relief; more often, as night approaches, the incoherence becomes wild delirium. Ex- haustion rapidly supervenes; a profuse and clammy sweat appears on the face, and spreads over the whole body; the pulse becomes fainter and feebler, and with a sudden cessation of all movement, often preceded by a slight con- vulsion, the expression alters, and the patient is dead. In spite of the very great difference in the external manifestations of these two forms of shock, it is by no means improbable, just as under other circum- stances coma and convulsions may occur together, and be due to the same cause, that the same pathological condition underlies them both — of course in somewhat different measure ; at least, the distinction is so slight that either may succeed the other, and no prediction as yet is possible either from the constitution of the patient or the nature of the lesion, as to which may be the form which will supervene. But even these are not the only, though they are perhaps the most striking, forms in which the intense depression of vital power that follows serious injury may manifest itself. Sometimes, and it is more particularly after rail- way injuries, as a result, perhaps, of the fright — perhaps of the violent concus- sion sustained by the whole body as it is violently projected into space, or jerked backwards and forwards with all the muscles unprepared — there is seen a form so insidious as to falsify the most guarded prognosis. After the accident, the patient, who has sustained no apparent bodily hurt (and this seems to be essential), appears perfectly calm and unaffected — often unnatu- rally so — congratulating himself on his escape; his color is good ; pulse quiet; respiration tranquil ; there seems nothing wrong. But at night there comes an inability to sleep, and a tendency to become feverish ; the pulse becomes quicker and softer; the eye bright and restless; the extremities cool; and, even within the space of three or four days, persistent vomiting and exhaustion, running on to prostration and coma, may supervene. More frequently the time occu- pied is much longer, and there follows a condition which has been variously called, for want of a better name, hysteria, or hypochondriasis. It is true that much doubt has been justly thrown on a great number of these cases; in many, the symptoms have been simulated completely ; in others, and proba- bly the greater number, the real cause has been a slowly progressing, chronic cerebrospinal meningitis; but there still remain a few (presenting no objec- tive signs) to which this explanation will not apply; a few in which, as the 364 shock. result of an accident, and coming on too soon afterwards for inflammation to be the cause, there has followed either some defect or perversion of nutrition, or more or less complete loss of that which may be most aptly compared with what is known in physiology as inhibition — moral control. It has been said that this condition is really due to anaemia of the spinal cord ;' it may be so, and this state presents a certain, but by no means close, analogy to a somewhat similar condition of the brain; but while it is exceedingly hard to understand how such a condition could have arisen primarily, it is still more difficult to imagine how it could persist; and it must always be recollected that it is a doctrine resting on clinical evidence only, there being no pathological fact that can be urged in its support. It must, however, always be remembered that it is essential to the concep- tion of shock, that the symptoms, or some of them in their lighter form, should make their appearance immediately after the accident, It cannot -be doubted that many of the cases of sudden death which have hitherto been placed in the category of shock — cases in which an interval of some hours, or even days, have elapsed after the receipt of an injury or the performance of an operation without the appearance of any untoward complication— have not been due at all to shock in the strict sense of the term, regarding it as ex- treme vital depression caused by reflex nerve-influence. The greater number may probably be accounted for by hemorrhage, especially those later effects of it to which Nussbaum 2 attributes the strange results of accidents in advanced life ; or by septic collapse, from the sudden absorption of poisonous matters by a large serous surface, such as the peritoneum ; or by fatty embolism, which has been shown of late by "Wagner and others to be strangely frequent after injuries, especially when involving bones. The symptoms of shock do not by any means always present the gravity of the cases described above; there may be merely a temporary impairment of mental vigor, with a transient diminution of muscular energy, and a slight irregularity in the heart's action ; signs which it is very hard to distinguish from those of syncope, if indeed it is possible. Travers 3 has said that a fit of syncope and the recovery from it present an epitome of the phenomena of shock. There is, however, in syncope one characteristic feature — so characteristic as to have given it its name — which is very rarely met with in shock, perhaps never but in those cases which have a rapidly fatal termination; and this is the sudden and complete loss of consciousness always present, and due to the suspension of the function of those parts of the brain which have' to do more especially with the intelligence. It is scarcely necessary to bring forward evidence at any length to prove that deficiency in the supply of blood to the brain is the pathological condition underlying the symptoms of syncope; the striking pallor of (he. face, coming so suddenly, would alone be almost suffi- cient ; or any of those cases in which the heart being enfeebled, the sudden assumption of the erect posture is at once followed by loss of consciousness — even if Sir Astlev (doper, by ligaturing the carotids, and Flemming, by com- pressing them, had not shown beyond all question that it is the local change thai is the cause. Nor is there any anatomical difficulty in the supposition of a sudden diminution in the quantity of blood entering the cranial cavity, for this is no longer regarded as closed, but as having sufficiently free com- munication between the ventricles and the subarachnoid spaces to enable the alteration in pressure to receive immediate compensation. In shock, on the other hand, it is rare lor the loss of consciousness to be complete: the brain 1 Eriehsen, Railway Injuries. 2 Arztlichea Intolligenz-Blatt, Marz 13, 1877. * Op. oit., \>. 467. PATHOLOGY OF SHOCK. 365 is still active, though quite unequal to the higher efforts of intelligence ; its power is impaired, not abolished ; and, as in syncope it appears to be the only part of the nervous system (as far as it is admissible to use the expression) atfected, so in shock it sutlers equally with all the rest; for in the one, the simplest cause that is efficient, is a diminution of the blood pressure within the cranial cavity ; in the other, the only one that can oiler any explanation of the symptoms, is a fall in the vascular tension, which is general, extending throughout the whole body. Even when there has been no loss of blood, the lividity and pallor of the skin ; the diminution in sensibility ; the sluggish- ness of the cerebral functions; the lessened vigor of contraction and readiness to respond to stimulus, shown by the muscles; the rapidity, smallness of volume, and compressibility of the pulse ; the partial suppression of the secre- tions ; and especially the long continuance of the symptoms, which are not capable of passing off within a few minutes, as in syncope — all point to some general check to the capillary circulation, and through this to an equally general failure in the arterial tension. Pathology of Shock. It is to experimental physiology alone that must be given the credit of not merely a plausible, but almost certainly the true explanation of the manner in which these changes can take place. It has shown that, while, on the one hand, the heart is so independent of other innervation than that contained within its own walls, for the orderly continuance of its action, that the whole of the great nervous centres may be gradually removed without destroying this ; on the other hand, it is so directly under control that not only may irri- tation of a particular nerve running to it bring its movement to an instan- taneous stop, but that even, as long as the connections are intact, the same result may follow reflexly from a stimulus applied to a centripetal nerve. It has shown, further, that the bloodvessels, veins as well as arteries, are under a control so closely resembling this, that it may be brought into action by the same stimulus ; as, indeed, might have been presupposed from the close resemblance which the vessels present to the heart, in their first development. For whether the history of the individual or of the race be contemplated, in the one as in the other, at its first origin, the circulatory apparatus is uniform and simple in structure and relations ; only with increasing size and com- plexity of other parts of the bod} r , in accordance with the ordinary principles of the division of labor, does it become itself so complex that at length some divisions attain such a degree of specialization that they are usually thought of and studied as if they were independent and distinct from the rest. It is true that this similarity in nerve control does not seem at first sight so cical- as it might be ; for, according to general statements, the vasomotor system is not automatic and not distinct from the central nervous system, but reflex and situated in the medulla oblongata, with a prolongation, as experiment has. recently shown, down the spinal cord ; but that the power of independence, comparable to that possessed by the heart, is still retained, though, perhaps, dormant and subordinated, is shown by experiments in which the whole vasomotor supply of some part of the body has been cut oh 1, permanently ; at first, the vessels dilate passively, and remain in this condition for some days, perhaps even weeks ; but then they gradually recover their tone, and can con- tract and dilate just as before, but now, of course, only in response to local stimuli. It may be, to use the language of teleology, that for the convenience of the rest of the organism the nerve centres that control the vessels, in place of 366 shock. being widely scattered all over the body as they would have to be if they were placed on the walls of their own vessels (as in the* case of the heart), have been gathered together into one group and placed centrally, still, how- ever, leaving throughout the body some trace of independent control, or at least some power of developing it. ISTor is this the only way in which the vasomotor centre maybe compared with the cardiac ganglia, seemingly so unlike: for just as the latter maybe inhibited through some special nerve, either by direct irritation or reflexly, so also may the former, except that, from its central position, no other than a reflex path can be known. And thus the broad principle may be admitted, as a general statement, that the heart and the vessels are but co-ordinate parts of one system, and may be simultaneously influenced in the same direction by a single stimulus ; and that while Travers regarded shock as the result of nerve action on the heart alone, there is nothing in the physiology of the circulation that would pre- clude the posibility of a much more general effect on vessels and heart together. But this is by no means all that the subject of shock owes to the recent extension of physiological inquiry : it is not enough that the action of the heart and the tone of the vessels (on which, with the resistance of the capil- laries, depends the blood pressure), may be suspended by the direct or reflex irritation of certain nerves ; it has been shown in the clearest manner that this result with all its consequences may follow distant, external injury ; and external injury moreover of that peculiar form which is more likely than any other to cause shock — abdominal contusion. This was shown by Professor Goltz, 1 of Strasbourg, by a remarkable experiment : — A frog was taken and suspended in a vertical position, with the legs downwards, and the heart exposed. After waiting a short time, till the beats were fairly regular and sent the usual amount of blood into the aorta, the frog's intestines (or the surface of the abdomen) were struck with some violence, and the result on the action of the heart and on its blood-supply noted. It was found at once that the heart had stopped; the irritation had been carried up to the medulla oblongata, and reflected thence down the vagus. After a little while, the heart seemed to recover and began to pulsate again. But there was a very remarkable difference between its appearance now and its appearance before the blow had been given. Instead of becoming filled with blood during each diastole, and assuming a deep red color in consequence, it remained quite pale and empty, and, although it contracted vigorously, the circulation remained stopped, for the heart had no blood to propel. The cause of this was not far to seek : the frog was hanging with its legs downwards, and the upper part of the vena cava was empty ; the veins of the intestines, generally kept in a state of semi-contraction by the vasomotor nerves, had become relaxed, and the blood which would have filled them completely up to the heart was not sufficient, so that they were only halt full. Not only had the inhibitory nerves of the heart been called into activity, but. that also which regulates in a similar manner the vasomotor centre; for this result did not fol- low when the animal was fully under the influence of an anaesthetic, or when the vagi or splanchnics had been interrupted. In the frog, recovery followed as soon as it had been placed in :i horizontal position, so that the blood could reach the heart again ; in man, the stoppage of the heart in diastole would be instantaneously fatal ; its weakened action, and the dilatation of the abdominal vessels, allowing the accumulation of such an amount of blood — all really as much withdrawn for the time from the general cir- culation as if there had been actual hemorrhage — would lower the general arterial pressure, and cause the symptoms of shock. There can be no doubt that experiments such as these, which do not vary in the bands of physiologists, have thrown a flood of light upon much that before was mere conjecture. The suggestions of Travers and others, that 1 Virchow's Archiv, xxvi. and xxix. PATHOLOGY OF SHOCK. 367 such phenomena as arc presented in shock can only be produced by the sus- pension of the nervous power manifesting itself through the circulation, have found their clearest proof in the facts of physiology ; and it may be taken as demonstrated beyond dispute, that in shock there is a reflex paralysis of the heart and the abdominal .vessels. There are facts, however, which show that its action cannot be limited to these alone, but must, as might be expected from what has been said above, be extended over the whole vascular system, if not even, as Brown-Sequard has suggested, over the relation that exists normally between the blood in the capillaries and the tissues around them. For the symptoms of shock are not identical with those of hemorrhage, as under these circumstances they probably would be; and, although dilatation of the abdominal vessels leading to passive congestion has been noticed (as, for example, occasionally during ovariotomy), it does not reach, if we may trust post-mortem records of fatal cases, that extreme degree necessary to account for the symptoms. Further, Tappeiner 1 has shown, by ligaturing the portal vein and then estimating the amount of blood contained in its radicles, that even in mammals, such as rabbits, with relatively large abdo- minal viscera, contrarily to the generally received opinion, all the vessels of the abdomen, veins and arteries together, are not of sufficient capacity to hold more than sixteen per cent, of the total amount of blood in the animal's body — a quantity, as long as the other bloodvessels preserve their innervation intact, quite unable to cause such a loss of pressure ; for Midler 2 demonstrated that, as long as the vasomotor nerves retained their power, the total amount of circulating blood might be halved or doubled without producing any appreciable- difference. The same result is arrived at after section of the splanchnic nerves on both sides: by doing this, all the vessels of the abdo- minal viscera are completely cut off from their vasomotor nerves, and dis- tended to the utmost by the blood stagnating in them (for it does not seem likely that active dilatation can ever take place; the nerve-supply is doubt- ful, and the muscular mechanism in the walls unknown) ; yet by actual measurement, with a manometer, of the arterial tension after this has been done, it is found that the fall is never equal to, and in the majority of cases not half as great as, that which must occur in a case of hemorrhage if the symptoms are comparable in their severity to those of an ordinary case of shock. 3 Indeed, so far is the general arterial tension from falling below the point consistent with the maintenance of life, that animals in which this has been done on both sides simultaneously, have been known to make a thor- oughly good recovery — the local centres assuming the function which the medulla and spinal cord are no longer able to carry out, and the vessels grad- ually resuming their calibre and regular tone. 4 From these experiments it is legitimate to infer that something further is necessary ; and Fischer is probably correct in stating that in shock there is paralysis of the whole vasomotor system, that of the splanchnics being, on account of their peculiar distribution, the most marked. As the vessels have been shown to be all under the control of the same nerve-centre, it must be admitted that there is nothing improbable in this ; and it certainly affords a reasonable explanation (through the stagnation of venous blood in the capil- laries) of the lividity of the skin and all the visible parts, so different from the waxy pallor of hemorrhage. There are a few facts that point to the possibility in some cases of different parts of the vascular system being affected in different degrees. Goltz, in his experiments, sometimes found that the heart was very much more interfered with than the vessels ; some- 1 Tappeiner, Ludwiei's Arbeiten, Leipzig, 1872. 2 Miiller, Ludwig's Arbeiten, 1874. 8 Tappeiner, loc. cit. 4 Asp, Ludwig's Arbeiten, 1867. 368 shock. times, with conditions apparently similar, the reverse ; and, perhaps, some- thing of this kind may be suggested as an explanation of the extreme con- gestion of the portion of intestine above a strangulation, as compared with the condition of that below. It is to be feared that this theory, which has been adopted in its entirety by Fischer, and which must be regarded as an enormous advance upon all previous views, cannot yet be admitted as thoroughly sufficient. It cannot but be considered as most strange that injuries to the cervical spinal cord are not invariably followed by instant death ; for while the heart suffers under the general shock, there is absolute paralysis of every vasomotor nerve in the body, head and- upper extremities included ; yet, though the shock is sometimes undeniably severe, it is certainly not in the majority of fatal cases the cause of death ; and there are several instances on record of continuance of life with complete paralysis of motion and sensation in all parts below the seat of injury, the normal arterial tension being restored and maintained as usual by means of the peripheral mechanism, and perhaps of that portion of the great centre contained in the spinal cord. Nor can it be argued that the vascular tension is at once restored, even in part, by this por- tion of the vasomotor centre in the cord below the seat of injury; for it is well known from experiments on animals that, even after simple section through the spinal cord, no reflex movement of any kind can be excited for some time in any nerve that is dependent on the distal, severed portion. There is, further, an observation made by Weir Mitchell 1 to the etfect that in the variety of the cerebral phenomena presented by eases of shock, there is evidence of a change, less constant in its effects than would be that of mere alteration in the amount of blood. Nor is there any improbability in the suggestion that the peculiar power of inhibition, in which, as far as is known, all nerve structures share, and which is probably brought into play during the co-ordination of every nerve impulse, instead of only indirectly causing the symptoms of shock through its action on the vascular system, may be the direct and immediate agent influencing the nerves that govern sensation, motion, and volition, as much as those that control the walls of the bloodvessels. It has been shown beyond the shadow of doubt that, as a consequence of injury, the molecular motion which constitutes nerve force may be interfered with, perhaps even inter- rupted, in certain centres that control the heart and the vascular system ; may it not be that the paralysis of motion and sensation, and the impair- ment of reflex action, instead of being merely secondary effects produced through the agency of the circulation, are also due, wholly or in part, to a similar interference with the molecular motion in other centres? and that shock is to be regarded as an extreme and general manifestation of that inhi- bition, with the power of which, as regards a lew organs, physiology has made us acquainted? It is highly probable that many of the so-to-speak accessory consequences of injuries, the immediate dependence of which on the actual damage is not apparent, are due to some cause closely analogous to this; and especially is this true of injuries to the nerve centres, and of conse- quences thai make their appearance at once and gradually disappear. A powerful stimulus applied to a sensory nerve can entirely obHterate a slighter one. After laving open the spinal canal, irritation of the posterior roots is for some time followed by no result. After section through the Spinal cord, reflex phenomena are not witnessed till the inhibitory influence is wearing off ; and if when these have returned, and the animal has recov- ered as far as is consistent with the continuance of paraplegia, a second sec- 1 New York Medical Journal, 18G6. PROGNOSIS OF SHOCK — REACTION. 369 tion is carried through, higher up, only those parts of the body are affected which are indebted for their innervation to the portion of cord above the original section — showing that it is only along nerve paths that the influence of shock can make itself felt ; the lower limbs, in an experiment of this kind, 1 severed from all nerve connection with the part of the cord that has sustained the most recent injury, manifest no diminution whatever of reflex excitability, none of the symptoms of shock, only a contraction of their blood- vessels, secondary to and consequent on the loss of pressure in the rest of the body. More recently, Lewisson 2 has established, by means of experiments, that in a frog it is quite possible to suspend the activity of the reflex centres by the irritation of sensory nerves ; that if the irritation be sufficiently pow- erful, this inhibition may be extended to the voluntary movements ; and that finally, in a rabbit, by crushing the kidneys, uterus, bladder, or intestine, all control over the lower extremities may be abolished, the paralyzing influence continuing for some time after the cessation of the irritation, and lasting the longer in proportion to its violence. It is possible that these results, of such importance in this question, may be due to a condition of spinal anaemia ; some experiments of Brown-Sequard, 3 showing the contraction of the vessels in the pia mater of the cord, resulting from such an injury to the abdominal viscera as passing a ligature round the hilus of a kidney, would -point in this direction ; but the result is not one which is material to the cause at issue, and the experiments are of such difficulty and have been repeated by subse- quent observers with such slight success, that Vulpian at least considers it more than doubtful if the conclusions are justified. It remains that, as a result of injury, either directly involving the nervous centres or indirectly influencing them by the effect produced on distant organs (especially those of the abdomen), there may be produced in animals a condition which, after due allowance has been made for the difference in cerebral organization, cannot be distinguished in many of its features from that known as shock ; and which not only finds in physiology its nearest and best known parallel in the effect produced on the circulation by the irritation, direct or reflex, of certain nerves, but actually presents this effect as one of its best marked symptoms. In short, shock is an example of reflex paralysis in the strictest and narrowest sense of the term — a reflex inhibition, probably in the majority of cases gene- ral, affecting all the functions of the nervous system, and not limited to the heart and vessels only. Prognosis of Shock. — Reaction. _ Shock may be fatal within the space of a few seconds, as in the example given above, or, as frequently happens in severe and extensive injuries, the patient may sink gradually, after a longer or shorter time, without any at- tempt at recovery. Even if reaction does set in within a reasonable period, and the longer the delay the greater the danger, all fear from this cause must not be laid aside; sometimes, it is true, recovery is gradual and uninter- rupted ; more often its course is much less uniform, fluctuations more or less alarming often being present ; and sometimes, when all seems progressing favorably, the heart fails suddenly as if its reserve of strength had "become exhausted, and the patient dies in very much the same way as in secondary asphyxia. It is difficult to define the precise moment when reaction commences. 1 Goltz, Pfliiger's Archiv, 1875. Quoted by Fischer, loc. cit. 3 Archives Generales de Medecine, 5e serie, tome viii. lSSti. vol. i. — 24 370 SHOCK. Furneaux Jordan wouia place it very early, believing that there is in shock, at first, a diminished frequency of pulse that soon passes off, giving place to rapid and irregular action. The most satisfactory sign is an increase of strength in the heart's heat ; this soon leads to diminished rapidity and more regular rhythm. Vomiting, especially if the stomach is full, is very com- mon ; but it should not continue, and must not be confounded with that sign of the persistence of shock, intense irritability of the stomach allowing nothing to remain there. Then the respiration becomes deeper and more even, the face loses its livid pallor, the countenance begins to show some ex- pression, and the limbs, instead of lying helpless, are moved to more com- fortable positions ; but it is a long time, even if no fever sets in, before the will acquires its accustomed power; and it maybe as much from this as from anything else that prolonged retention of urine is so often met with. In general, even if there has been no wound, reaction is marked by a certain amount of fever ; the skin becomes hot and dry, the face flushed, the urine scanty and high colored, the pulse full and bounding, and there is thirst, with restlessness and headache. Where shock after accidents or operations has been severe, there is an attack of ordinary traumatic fever, varying with the nature of the accident, the method of its treatment, and the constitution of the patient, from a slight rise of temperature attended with the ordinary sleeplessness and constipation, to a condition of the most extreme excitement, rapidly running on to fatal exhaustion — that form to which Travers gave the name of " prostration with excitement ;" then the languor that character- ized the early stage passes, after a variable interval, into restlessness, jactita- tion, and precordial anxiety ; often, but not always, there is delirium varying in degree from occasional incoherence to wild and fierce excitement, more frequently occurring and more marked during the night ; at times the con- dition is scarcely distinguishable from that in an ordinary case of Delirium Tremens. Soon succeed exhaustion, marked by somnolency ; a profuse chill and clammy sweat; a haggard and livid aspect; a small, irregular, or flutter- ing pulse ; innumerably rapid, panting respirations ; passive convulsions, hiccough, and subsultus ; the stupor and stertor of apoplex}^ and death. The question of prognosis must be answered in each case mainly from the degree of the injury sustained: for, though shock is by no means wholly dependent on this, generally, in severe cases, there is either great injury or injury of some great part. Loss of the power of swallowing, showing that. probably there lias been inhibition of the glosso-pharyngeal centre in the medulla oblongata, in the immediate neighborhood of other centres indis- pensable to the maintenance of life; and insensibility of the conjunctiva, leading to the conclusion that the fifth pair of nerves has become implicated, must each of them be regarded as of the gravest import. Any hemorrhage, even if slight, is a complication much more dangerous than would at first be supposed, owing to the extreme depression of arterial tension already exist- ing; the clinical observation made by Travers, with regard to the very serious import of the loss of even a small amount of blood in syncope or shock, luis been demonstrated and explained by the physiological experimen is of Tappeiner. The longer reaction is delayed, and the more incomplete and fluctuating it is, the more hopeless the case. Still, even in the worst, some- times recovery docs take place, against all hope, when the patient has lingered hours and even days in an almost lifeless state. Among conditions usually regarded as unfavorable, musl be placed either extreme of life ; and, of the. two, advanced age as the most threatening; and similarly that condition of premature degeneration of which the abdominal viscera especially present such frequent examples. In the case of operations, prognosis may often be rendered much more easy TREATMENT OF SHOCK. 371 and certain b} 7 a careful, previous study of a patient's habit of thought and feeling ; whether he is hopeful and cheerful, looking forward to speedy recovery, or downcast and despondent, with a dogged conviction that cannot be reasoned with that things will not go well — a conviction in itself appa- rently enough to cause the worst result. For there are too many recorded cases of death after slight operations, and after perfectly natural labors, and even on a fixed day, for there to be any longer doubt as to the very grave addition that has to be made to the unfavorable features of a case, when the patient entertains a fixed idea that recovery is impossible. There are at least two distinct forms of mental influence which operate powerfully upon the result. The first is either the buoyancy produced by hope, and a firm belief in a successful issue ; or the depression produced by despondency, and a rooted conviction that the result will be fatal. The second is either a calm and equable disposition, patient and enduring ; or a peevish and irritable temper, restless and complaining. The former of these is usually influenced by age, the latter by sex. The young are the most hopeful, and women, as a rule, endure most patiently. 1 Treatment of Shock. Though it does not seem probable, in the present state of knowledge, that shock can be altogether prevented, especially when regard is had to the fortunately exceptional cases of very sudden death, yet undoubtedly, as far as operations are concerned, its severity may be in some measure diminished ; and not only in cases of disease of long standing, in which amputation or excision may be required, and in which the state of health of the patient may have been already much modified by the confinement or the other conditions to which he has been subjected, but also in such operations as the removal of tumors, or lithotomy, when the patient, as far as can be ascertained, is in a condition of complete health, and no part of the body through long-continued suffering has come to bear an altered relation to the rest. The care taken in the preparation of a patient, accustoming him to altered rules and conditions of life, and rendering him familiar with persons and things about him, is labor well spent, even if light ; and there is not a little in the conduct of the operation itself — the restraint of hemorrhage and the avoidance of cold or exposure while the patient is on the table, and of unnecessary delay during its performance. How far anaesthetics are of use in the prevention of shock, is a question that had best be considered with that of their advisability during its continuance. [Easley and McGuire recommend large doses of quinia, before an operation, as a means of preventing shock.] In the treatment of a person suffering from severe shock after injury, the first care should be to loosen everything around the neck or chest, that can in any way impede respiration, and to place the body in a recumbent position, with the head as low as possible ; even a pillow is not always advisable. Of course, any source of hemorrhage should be at once investigated, but, during shock at least, bleeding is not of common occurrence. And, above all tilings, it is necessary in every way to maintain the temjieraturc of the body as near the normal degree as possible : as the circulation fails, the temperature falls ; the bed and the room should be warmed, warm blankets and hot bottles should be placed around the patient, and the extremities should be well rubbed. It has even been recommended (and carried out successfully by Hunter, of Philadelphia) that patients when suffering from shock should be placed in a 1 Savory, loc. cit. 372 shock. hot bath, beginning at a temperature of 98° F., and gradually increasing it to 110° F. By leaving a patient in a batli in this way for a quarter of an hour, the temperature of the body has been raised from 96° F. to 98°. 5 F., the respirations reduced in number from 36 to 20 in the minute, and the cold and clammy skin rendered warm and dry. When the heart shows signs of foiling, external heat is sometimes of further use in the form of flannels or sponges wrung out of water as hot as can be borne, and applied to the cardiac and epigastric regions. Counter-irritation more vigorous than this is of question- able service, though there can be no doubt that sinapisms and blisters applied to the extremities can, by the irritation of sensory nerves, cause a slight elevation of the general blood-pressure. In persistent vomiting, a mustard- plaster may sometimes be applied, with very good effect, to the pit of the stomach. The use of stimulants cannot be avoided in a severe case of shock. It is quite true that a patient may recover without their employment, but no one who has ever seen the color come back rapidly to a patient's face, or felt the pulse beat stronger at the wrist, after a small quantity of brandy has been swallowed, will hesitate again as to the propriety of their use. The quan- tity must be judged of individually in each case, but need never be great; if reaction is coming on fairly, and continuing evenly, very little is required ; if the reverse be the ease, and one or two ounces of brandy produce no effect, it is probable that it is not being absorbed by the stomach, and the ingestion of a further quantity would only result in causing vomiting. In this case, or where the power of swallowing has been lost, enemata of small volume containing brandy may be tried, or subcutaneous injections of brandy or of ether, 1 but usually, it must be confessed, with little hope. Afterwards, when reaction has fairly set in, there is no proof that stimulants are of much avail ; nourishment of a more lasting character is required, but a very careful watch should be kept on the pulse, and a small quantity of brandy administered whenever this shows signs of failing, and repeated every half hour if need be. Opium, in some form or another, is nearly always required to allay pain and to procure rest ; if this can be obtained, nourishment need not be pressed just at first. Opium seems of equal service, however given : by the mouth, by the rectum, or hypodermically ; if it cause sickness when injected under the skin, it may be combined with atropia ; or it may be given by the mouth, the required quantity, in form of the liquor opii sedativus, undiluted, being placed upon the tongue; or sometimes a freshly made pill of crude opium will answer the purpose when nothing else- is successful. It must be very seldom that a case presents such peculiar features that artificial respiration would be of any serviee ; it is nearly always the heart that gives out first, and death from asphyxia, due to the lungs failing to act, must be very rare. Transfusion has been tried in a sufficient number of cases f<> prove its futility, as long as shock is unaccompanied by serious hemorrhage; when Ibis is the case, the question rests on altogether different grounds. EJp to a certain point, simple hemorrhage has scarcely any effect upon the blood-pressure, the vasomotor nerves causing the vessels to contract in proportion to the loss of the circulating fluid; but beyond that pointthe compensation fails, and the pressure talis with great suddenness. If, iu a case of this nature, uncomplicated, transfusion be resorted to at this critical ' Verneuil (Journal de Med. et de Chir. Pratiques, Mars, 1877) recommends subcutaneous injei i iona of ether, L5 minims, repeated in mi hour's time if required, stating that he lias seen very great benefit derived from it. [The editor is oonfident that he has saved life, in cases of severe shook, by the hypodermic use of ether; it. may be administered very freely, a syringeful (about 30 minims) being injected every liv • ten minutes until the patient is able to swallow, when carbonate of ammonium, 5 grains every half-hour by the mouth, may be substituted.] TREATMENT OF SHOCK. 373 moment, a relatively small amount of blood may save the patient's life. But in shock, in which the vasomotor mechanism is almost, if not completely paralyzed, and in which the most serious symptoms, even death itself, may occur without the loss of a single drop of blood, the question is totally dif- ferent. Injection of more blood only increases the amount stagnating, and does nothing to raise the pressure. The limits within which vascular tension is independent of the amount of blood, are very wide. It has been suggested that in cases where the external jugular veins stand out prominently, and where presumably the right side of the heart is full of blood, venesection would be of some service, and might, by relieving the dis- tension, stimulate the heart to fresh action. But this condition points to asphyxia, and not to shock; and in the face of the serious influence of acci- dental hemorrhage, can scarcely be advised. The heart is distended because it is paralyzed; not paralyzed because it is distended. The intravenous injection of ammonia has been tried in a few cases with sufficient success to warrant a repetition of the experiment; by this means Penfold 1 probably saved a patient in extreme collapse from continuous purg- ing; and Tibbits, 2 after trying it unsuccessfully in a case of septicaemia, and another of hemorrhage, brought around by its aid a very severe case of rail- way injury, in which the pulse at the wrist was quite imperceptible, and the patient had already lost all power of swallowing. The quantity injected at one time should not exceed ten minims of the liquor ammonia? fortior, and care should be taken not to send it into the subcutaneous tissue ; the degree of dilution is not, according to Harford, material. [As pointed out by Dr. Richardson, ammonia, whether given in this way or by the mouth, both acts as a stimulant and is useful by maintaining the fluidity of the blood, and thus obviating the risk of heart-clot — a pathological condition found in most of the cases of so-called "secondary shock."] There are three drugs, strychnia, belladonna, and digitalis, the use of which, from their action on the blood-pressure and the vasomotor nerves, has been particularly recommended during the continuance of shock, in the hope of relieving at least one, and perhaps the most prominent symptom. Of these drugs, the last named is perhaps the most hopeful, from the power which it has been shown to possess both over the heart and the arterioles, diminishing the rapidity of contraction of the former, and increasing its strength, while at the same time it stimulates the muscular walls of the latter. It has, indeed, been employed by Dr. Wilks 3 for this purpose, in a case of shock following parturition: the patient was apparently in articulo mortis ; her limbs were cold ; her body in a state of deathly, clammy sweat ; the face was livid ; no pulse was to be felt at the wrist ; and a mere fluttering was heard when the ear was placed over the region of the heart. Brandy and ether had been em- ployed without any good effect, and, as dissolution was imminent, it was determined to try digitalis. Half-drachm doses of the tincture were given every hour; after four doses reaction set in, and after seven, complete recovery "began. Dr. Lauder Brunton remarks on this case that a consideration of the encouraging results obtained can hardly fail to gain for digitalis a much more extensive application in cases of shock than it has hitherto received. \ et this mode of treatment does not seem to have been resorted to by others. Strychnia, which, like digitalis, may be given either by the mouth or sub- cutaneously, in cases of this kind, derives its chief recommendation from the result of experiments by Mayer 4 and Prokop Rokitanski, 5 showing the power 1 Australian Medical Journal, January, 1873. 2 Med. Times and Gazette, November, 1872. 3 Mod. Times and Gazette, January, 1864. 4 Med. Jahrbiicher d. k.-k. Ges. d. Aertze zu Wien, 1872. 5 Quoted by Brunton, Saiut Bartholomew's Hospital Reports. 1S79. 374 shock. it possesses over botli the vasomotor and the respiratory centres in the me- dulla oblongata and spinal cord; but actually, in the only case in which I am aware that it has been tried, the result was not satisfactory. Belladonna, 1 too, in very small, repeated doses, acting as a stimulant to the vasomotor sys- tem, is perhaps worthy of a trial. With regard to the employment of an anaesthetic when an operation is required in a case of shock, and still more with regard to the choice of the par- ticular substance to be used, there is very great diversity of opinion. On the whole, it may be said that the balance is at present decidedly in favor of the administration of these agents, and of ether rather than of chloroform. It is true, as Fischer has remarked, that patients seldom feel to any extent, and that sometimes, when no anaesthetic is administered, the pulse improves even during the operation ; but the former statement is not worth much as an argument; and the latter is of no avail against the employment of ether. Indeed, the only objection that can be urged against the latter, is that in the ordinary methods of administering it, the supply of oxygen to the patient is too much interfered with. Chloroform, which is used, perhaps, less than it was, but is still preferred by some experienced administrators in these cases, is undoubtedly, when pressed at all far, an exceedingly dangerous agent ; a minimum quantity is required to anaesthetize the patient, and only a drop or two occasionally to maintain the influence of the drug ; anything over this, quite abolishing the action of the cerebral hemispheres, will be probably dis- astrous. For, as Brunton 2 has pointed out, the violent irritation of a sensory nerve affects the heart refiexly, but compensates itself by causing the small vessels to contract, and so raise the blood-pressure ; if the quantity given is sufficient to do away with sensation completely, the compensating action is lost, and there is danger; if the chloroform is pushed further still, the reflex centre in the medulla inhibiting the heart becomes .affected equally with the cerebral hemispheres, and the danger is past; and Brunton cites Syme as always having used chloroform with a free hand. But in shock there is cer- tainly no need to proceed as far as this. A great deal has been said about the choice of the time for performing an operation ; whether to operate at once, wait till reaction is commencing, or until it has fully set in ? Xo doubt each case must be judged on its merits, but still some general rules may be laid down. The main guide, of course, is the severity of the shock sustained, as evidenced by the patient's pulse and general condition. If it is not severe, it need scarcely be regarded ; if so grave that it is questionable whether react tion can set in, every means should be tried to bring the patient around before operation is attempted; in all other cases, it is probable that Guthrie's advice will be admitted by most at the present day to be the most reasonable: wait two, tour, or six hours if need be, till the pulse is beginning to regain some of its strength, and till the patient is recovering sufficiently to become conscious ofpain. [Some information maybe gained by observing the temperature. 1 1' this be below 90° F. (35°. 5 C, Redard), no operation should, as a rule, be performed. J Fatty Embolism. Tn discussing the symptoms of shock, it was mentioned that many of the fatal cases Hitherto ascribed to its influence must be referred to some other cause especially when after an injury or operation the patient continues to present a perfectly satisfactory condition for some hours or even day's, and then, more or less suddenly, is seized with symptoms indicative of some great 1 Gasquet, Practitioner, May, 1S79. * British Medical Journal, December, 1S75. FATTY EMBOLISM. 375 disturbance, and dies. It is not possible to understand how any effect of nerve influence that was caused by injury, could remain for two or even three davs concealed so thoroughly that there should be no suspicion of its exist- ence, and then manifest itself with such intensity and rapidity as to occasion death within a few hours. Some other explanation manifestly is required for such cases as these ; and within the last few years it has, so it is believed, been found, for many at least, in what is known as Fatty Embolism, that is, embolism of the small arteries in the lungs, and very commonly in other organs, due to minute drops of fluid fat which, having been set free some- where in the periphery (generally in connection with the medullary cavity of bones), are carried into the circulation and follow its ordinary course. It was not, however, in connection with any case of injury that the exist- ence of fatty embolism was first discovered ; for the earliest observation 1 on record refers to a case of contracted kidney, in which the choroidal vessels were found to have been plugged with particles of fat supposed to have come from an atheromatous aorta; and in the next, 2 in which after severe injury to the bones the pulmonary vessels were loaded with fat, the significance of the lesion was quite missed ; and when, shortly after this, Wagner 3 made a similar observation in two fatal cases of pyaemia, the suggestion was imme- diately raised that the fat was in some connection with the metamorphosis of pus at the periphery, and the development of metastatic abscesses in the lungs. Some experiments, in which the necessary conditions were not main- tained, served to perpetuate this view till 1865, when Warner 4 published the results of forty-eight cases in which he had found this lesion (fifteen of these being instances of rapid death after severe injury to the bones and soft parts); and Bosch demonstrated by cinnabar injections that; immediately after injury to the medulla of bones, it was possible for particles of fat to enter the open mouths of the lacerated veins and be carried into the pulmonary arterioles, causing embolisms, without, however, necessarily entailing abscesses or inflam- matory disturbance. From these facts, and from experiments by Bergmann 8 on the intravenous injection of oil, \Yagner was led to the conclusion that the coexistence of fatty embolism with pyaemia was merely accidental ; and since then it has been shown clearly that the very different results to which fatty embolism may lead, depend on whether it occurs after subcutaneous injury, or is due to some disturbance set up in the neighborhood of a septic wound. The appearance that the lung presents is exceedingly suggestive of a pro- cess of embolism : if this- has been very extensive, the smaller vessels may be so distended as to be visible to the naked eye, and hemorrhage or infarction imj occur ; while under the microscope, the lung-stroma shows a regular injection, mapping out all the capillaries and filling them with some liquid, which, from its reaction with perosmic acid and its rapid disappearance under ether, can be nothing else than fat. More often there is only a condition of hyperemia and oedema, and then there may be found here and there, with tolerable regularity, minute drops and short cylinders. These changes are not limited to any part of the lung, though they occur, as might have been expected, most plentifully in the lower lobes. Xot unfrequently oil-drops have been found in the clots in the branches of the pulmonary artery, in the right side of the heart, and in the large veins leading to it from the seat of injury. So that post-mortem evidence alone renders certain the presumption that the process is really one of embolism. 1 Miiller, Wurzburg med. Zeit., 1860. 8 Zenker, Beitrag. z. norm, unci path. Anat. d. Lunge, 1S62. 8 Wagner, Archiv d. Heilkunde, 1862. * Ibid. 1865 6 Zur Lehre v. d. Fettembolie. Dorpat, 1863. 376 shock. The nature of the accident or disease in which this complication arises, renders it still more clear : it is always one in which the rupture of fat-cells may reasonably be supposed to occur ; and the greater the chance of this, the more extensive the embolism. This is probably the reason — joined to the fact that the veins are torn and cannot close— that it has been observed with such frequency after fractures ; so frequently, indeed, that it has been said to be a normal occurrence. Thus it is always proportionate, in simple fractures, to the amount of injury inflicted on the medulla, and to the number and size of the bones that are broken ; bearing out thoroughly the experiments of Vulpian, 1 who showed that in animals, while in simple fracture embolism was sometimes hard to find, yet, when a foreign body Avas introduced into the medulla, there never was any difficulty in tracing the fat through its whole course ; while, if the foreign body was a tent, the lungs were simply gorged. But though most commonly met with after simple fractures, and perhaps in them of greatest clinical interest as offering an explanation for deaths that under ordinary conditions seem utterly unintelligible, fatty embolism is by no means confined to them. Many of Wagner's instances occurred in cases of compound fracture, and especially after secondary ampu- tation, or were found after acute periostitis (when metastatic abscesses were nearly always present) ; while the lesion has been noticed after simple suppu- ration in the connective tissue; after crushing injuries of only the fleshy parts of the body, especially if they contained much adipose tissue ; after rupture of fatty liver ; in chronic inflammation connected with bone ; as the result of fatty degeneration of thrombi ; in icterus gravis, and in diabetes. Indeed, so common is it, that Flournoy, 2 examining all the bodies brought into the Pathological Institute at Strasbourg, found it in no less than ten per cent. Quite a number of observers have seen, in compound fractures, oil-drops flowing out with blood from the medullary cavity, and haA T e afterwards found similar ones in the veins leading from the limbs ; but till recently it was believed that this was the only channel by which the fat was taken up ; it is, however, clear, from fresh experiments, 3 that tatty embolism of the lungs may follow within a few hours if any oil gain access to a serous surface, and even, though at a much later date and to a much more limited extent, when it is set free in the connective-tissue spaces. The delay and the diminution may probably be accounted for by the fat having to pass through lymphatic glands on its way, and probably becoming emulsified in them. It is not easy in all cases to account for the force which is necessary to cause the oil-drops to enter the veins ; sometimes, perhaps, the nature of the accident itself will give a reason for it ; in other cases, it has been suggested that the liquid fat from the broken-down cells stagnating in a wound, is sud- denly caught up when the state of syncope passes off and the heart recovers ; or it may be, as Vulpian's experiments suggest, that from the commencement of inflammation there is a sudden increase of pressure and local tension. In studying the effect of fatty embolism, it is necessary to distinguish clearly between the results of clinical observation and the data furnished by experiment ; for while in the latter every precaution can be taken to exclude other influences, there can be no question that, in the former, other things besides fat can gain access to the circulation. The most recent and careful experiments that have been conducted for the purpose of ascertaining the cause, of death, are detailed by Scriba 4 in a monograph on this subject. By injecting carefully purified oil into the veins, into the medulla of bones, and 1 D6jerine, Progrfes Medical, 1879. 2 Egli-Sinclair, Corresp.-Bl. f. Schweizorische Aerzte, No. vi., 1870. 8 Wiener Archiv f. exper. Path., Bd. xi. * Uutersuchungeii iil>er die Fettembolie. FATTY EMBOLISM. 377 into the peritoneal cavity of rabbits, Scriba has been able to confirm the views of Bergmann, 1 that the symptoms depend mainly on the quantity injected and the rapidity with which it is introduced, or the proximity of the vein selected to the heart ; in this way it is possible to vary the result from a death so instant as only to bear comparison with the injection of air into the veins, to the slightest possible dyspnoea ; and even this may be wanting, though after death the fat may actually be found arrested in the lungs. Scriba finds, moreover, that, if the distance from the heart of the point of entrance of the fat into the circulation be at all great — as in the majority of fractures taking place in the human subject it would be — and if the force that propels it into the veins be slight, the quantity required to produce any alarming symptoms in an animal is very great; in no case is Scriba of opinion that death can be caused by the injection of less than three times the amount of blood present in the femur of an animal. Further, much light has been thrown by experimentation on the ultimate destiny of the fat that is carried into the pulmonary capillaries — a point of great clinical significance ; for it is not impossible that, in some cases, the particles may be carried off, and, by their subsequent impaction in other organs, cause even more serious mischief. Some undoubtedly pass at once, without any detention, through the pulmonary circulation, and either form emboli elsewhere, or are caught up by the glomeruli of the kidney and excreted with the urine ; for, after injection of fat, large masses have been found in the urine and the vasa atferentia ; glomeruli and tubules have been seen full of it, while the same condition has been detected after fractures in man. Indeed, from the intermittent appearance of oil in the urine, from its abundance for the first few days, and then its absence till the end of the second week, when it may appear again for a short time, Scriba concludes that in man, after the lapse of from six to eight days, the emboli become detached, and that they then pass on either to be excreted by the kidneys, or to be caught by the capillaries in other organs — these in their turn setting free the particles they originally detained to be carried into the veins, and so cause, as it were, secondary pulmonary embolism. It has happened, somewhat unfortunately, that in very many of the recorded cases no observations were made on the presence of oil in the capillaries of other organs ; but it has been observed in the liver (though not to any large extent, possibly from the action of the hepatic cells which may take it up), and on several occasions 2 in the brain and spinal cord. The symptoms characteristic of fatty embolism, when uncomplicated, besides the presence of oil in the urine at irregular intervals, and the dys- pnoea, which of course varies with the number of capillaries obstructed, are a fall rather than a rise of temperature, slight haemoptysis with irregular action of the heart, pallor and lividity of the skin, shallow respiration grad- ually passing into Cheyne-Stokes breathing as the case becomes worse, and loss of reflex excitability with, at times, spasms of various kinds, or paral yses. But it is very seldom that the symptoms met with after accidents or operations resemble these ; much more often there is observed a condition of which an excellent example is given in a case related by Southam : 3 the operation (primary amputation of both lower extremities) was borne well ; a comfort- able night was passed ; and the general condition was regarded as satisfactory, though the temperature had risen from 101°. 2 F. the previous evening, to 103° F. in the morning. Suddenly, in the afternoon, the patient became restless and excited, his face wore a dusky look, his pulse and respiration 1 Berliner klin. Wochenschrift, Aug. 18, 1873. 2 Czerny, Berlin, klin. Wochenschrift, Nov. 1875. Lancet, July 10, 1880. 378 shock. became more rapid and feeble, and, though there was no rigor or marked dyspnoea, by the evening the patient was delirious, sinking fast with a tem- perature still rising, and it was evident that the wounds were no longer aseptic. At the autopsy, though no change of importance was visible to the naked eye, yet microscopic examination showed the capillaries and arterioles of the lungs to be simply tilled with oil globules. In nearly all the instances that have recently been reported at length, the symptoms resembled these. Boettseher 1 gives the particulars of a case of gunshot wound of the knee- joint, fatal on the third day from sudden collapse, and states that the lungs were intensely hypersemic and full of fluid fat. Czemy's 2 case was somewhat different, in that it was one of simple fracture of the femur ; but, like the rest, there was a gradual rise of temperature with sudden dyspnoea and cyanosis on the morning of the second day ; post-mortem evidence of fatty embolism was abundant, not only in the lungs but in the brain, liver, and kidneys, all of which were studded with small ecchymoses. Dejerine 3 gives the particulars of a case in which a leg was severely crushed, and which proved fatal within seven hours; but, though the lungs were full of oil, there had been no marked dyspnoea. In short, it seems impossible to reconcile the clinical data with the knowledge derived from experimentation ; in the latter the conditions are known ; in the former there must be something else to cause the rise of temperature and other symptoms. It is not meant that fatty embolism does not take place after accidents, or that when it is extensive it is not dangerous from the effect which it must produce on the respiration and circulation, and perhaps from another cause recently pointed out, the solution of blood corpuscles by its agency; but that it is scarcely possible to conceive of its being so extreme as to obstruct the circu- lation through the lungs and so cause death ; or so extensive as to bring on the same result by occluding small vessels in the brain or spinal cord — the conclusion at which Scriba arrived from the artificial production of uncom- plicated fatty embolism in animals. It seems, on the whole, much more rea- sonable that it should be regarded either as an addition to that form of acute blood-poisoning known as " collapse with cyanosis," which is particularly likely to set in on the second or third day after an injury, and which is much more consonant with the symptoms in the majority of the eases; or, where the change has set in earlier, as a complication which, added to the already exist- ing nervous prostration and the loss of blood, is sufficient to turn the scale. But a much wider series of observations is required before this question can be regarded as in any way definitely settled. Of its importance there can be no doubt; already upwards of one hundred and forty instances have been recorded in Germany alone, and the fatty embolism was, according to Egli- Sinclair, the cause of death in no less than thirteen per cent, of these. Still less is known with regard to the significance of fatty embolism in diabetes. The occasional lactescent state of the blood serum in this disease, has long been known; and recently 4 it has been shown to be due to the pres- ence of fine molecules of oil ; and fatty embolism of the lungs and kidneys, exactly similar to that appearing after fractures, has been found in a patient dying in thai condition of coma which is not uncommon towards the end of this affection. But the relation existing between these conditions is quite uncertain ; death in a state of coma, with an enormous increase in the amount of molecular oil in the Mood, is at least quite consistent 5 with the complete absence of fatty embolism. 1 Dorp.it. mod. Zeitschrift, 1877, S. 326. « Berliner klin. Wochenschrift, Nov. 1878. 8 Progrea Me'dical, 1879. 4 Edinburgh Med. Journal, 1879. 6 Gamgee, Physiological Chemistry, p. 171. TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. BY WILLIAM HUNT, M.D., SENIOR SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. Traumatic Delirium. The word Delirium has rather a curious derivation from de (from), and lira (a ridge between two furrows). The Latin verb deliro is defined as " to make a balk in plowing." A free translation, therefore, would be to deviate or wander from a prescribed line. Hence the word "wandering," that is often used to express the presence of delirium in disease. Those who coined the word did better than they knew, if our present knowledge of the brain and its func- tions is taken into account. As knowledge of the localization of nerve centres and their conducting fibres becomes more and more developed, we can readily understand how the furrows and ridges and folds of nerve matter may be disturbed by a balk of the driver (external impression), or by a stump in the furrow (internal disease). A temporary derangement of the intellectual and perceptive faculties, manifested through the speech and actions of the patient, is the necessary characteristic of delirium. The wandering need not be by speech alone, for a deaf mute, or an aphasiac, may become as delirious as any one else, and delirium is uncmestionably experienced by, and may be produced in, animals. Continuous or chronic delirium necessarily becomes insanity, and techni- cally should be considered under that head. The case may be a fatal one, as far as the individual patient is concerned, and the delirium, in a more or less acute form, may be continuous until his death ; but should he survive, and the delirium persist indefinitely, his place would be among the insane. This temporary character of true delirium varies in its expression to a remarkable degree. Sometimes it shows itself as a mere passing fancy, and is difficult to detect; again, the patient may be perfectty himself as long as his attention is directed by another, or to some special object, but, these conditions ceasing, he relapses into his absurd utterances or actions. Then moments, and sometimes extended periods, of normal consciousness follow, during which he will be more or less aware of what has passed, and will own to himself, or to his attendants, that he has been "making a fool of himself," and will declare that he will not do it again. Soon, however, there is a recurrence of the wander- ing and the nonsense, and, should the disease get the upper hand, these may continue in a more aggravated form and without intermission until death. The actions of the patient also vary very much, and range from trivial devia- tions from the normal standard, such as it would require an expert to detect, to the most violent efforts, threatening injury to himself and to his caretakers. (379) 380 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. Anatomy of Delirium. — Delirium is eminently one of those conditions to which the convenient word "functional" is applicable, when we seek for an explanation of its phenomena. It manifests itself, as far as we know, through impressions made upon the cortical gray substance of the brain. The cells and fibres of this substance, therefore, must be in a receptive condition, and need not of themselves deviate from the normal state. In fact, a perfectly healthy cortical matter, if the received physiological views of its purposes are correct, is more consistent with the occurrence of the severest forms of delirium than one which is otherwise. Its functions are disturbed by its environment, in the form of meningeal inflammations, or by slight irritative exudations or hemorrhages pressing upon it. Great pressure would sup- press its workings altogether. Again, it may be harassed from without by alterations in the quantity and quality of the blood which is sent to it, and which may be charged with the products of disease, or overloaded with poisons. Then the special senses, being set agog from the same causes, bring wrong impressions to it, which it must needs take up and discharge, in the form of wrong thought, wrong talk, and wrong action. The necessity of this recep- tive faculty of the gray matter for the production of delirium, is further proved by the meagre mention of delirium as a symptom, when the brain itself, excepting the cortex, has been made the subject of experiment or clini- cal observation. 1 Thus in lesions of the Pons, a tendency to cry more than to laugh is noted. There is emotional weakness, which might be taken for hysteria, but no men- tion of delirium. The Crura being disturbed, paralysis of the third nerve follows, and the diplopia and confusion of vision thus caused, together with a certain confusion of speech, probably owing to some facial paralysis, may readily give rise to the idea that delirium is present, when really the intel- lectual faculties are undisturbed. After the first effects of a lesion of the corpus striatum are over, the absence of mental disturbance is particularly noted. There may be slight thickness of speech and also emotional phe- nomena, but no delirium. Injury of the thalamus is attended by less distinct signs than injury of the striate bodies; but delirium is not noted as one of its symptoms. Injuries of the white substance of the hemispheres are not pro- ductive of delirium, nor do I find it mentioned as belonging to lesions pur- posely inflicted upon the cerebellum. The posterior and inferior parts of the frontal lobes, being injured, give rise to typical aphasia, and a careless observer might construe its manifestations as those of delirium. Certain portions of the cortical gray matter, then, of the surfaces of the hemispheres and their convolutions, being subjected to irritative influences, are the seats of delirium. These remarks are confirmed by clinical observa- tion. It is to be understood that delirium may coexist with affections or injuries of some of the other regions above mentioned, but when it does so, there is every reason to believe that, in most cases, it is due to the neigh- boring meninges being more or less involved. Dr. Morris Longstreth informs me that he has analyzed the histories of more than three hundred brain tumors, and that delirium is rarely mentioned as one of their features, and that, when it is, it may be readily accounted for by implication of the mem- branes, these in their turn affecting the cortical matter. When formerly Demonstrator of Anatomy in the University of Pennsylvania, I have no dpubl that I showed many splendid brains, the original possessors of which had been "mad as March hares." The supply of subjects was large, and many of them must have come from the " Insane Wards" of the Almshouse. J can call to mind glued membranes, masses of old lymph, pearly arachnoids, and 1 Carpenter, Bastian, Ferrier, Charcot. CAUSES OF TRAUMATIC DELIRIUM. 381 ossific deposits ; but, these being removed, I sliced and dissected and lectured upon as pretty brains as an enthusiast in anatomy would wish to see. I remember one in which the old lymph mass was so extensive, that it actually formed a secondary membrane covering both hemispheres; and yet beneath was a beautiful brain. What havoc must have been caused to the intellectual and perceptive demonstrations of the cells of the cortex! My own clinical observations incline me to agree with those (Hughlings Jackson and others) who think that the posterior lobes of the hemispheres have more to do with ordinary intellectual processes than the anterior. A very large number of cases of injury of the cortex have come under my care, and I have frequently noted and spoken of the almost absolute indiffer- ence in this respect with which enormous injuries to the frontal lobes are borne. I have seen masses of brain come away from these, and also from the middle lobes, without any apparent intellectual disturbance. If the case were fatal, delirium would come on towards the end, there having been ample time for the irritation to spread ; but, recovery following the injury, I have known the patient to convalesce without a single incoherent manifestation. In fact, I am disposed to think that in such cases recovery is the rule rather than the exception. I am sure, however, that this is not so when the posterior lobes are the seats of cortical injury. Delirium then often sets in at once, and may cease as pressure from hemorrhage or effusion increases, but, this being removed by operation or absorption, is apt to return, and will abate or increase in accordance with the progress to recovery or death. These inju- ries, therefore, are much more dangerous to life and. to mind than the others. Inflammatory products, effusions, hyperemia and anosmia, alterations in quality as well as quantity of blood supply, are then more potent causes of the symp- tom delirium, than pathological changes in the nerve substance proper. Causes of Traumatic Delirium.— The foregoing remarks have necessarily included the consideration of those forms of traumatic delirium which accom- pany immediate injuries to the brain substance and its membranes. By far the greater number of cases of delirium coming under the notice of the sur- geon, as well as of the physician, arise from causes external to the brain, and consequently have their origin in anything which may affect the quality or quantity of the blood. Of these, those affecting the quality are the most numerous, and hence immediate delirium is not nearly so common in exter- nal, surgical cases, as the delirium which ensues after time enough has elapsed to bring about various septic changes. One cause of immediate delirium is great and sudden hemorrhage. This variety generally finds expression in a mild form of rambling, that is more apt to be indicative of pleasant sensations than otherwise. Should fainting occur, sufficient to check the bleeding, and if, in the mean time, surgical appliances be successfully used to prevent its recurrence, the patient reacts, sometimes very rapidly, and will often speak regretfully of the glories through which he has passed. If the case prove to be a fatal one, a distressing rest- lessness sets in, and this with the delirium continues until death. There is a rather rare form of immediate traumatic delirium, which neverthe- less must be more or less familiar to every surgeon of a great accident hospital, or to those who are in any position, as upon the battle field, where they become familiar with severe and sudden casualties. Delirium might appear to some to be a misnomer, for the characteristic is that every word and idea are per- fectly coherent. There is great exaltation of mind, but an utter want of ap- preciation of the bodily injuries. Commonly the spine has been involved in the crush, and the line of communication with the brain has been cut off, but this is not necessarily the case. There is no collapse at first: the skin has its 382 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. normal temperature, the pulse is full and rather frequent, the face may be more flushed than natural, the eyes bright, and the expression good. The surgeon enters a ward some morning, after a terrible accident has occurred, and finds that a victim of this kind has just been brought in and laid upon a bed. He is at once recognized by the patient as one in authority. " How are you, doctor," he says, in a high voice; "what have they brought me here for? I'm not hurt! No, sir! Look at that," and out goes an arm with the force of a prize fighter delivering a crusher. " Look here," and he tries to lift a leg, which his sensorium falsely tells him he has done, although his expression may indicate a vague and passing doubt. " Why there's my wife ! Molly, what are you doing here ? don't cry ; what are you crying for ? I'm not hurt; go home to the children and tell them I'll be there to supper and at the mills to- morrow. "Won't I, doctor? Go home!" Soon this great tension gives way, collapse comes on, and by night the patient is in another home than that in which he promised to be. I have never known such a case to recover. With all its coherence, with every intellectual and perceptive process cor- rect as far as external matters are concerned, every word and thought as to other persons and objects right, everything as to himself wrong, how are we to classify this state, except as one of delirium ? Important questions might arise as to the testamentary capacity of such persons ; from what I have seen and described, there is nothing in their condition inconsistent with full ability to direct the management of their estates and effects. Shock after injury is a condition so intimately involving the nervous sys- tem, both cerebro-spinal and organic, that delirium might be reasonably looked for as a common accompaniment of it. This symptom, however, is rarely present during the stage to which the term shock is applicable. The intellectual and perceptive faculties simply experience the profound depres- sion which is present everywhere. The nearly pulseless, pale, cold body ; the dull eyes and drooping lids ; the slow and feeble respiration, and the shrunken and clammy skin, are all expressive of that general condition, in which the brain itself takes part. In fact, shock without reaction means death, and many die in this condition. During its continuance, there may be some slight mutterings, which increase if death is to come; but upon being spoken to, it will be found that the patient's intelligence is retained, and only sluggish. He wishes to be let alone, is indifferent as to what it all means, becomes colder and weaker, and dies ; or warms up, it may be sleeps for a short time, and lives. It is in this latter event, when reaction is taking place, that delirium frequently occurs. It is apt to be wild, especially in children. Its degree is in accordance with the rapidity of return of the general functions. The re- bound oversteps tiie mark, and disturbance of the cortex is one of the results. E'ortunately this kind of delirium does not often last long. As the skin, kid- neys, ;n id other organs resume their normal actions, it subsides. Delirium may recur in the future progress of the case, but will have other causes for its production than what happened at the start. Embolism of the cerebral vessels, from the suddenness with which it some- times takes place, one would think would he a cause of immediate delirium. 1 do not, however, find tins mentioned as a prominent symptom, or even as an ordinary one, in cases where the lesion is suspected. It may be that the limited area of cortex which is supplied by the special vessel or vessels in- volved, is nourished sufficiently from collateral sources to maintain its integ- rity, or that, if the blood is entirely cut off, local death of the delicate cells and fibres takes place so rapidly that their receptive and demonstrative pro- perties are lost at once. Thrombosis, from the comparative slowness with which it mostly occurs, would be more likely to he accompanied by delirium ; hut as the vessels of the brain involved in this process are generally large and CAUSES OF TRAUMATIC DELIRIUM. 383 basal ones, their influence upon the cortex is remote, so that the symptom is not one of special note. I recently had the rare opportunity of observing the invasion of an attack of apoplexy in which the lesion, I think, must have been in the pons, although no autopsy was allowed to confirm the opinion. When I first saw the patient, she was entirely sensible, but in a high state of emotional excitement. She complained much of lateral and posterior headache. There was no delirium : answers to questions were promptly and properly given — but there was great restlessness in addition to the excitement; paralysis was not then present, for various acts were performed as requested. Knowing something of the patient, I was inclined to regard the attack as hysterical, and to prescribe and leave the house. Fortunately I remained, for soon quiet came on, the countenance became suffused with redness, stertorous respiration began and grew worse, and death took place in a few hours. Probably a basal thrombus had been slowly forming, which was finally followed by rupture ; and it may be that some peculiarities, which we are apt to call hysterical, had, in this case, their origin in a pathological condition which was not a re- cent one. Immediate delirium may also be brought on by so-called subjective sensations arising from irritations or injuries of the nerves of special sense. The particular parts of the cortex (supposed by some to be chiefly in the posterior lobes of the hemispheres) which have to take up impressions from these nerves and discharge them as perceptions, know nothing else than to develop these perceptions as objective truths to the intellect. Should these apparent truths assume distorted, frightful, or absurd forms, it is easy to understand how the confusion created would upset the centres of congruity and produce delirium. I have already spoken of the fact that some authorities are disposed to give the cortex of the posterior lobes of the hemispheres the preference over the anterior ones, as seats of intellectual processes. May it not be that the more intimate rela- tions of the former with the phenomena of perception, and the close connec- tion of these phenomena with the ordinary manifestations of intellect, bring their operations more readily under observation ; and that deeper or abstract ideation has its nerve centres in the anterior lobes, these requiring for their accommodation those cranial forms which s;ive to higher man " the front of Jove himself?" Comparative anatomy and the doctrine of evolution both appear to sustain this view. As to delirium, the clinical facts which I have related about injuries to the cortex of the frontal and posterior lobes of the hemispheres, also support it. Delirium does not deal with the abstract, but is developed in its highest degree by disordered perceptions sending false im- pressions through their transmitters, which in turn disorder the receivers. Whatever the middle lobes may have to do with ideation, the fact of their beiug the seat of centres through which the will produces motor acts, seems to be well established. I have one important clinical observation to sustain this view. In Ferrier on " The Functions of the Brain," 1 there is a drawing of the surfaces of the hemispheres to illustrate the effects of local electrization. One of the parts mentioned occupies the adjacent margins of the ascending frontal and ascending parietal convolu- tions, and this statement is made in regard to a certain part when it was the subject of experiment, " Retraction with adduction of the opposite arm, the palm being directed backwards." Now there was a sailor under my care, in 1879, whose case I have fully reported. 2 While at sea, he had inflicted very serious injuries upon the middle lobes of his brain, by fracturing his skull with repeated blows of an axe whilst he was, there is every reason to believe, in the delirium of heat fever and exhaustion. The delirium actually disappeared after he picked the pieces of bone away. The patient landed in New York ' London, 1876, p. 142. 8 Medical News and Library, Philadelphia, July, 1879. 384 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. four or five days afterwards, came on to Philadelphia, and walked to the hospital. He was perfectly conscious and very intelligent. Soon there was paralysis of the left arm, with retraction (position of palm not noted), and then paralysis of the leg of the same side followed. On dressing the wound, two pieces of hone respectively a quarter by half an inch and three-quarters by three-eighths of an inch in size, were found under the anterior right margin of the sound bone, and -precisely, it is lair to say, in the ]>osition which Dr. Ferrier pictures. Upon removing these pieces, the paralysis at once disap- peared from the arm, and by the next day it was gone from the leg. There was no active delirium at any time after the patient's admission to the hospital. I recall the fact that I ordered him to the basement of the building, fearing that he would throw himself from the window should delirium come on. After having been there one night, he protested against it ; said he was perfectly himself, and begged to be removed to his room up stairs. His request was complied with, and he remained quiet and rational until a day or two before death, when coma came on without antecedent delirium. As the brain became more and more disorganized, the paralysis returned and became general. He lived twenty-four days after the removal of the pieces of bone, and forty days from the time of the original injury. The lesion here was in the middle lobes; a very extensive abscess had formed, and the softening had extended as deeply as the corpus callosum. Immediate traumatic delirium, it might be reasonably inferred, would be among the symptoms following the bites of poisonous serpents. Besides the specific virus, there are the elements of horror and fright to aid in its pro- duction. Experience, however, does not at all confirm such an inference. Deaths from snake-bite are preceded by stupor and coma,but delirium rarely exists, even for a short time. This is true not only as to fatal cases, but also as to those which end in recovery. A very large number of cases of snake-bite are reported by Sir J. Fayrer, in his splendid work, "The Thanatophidia of India." I have looked carefully over these reports, and have not once detected the word delirium; yet there was everything to suggest it. The words fright, depression, lethargy, stupor, coma, and unconsciousness, are continually used in the descriptions. But, until these last phenomena occurred, the intelli- gence of the victims appears to have been remarkably good. In some cases it took a few minutes to kill, and in others hours ; in one doubtful case, nine days ; and yet no delirium is mentioned. As Sir J. Fayrer says, the poison "kills by annihilating the source of nerve force." He mentions the fact that pyaemia may arise, when the patient lives long enough to have a suppurating wound from the bite. Then of course delirium might exist as a consequence of this affection, but I do not think that any case in which it occurred is given. Fright is sometimes so excessive as to bring the patient near unto death, and we are told to encourage and cheer him as a part of the treatment, This of course would be useless if he were in a state of delirium. The same may be said of cases of rattlesnake poisoning. Dr. R. M. McClellan, who lived tor some years in a part of Georgia where rattlesnakes are very common, tells me that he has seen from ten to fifteen cases of persons bitten by them. The nervous symptoms, as from the bites of the Indian serpents, were those of stupor and coma, but there was no delirium. Even enormous amounts of whiskey, used as a remedy, would not occasion the excitement of drunken- ness. Dr. E. B. Shapleigh treated a case of rattlesnake bite which occurred in this city (Philadelphia). The patient was rational throughout his brief illness, ami made his will twenty minutes before his death. Dr. Weir Mit- chell, who made some years since an exhaustive study of the effects of rattlesnake bites, also confirms these views. These observations are of prac- tical value. II' intense hysterica] excitement, approximating delirium, or even delirium itself, should follow in the case of a, person supposed to have been bitten by a poisonous snake, there would be almost a certainty that the CAUSES OF TRAUMATIC DELIRIUM. 385 accident had not happened. Sir J. Fayrer, indeed, relates one case in which the patient was almost frightened to death, but recovered rapidly on its being found that the snake which had bitten him was not poisonous. The bites and stings of certain venomous spiders and insects, not being so overpowering as those of serpents, might possibly give rise to delirium. A sort of delirium is described as following the bite of the tarantula; but there is reason to believe that much, if not all, that is related about this creature is fabulous. Death sometimes follows the stings of bees, wasps, or hornets. In such cases, there is nothing more likely than that delirium should arise, both from the pain and from the extent of surface affected. There is a con- dition produced analogous to erysipelas, and, if extensive enough, high febrile excitement with consequent delirium might occur. The furious stage in hydrophobia is one that might be classed with delirium, from its temporary character, and yet during the paroxysm, when phrensy appears to possess the brain, there is a mental clearness inconsistent with the idea of delirium. The derangement expresses itself in acts rather than words ; incongruous thought is not a part of it, for the patient seems fully aware of what" is going on, though he has no power of will to control his deeds. A low and true delirium, indicative of exhaustion, may come on as death ap- proaches. In tetanus, there is no delirium. Even during the most violent spasms, the mind remains perfectly clear. The excito-motor and sensitive tracts of the cord, both direct and reflex, are strained to their utmost, whilst the cortex, unhappily maintaining its integrity, does its full part here in the development of su tiering. In chorea, there is no delirium even when the subjects of it have received most severe injuries, or have undergone operations. I have reported a case 1 of fracture in such a patient, who actually died from the exhaustion of his incessant movements and the consequent irritation of the broken fragments of bone. His brain was a perfect one. Yvliat morbid force kept up the involuntary motor excitement, I do not know; but it was certainly not expended on the cells of the cortex. Sometimes traumatic delirium comes on shortly after capital surgical opera- tions have been performed on account of severe injuries. This is much more apt to be the case with children than with adults, and it is also more likely to follow operations for recent, than those for old, injuries, or than those for disease. The symptom is a very bad one. After eliminating any cause which might exist for a short time, such as fright, the effects of the anesthetic, etc., if the delirium should continue and increase in severity, a fatal prognosis would be justified. Delirium in disease is a very common symptom with children, the slightest fever being sufficient to cause it in some instances. Being creatures of perception rather than judgment, the brain balance is in them readily disturbed ; and if such a trivial cause as a little rise in temperature is able to do this, how great must be the disturbance which may follow a serious injury, combined with a serious operation. I can give no better illustration of this than the annexed chart (Fig. 28) of the history of a case of compound luxation of the elbow-joint requiring excision. One may see at a glance how temperature, pulse, and respiration, moved nearly 'pari passu until the tenth day ; then, exhaustion following the intense excitement, there was great recession, with chill, after which, new force being gathered, the delirium became more violent, and only ceased with the collapse of death. Surgical or traumatic fever is very apt to be accompanied with delirium. By this term I mean that fever which is almost a necessary consequence of 1 Pennsylvania Hospital Reports, 1869. vol. i. — 25 386 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. great operations or severe injuries, such as compound fractures. The phrase is often inadvertently used for the fever of the various septicaemias. This is wrong, for there is nothing of a septic character analogous to those conditions about it. The phenomena of fever are set up from the great local irritation. Fig. 28. e P Aug. 30 31 80 a o 03 Temperature. 98 99 100 101 102 103 104 105 106 107 _• » • i i . • i , \ i \ i i i i i i i i iii. j i i • iiii .ill ■ M. 20 E. 75 85 18 18 M. E. ~M.~ ~ET ~m7 e7 ~m7 Sept. 1 2 3 4 5 6 7 8 9 10 11 12 75 80 85 105 104~ 106 124 ii6~ 125 143" 18 18 22 "28 40 34 36 40 38 42 E. M. "E. M. -+- I.I. .tJ.U, ■ i i i ill! — , -*- j-l . i ! 1 J I E. 118 36 M. 140 44 . E. ~w. "e7 M. ~ E 80 120 112" 32 38 ± 38 — — ~ _ 120 124" 120" 116 120 140T 150 156 130" 32 32 40 ^^ M. E. M. ~E. M. E. 24 40 38 44 44 ~ +■ 1/ , . M. iii. , , 1 1 1 '..L.I l l 1 1 •I J j.l E. 13 14 15 L36 165 142 L64 L56 46 IJ 44 46 44 ' ' - +' E. M. E. 38 " M. ..iii i i i i .ill i i i .III ill, i .1 1 . ' I - ' 1 mi" E. 98 99 100 101 102 103 104 105 106 107 Temperature chart of M. N., aged 10. Traumatic delirium following excision of elbow for compound dislocation. The (4-) indicates a rise of temperature after a chill. The operation was performed mi August 30, 1880. The delirium, which began on September 4 (sixth day) and persisted until the patient's death, was throughout very noisy and violent, with distressing hallucinations. The treatment consisted in the administration of bromide of potassium, morphia, ami assafcetida. Temperature rises, as docs also the. pulse; possibly there is an accumulation of combustible products. The quickened circulation and the heated blood play upon the gray cells of the cortex, and hallucinations and delirium CAUSES OF TRAUMATIC DELIRIUM. 387 are the consequence, the vagaries not unfrcquently having reference to the functions of the affected part. These symptoms mostly* subside after active suppuration has been established, but sometimes death occurs before this happens. How truthfully a case of this kind is described by Dr. John Brown, in "Rab and and his Friends." "Ailie's right breast had been amputated — one night she had fallen quiet, and as we hoped asleep ; her eyes were shut. We put down the gas and sat watching her. Suddenly she sat up in bed, and taking a bed-gown which was lying on it rolled up, she held it eagerly to her breast — to the right side. We could see her eyes bright with surprising tenderness and joy, bending over this bundle of clothes. She held it as a woman holds her sucking child ; opening out her night-gown impatiently, and holding it close and brooding over it, and murmuring foolish little words as over one whom his mother comforteth, and who sucks and is satisfied. It was pitiful and strange to see her wasted, dying look, keen and yet vague — her immense love. ' Preserve me !' groaned James, giving way. And then she rocked backward and forward, as if to make it sleep, hush- ing it, and wasting on it her infinite fondness ' Wae's me, doctor ; I declare she's thinking it's that bairn.' • What bairn ?' ■ The only bairn we ever had, our wee Mysie ; and she's in the kingdom forty years and mair ' It was plainly true; the pain in the breast telling its urgent story to a bewildered, ruined brain, was misread and mistaken ; it suggested to her the uneasiness of a breast full of milk, and then the child ; and so again once more they were together, and she had her ain sweet Mysie in her bosom." The record of a favorable case of surgical fever with traumatic delirium, after operation, is here presented. (Fig. 29.) The age of this man had doubtless something to do with the symptoms, for it should be noted that persons over 65 or 70 years old are almost if not quite as liable to be affected with delirium, after great injuries or operations, as children. The form of delirium is generally like that set down in the chart. Independently of operations, compound fractures are very apt to be accom- panied by delirium, after a few days from the time of the accident. Fortu- nately, except in cases complicated with the effects of drink, which will be considered under the head of delirium tremens, the delirium is not apt to be violent, at least in adults. During febrile exacerbation, it takes the form of mild wandering, which is not accompanied by uncontrollable acts. It may be that the local injury is a constant reminder, through pain inflicted by move- ment, and that thus the judgment is enabled, in a marked degree, to control the wandering senses. This form of delirium is not at all serious in its import. It gradually subsides, and is not apt to return without some extraordinary cause. As in almost everything else, the patient becomes accustomed to his own condition and to his surroundings. Then fever may occur, as, for ex- ample, during the separation of a piece of bone, but the brain will be wholly indifferent to it. Simple fractures in the old not un frequently give rise to delirium, which is also not violent in form, but much more serious in its indications than that which I have just described. Senile delirium is always a bad symptom in surgical cases, especially so when comparatively simple causes give rise to it. It indicates an inherent Weakness, not only in the brain itself, which is pro- bably affected by reason of deterioration of its bloodvessels, but also in other important structures, which are undergoing the alterations of age. Extensive lacerated wounds will often give rise to delirium, which may last but a short time, the accompanying fever being ephemeral in character and scarcely worthy the title of surgical fever. I have the chart of such a case, which gives the record of what followed a lacerated wound of the forearm in a woman 38 years of age. On the day of the accident, the temperature rose from 98|-° to 103|° F. On the third day, 104° F. was recorded in the 388 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. evening. After this there was a recession, and the normal standard was reached on the ninth day. There was passive delirium at night, but the Fig. 29. c "3 u p. Temperature. Remarks. 98 99 100 101 102 r . I l iiii Li.i_.-j i_i_ jl_l July 27 28 29 30 31 1 M. E. M. E. 1 Constant mild delirium, night and day, rather passive in cha- racter, taking the form of hal- lucinations as to locality, oc- cupation, and surrounding objects. 98 90 20 24 92 ~88~ 26 24 ^ M. 90 80 24 22 \ E. M E. "mT E. ^ 85 ~98~ 24 22 — 95 24 ^" Aug. 1 2 85 24 ^ M. 90 86 80 26 E. M. E. 24 ~2-T 1 1 i -1 3 4 5 6 7 8 60 84 80 22 24 M. ! E - 22 M. E. M. 84 ~85~ 24 20 85 20 E. M. E. 80 85 80 84 ~8lT 18 18 18 18 M. ~E. ~mT E. m". K 18 88 18 9 sf, 18 80 IS ___5 ' > ____._■_!_ 1 I 1 i , j r_ >___ 10 80 84 18 M. E. - i ■ i r . 1 1 98 99 100 101 102 Temperature chart of J. A., aged 67. Traumatic delirium following amputation of hand for machine injury. Treatment consisted in the administration of 20 grains of bromide of potassium with 5 drops of the tincture of digitalis every four hours, and the hypodermic injection of a quarter of a grain of morphia at night. Recovery. patient was rational in the daytime. Throughout, the wound was doing well, and a rapid recovery ensued. Such favorable progress of lacerated wounds is aot, however, always to be looked for, when as high temperatures as 104° V. are found to exist. One would reasonably fear an excess of inflam- matory action, which might he followed by gangrene. The sudden rise in the above case is a matter of note, for, instead of being alarming, it, with the delirium, simply pointed to the fact that the patient, although an adult, had the susceptibility of a child. There was nothing about the wound to account for it. Lacerated wounds in their ordinary progress may be the causes of true surgical fever, with accompanying delirium. CAUSES OF TRAUMATIC DELIRIUM. 389 Bums and scalds are probably more apt to be attended with delirium than any other class of injuries. In rapidly fatal cases, where there is no reaction from shock, the brain is generally clear, and remains so until death. During this time, all susceptibility to pain having been lost, and the sense of touch being gone through the destruction of its principal organ, the skin, the intel- ligence takes no cognizance of the vast calamity. I have seen, after deep and extensive burns, what seemed to be a living soul looking out of a crisp, charred, and dead body. I have seen a child thus burnt playing with toys an hour before its death. Sometimes, in this condition, there is what appears to be a pleasant and mild delirium. " Death having preyed upon the outward parts, Leaves them insensible ; and his siege is now Against the mind, the which he pricks and wounds With many legions of strange fantasies ; Which in their throng and press to that last hold, Confound themselves. 'Tis strange that death should sing." A much greater mercy is extended to these than to those whose burns are inevitably fatal, and yet who survive the shock for days, weeks, and it may Fig. 30. 6 ft "3 Ph a .2 '5, a K Temperature. 97 98 99 100 101, 102 103 104 105 May 11 12 84 33 1 M. E.~~ M. ~ET m7 E. M. E. M. E. M. E. = m E. M. 90 110 30 40 13 128 124 ~ 38 40 14 118 40 110 35 15 16 17 110 ioir 24 28 100 120 108 26 y 30 30 \ ^ 1 125 | 36 Till 1111 iiii 1 1 1 1 ^ , ' 1111 18 19 20 21 22 98 103 25 ~28~ E. M7 E. M. E. ~MT E. M. E. 100 100~ 95 112 105~ 120 24 30 23 30 32 86 . t 90 | 32 120 40 ; : ; ' 1 r , , 1 ! 11 Till 111, , "^~"~ - 97 98 9a 100 101 102 103 10 4 1C 5 Temperature chart of E. K., aged 37. Traumatic delirium following extensive burns of face, neck, arms, hands, and trunk, involving skin and superficial fascia. From May 14 until the patient's death, the delirium was active and constant, requiring mechanical restraint. The treatment consisted in the administration of 20 grains of bromide of potassium, with 10 grains of chloral hydrate, aud 5 drops of the tincture of digitalis, every four hours. m TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. be for months. Is it any wonder that these patients all become delirious, and that in some the symptom is continuous until the end ? Those who re- cover, also have delirium, which varies in extent and duration with the severity of the injuries. Touch, the master sense, of which all other special senses are modifications, and without which no knowledge of the external world is conceivable, is terribly deranged, and expresses itself to the sensor- ium only as pain. Myriads of fibres as conveyers, myriads of cells as receivers, are involved. There is so much wrong at the surface, that it would be a marvel if wrong did not follow at the centre. I should much sooner expect to find irritative exudations on the posterior surfaces of the cortex in fatal burns, than ulcers in the duodenum. Besides pain, as a producer of delirium in burns, surgical fever, with its ordinary phenomena, may also set in and develop it. This, however, is not often the case, for it is surprising to notice, after the surfaces have become clean and the papillae well covered w T ith healthy granulations, how tolerant the patient becomes ; and when repair is fully in progress, he passes on to a slow recovery without any mental disturbance. I have the charts of six burnt and scalded patients before me, all of whom had delirium. Four of these recovered and two died. One of the fatal cases illustrates a burn and the other a scald. These two charts (Figs. 30, 31; are Fi £ . 31. Pi O 3 P. Temperature. Pi 9 .1 |.| 100 i i i 101 1 1 1 102 103 104 105 106 Aug. 12 13 14 100 119 116 ~T04 114 20 M. "e7 20 18 ~T8~ 2d M. ~E.~ M. E. M. E. M. "eT M. E. 15 1G 17 18 116 ioii 106 1114 106 20 "20 18 To 22 ^s 116 110 22 22 M. E. 120 24 _1 1 1 1 1 ■ } ■ ' iiii i i i i 19 120 126 26 ' ' ' -^ M. E. 30 Aj , , t,, 1 kJ >~ 99 100 101 1( )2 1 33 104 105 106 Temperature chart of P. M., aged 23. Traumatic delirium following scalds of face, neck, forearms, hands, and air-passages (by inhalation). Violent raving delirium began on August 13 (second day), and continued day and night, until the patient's death, requiring mechanical restraint. The treatment consisted in the administration of 30 grains of bromide of potassium with 10 drops of the tincture of digitalis every (our hours ; of 10 grains of chloral hydrate every six hours ; and of half a grain of morphia, hypodermically, at night. annexed, as well as one (Fig. 32) of recovery from burn. In two, the delirium Bel in on the second, and in the other on (he fourth day, certainly too soon I think in all of them, and at least in the first two, for ordinary surgical fever. There was no delirium tremens in these cases. The absolute and cpiick de- CAUSES OF TRAUMATIC DELIRIUM. 391 struction of the papillary surface of the derm is not so apt to take place in fatal scalds, as in fatal burns. Hence a sudden delirium in the former may subside, after complete insensibility of the part occurs. Erysipelas is a fruitful source of delirium. Place and extent have their in- fluences in producing it. When the disease is in the face and scalp, active delirium may set in very promptly. There is no doubt, I think, that con- tiguity and similar blood supply, giving rise to meningeal congestions, have Fig. 32. 'a ft "3 Ph a o "3 'p. Temperature. 97 98 99 100 101 102 103 104 105 May 29 80 [ 20 ~92~| - i8~ M. E. M. 30 31 June 1 2 3 4 5 6 7 8 9 10 100 | 22 102 88 30 E. M. 24 100 100~ 122 100 108 118 28 — E. 30 28 M. E. M. E. "m7 E. M. ~eT - 24 28 30 118 32 122 24 120 31 90 102 20 20 M. E. 100 24 M. ~9lT|~23~ ^ E. 96 ~20~ "-— -. M. 106 ~W 88 86 ~28~ 24 20 y M. E. M. E. 20 78 76 22 ~18~ M. 86 22 iiii > 1 7 1 1111 lit, f i > i E. 97 98 99 100 101 102 103 104 105 Temperature chart of L. J., aged 21. Traumatic delirium following superficial and deep burns of face, neck, arms, forearms, hands, legs, and feet. From May 30 (second day) to June 6 (ninth aay) there was delirium, mild during the day, but noisy and requiring mechanical restraint at night. The patient was rational on June 8. The treatment consisted in the administration of 30 grains of bromide of potassium every five hours, with 15 grains of chloral hydrate at night and a quarter c* a grain of morphia when required. Recovery. much to do with the production of delirium under these circumstances, and that in the early stage the brain is more irritated by these conditions than by the presence of any specific poisonous products. It is at such times that blood-letting, if resorted to at all, is admissible. When much surface is in- volved by erysipelas, in other portions of the body, we have conditions analo- gous to those of an extensive superficial burn, and, as a consequence, delirium, generally of an active character, is produced. In phlegmonous erysipelas, 392 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. where the cellular tissue besides the skin is the seat of great inflammation and destruction, the blood no doubt becomes loaded with septic materials. Delirium, often very wild at first, is not uncommon. If the case is to end fatally, a state very like that of pyaemia is developed, and, as the patient grows weaker, the disordered, brain expresses itself in low, indistinct and unmeaning mutterings. Epileptic patients, becoming the subjects of injury, are not, according to my observation, more prone to delirium than others. In fact, I have seen some cases in which the brain irritability appeared, to be arrested or suspended for a time by reason of casualty. Whilst writing this article, a rare and curious case came under observation in the Pennsylvania Hospital. A man was admitted for an accident requiring excision of tlie right elbow-joint. A few mornings after the operation, he was found to be having an attack of catalepsy. His eyes were open and fixed ; his head was motionless ; no answers to questions were given. One leg was raised : it remained fixed and rigid in the air. The same was the case with the other leg, and also with the left arm. Where they were placed, the limbs stayed until they were put down on the bed. The mouth also could be opened and fixed in any position which it was capable of taking. The patellar tendon-reflex was present in a limited degree, but the groin or scrotal reflex was marked. There was complete anaesthesia ; no notice was taken of pins or pinchings. While I was in the ward, the man was observed to turn his head ; I went to him ; he was awake, but in delirium. This delirium expressed itself in delusions as to place. He could give a true account of his injury, and the name of the railroad on the line of which it hap- pened. He himself, however, was on top of a pole ; then in a churchyard ; then in the building of the Pennsylvania Insurance Company ; then on top of a railing. His occupation had nothing to do with these places. Being in the insurance company's building might have been suggested by his being told that he was in the Pennsylvania Hospital. The attack soon passed off, and on the third day the patient was entirely himself. He said that he had been subject to vivid and troublesome dreams, but both he and his wite declared that he had never before had a cataleptic fit, at least to their knowledge. In hectic, there is no delirium. Its absence, indeed, is the great fact that serves to distinguish hectic from other febrile troubles which occur in the course of surgical, as well as of medical cases. Why the cerebral system is so exempt from contamination in hectic is difficult to explain. There are continuous febrile conditions with exacerbations, many constant and morbid tissue changes giving rise to products that would seem to have all the ele- ments about them necessary to poison the blood, and so to work damage on the delicate cells of the cortex; there are exhausting discharges; excruciating pains often, as of the joints; colliquative sweatings and skin irritations enono'h to set a giant mad, and yet never an approach to delirium. This fact is so generally recognized, that when delirium arises in a hectic patient, some accidental cause, as for instance an intercurrent erysipelas, will be found to explain it, and when tliis is over the usual course is resumed. The freedom from delirium cannot he explained by assuming that tubercular and allied products are non-irritating in their character, for when, as in tuberculous meningitis, the cortex becomes directly concerned, there is marked, often violent and continuous, delirium, of a character that suggests something pecu- liar as its cause,and that is not explained merely by the local congestion. In this disease also, there is rarely time for the development of hectic. In hectic it is said I hat there is no materies morbi introduced into the blood from without, and that the products of tissue waste are carried oil' by the emunctories with such regularity and rapidity, that there is no accumulation of deleterious material in the circulation. This is an ingenious explanation, but not alto- gether satisfactory. It certainly favors the theory that causes giving rise to DIAGNOSIS OF TRAUMATIC DELIRIUM. S93 hectic are local in their origin, and are not due to antecedent blood contami- nations. It also helps to sustain the view that other febrile conditions, as the septicaemias, must have peculiar causes to originate them, these generally arising from without in the shape of organic germs, or animal poisons. It is in cases of this latter kind that we do have delirium, and their num- ber is probably greater than that of any other class in medicine and surgery. It is certainly so during wars and pestilence. Badly ventilated and crowded tenements; poorly constructed hospitals ; abodes of any kind presenting errors in drainage, in sewerage, in location (as of camps); wherever, in fact, masses of men are brought together, under unfavorable, and sometimes in apparently favorable, conditions, there, wounds or disease arising, the " pure brain, by the idle comments that it makes," too often " foretells the ending of mortality," for "the life of all the blood is touched corruptibly." Immense advance lias been made of late in checking the rise and progress of these " preventible diseases." It is too much to believe that they will eventually disappear, for the conditions for their production are constantly arising anew, or are being reproduced in places where it was thought that they had 1 teen al tated or stamped out. Pycemia, phlebitis, low forms of erysipelas, gangrene, malignant pustule, phagedena, carbuncle, any, indeed, of the diseases which from their very nature generate certain blood poisons, and produce febrile states analogous to those called typhoid or typhus, come under this head. They are truly classified as blood poisons, or septicemias, and when developed to any extent, they one and all give rise to delirium. This delirium is sometimes active, but is mostly of a passive character. When active, the brain membranes are probably the seat of local inflammations, which may arise early in the disease, and which are of very serious significance. The high excitement may be continuous until col- lapse and death occur. I have seen cases of this kind, but they are rare. Mostly, days elapse before delirium becomes a prominent symptom. It will appear during the febrile paroxysms, and pass away with them. If the case goes on from bad to worse, it will become continuous, and express itself in vague mutterings as long as the patient is left to himself. lie will, however, answer questions correctly, and take food without resistance, and sometimes with avidity. He soon lapses, loses his sense of locality, and "wants to go home;" then he becomes altogether unconscious, apparently more from exhaus- tion than from deep coma, for he babbles and mutters almost until he dies. Given the conditions, there is scarcely a form of surgical affection, in itself mild or severe, that may not take on the above characters. This is especially true as to all cases in which there are open or abraded surfaces, either simple or complicated, and this fact goes far to sustain the germ theory, however unproved it may be. In such a disease as cancer, we find that there is no delirium in its progress, that is, none belonging to it because of the cancer; and yet what is more professionally and popularly thought to be a peculiarly infecting disease than this ? As in the case of hectic, there is enough to produce delirium, but I do not remember to have seen a cancerous patient thus affected. We call the disease malignant, and so it is; but it rarely appears to express its malignancy on the gray cells of the cortex. Diagnosis op Traumatic Delirium. — Delirium declares itself, and hence there is nothing very profound to be said as to its diagnosis. It is the kind that requires discrimination, for restraint may have to be used, or else there must be great watchfulness on the part of the attendants. Ordinary delirium should be carefully distinguished from delirium tremens — a matter which will be discussed on a subsequent page. Sometimes delirium may be assumed. He would be a consummate malingerer who could keep up the deception for 894 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. any length of time. The coincident febrile or other symptoms would be wanting, and, by throwing the patient oft' his guard, it could very soon be shown whether or not he was in his right mind. A counterfeit delirium or wildness sometimes occurs in hysteria, often very difficult or impossible to tell from the real thing. In such cases time -alone will develop the truth. Treatment of Traumatic Delirium. — Delirium being a symptom, its treatment naturally consists in measures to remove the cause. In by far tbe greater number of surgical cases, where it exists, this is the course pursued. Sometimes, however, the symptom becomes so prominent, and so disturbing to what is being done for the main affection, that especial means are required to allay it. Indeed it is not uncommon to have to almost, if not altogether, abandon the original treatment for a while, and to address remedial measures wholly to the delirium. In the very active forms, cupping on the back of the neck, cold by ice-bags to the head, and free purgation with salines are required. Hot mustard foot baths are of great use, and may be readily given to the patient while lying in bed, should there be no surgical disability of the lower extremities. The bromide of potassium, or other bromides, may be administered in large doses. Opium is too much feared, and certainly should not be discarded altogether, as is done by some surgeons. Chloral hydrate is also of great use. Sometimes the necessities of the case may call for the use of ether or chloroform by inhalation. In the passive forms of delirium, re- quiring interference, depleting measures are not well borne. Good nourish- ment and stimulants, together with moderate doses of opium, will be found to allay the violence, if not entirely to prevent the occurrence, of the symptom in ordinary cases. Of course, nothing is to be gained by directing remedies especially to the delirium immediately preceding death, unless it should be very violent, which is not common. At the beginning of delirium, quiet, as absolute as possible, and isolation, are great factors for good. There should be no suggestive conversations with the patient, or with others in his hearing, for these might readily lead to unfortunate acts. A statement, interesting in this connection, bas been recently published in the medical journals. The delirious patients of one doctor, in a hospital, were found to have a great propensity to throw themselves out of the windows, and had to be carefully watched. The other doctors' patients were free from this tendency. A medi- cal man was taken sick in the hospital, and became delirious. He was under the care of the first doctor. He reported afterwards that this doctor was in the habit of giving directions about guarding the windows, in the hearing of bis patients. The sick man went through the same experience, and declared that, during his delirium, the impulse to throw himself from the window was so irresistible, that he would have done so had he not been guarded. Delirium Tremens. In a "tract" upon this subject, written "by Thomas Sutton, M.D., of tbe Royal College of Physicians, and Physician to the Forces" (London, 1813), the author says: " Delirium tremens, and likewise the treatment, which will be pointed qui as we proceed, are known to some professional men to a cer- tain extent; but to many they are wholly unknown ; and the disease has not ye1 taken a station in medical writings." In his practice between 1798 and 1807, the doctor " was led to see the distinction between phrenitis and de- lirium tremens, at least in regard to the treatment." , These remarks are introduced to show how comparatively late in the his- tory of medicine, a distinctive recognition was made between meningitis or CAUSES OF DELIRIUM TREMENS. 395 plirenitis, and delirium tremens, the latter having for its production a specific cause, and a pathological anatomy entirely distinct from that of the former. From the earliest times, excess in drink has been a habit among men, and it seems scarcely credible that the efiects of this habit in producing a pecu- liar disease of the brain and its membranes, should for so long a time have escaped attention. AVas it because everybody drank, and was drinking considered so innocent a pastime that it was not thought of as a cause of disease ? This also is incredible, for the evils of drink, as well as its pleasures, are dilated upon by the authors of all ages and countries. It is probable therefore that drink was known to be a cause of disease, but that the efiects were misinterpreted, and were considered to be evidences of active inflamma- tion. This was no doubt so, for the treatment of these cases was antiphlogis- tic to an extreme degree, and the mortality was frightful. A great advance, then, was made when it was recognized, both by the efiects of treatment and by the results of post-mortem examinations, that a true inflammation did not exist in this disease. Dr. Sutton was at first on the plirenitis side. He naively says : " The one party, with myself, considering the disorder to be active inflammation of the brain or its investing membranes, conducted the treatment according to this supposition ; the other, without pretending to any precise notions of this affection, in so far as the contents of the cranium might be concerned, were in the habit of using opium in large and repeated doses. / very soon perceived that the latter practice carried with it all the suc- cess" The post-mortem appearances, as far as the contents of the cranium are con- cerned, are peculiar in this, that they show T no sign of active inflammation, nor of any of its products. Instead of adhering membranes, thickenings, opa- cities, and pus, there is a condition, so characteristic in uncomplicated cases, that it has been named " wet brain." Passive congestion and serosity, the latter both subarachnoid, in and under the pia mater, and filling the ventricles and following the convolutions, are what are met with. The brain substance proper is not necessarily the seat of changes ; and what happens to it in fatal cases must be secondary, and not essential to the disease, else how could it be possible for so many to recover entirely from this affection, and, provided that there be no return to former habits, to pass their lives without showing any defect in mind or body ? In fact, what was said about traumatic delirium and delirium in general, is equally applicable here. A sound cortex, capable of being impressed by adverse influences, is in the best state to develop de- lirium. Repeated drafts upon this soundness, by renewed attacks, will finally affect it, and the victim will then too often lapse into imbecility or dementia. Causes of Delirium Tremens. — Delirium tremens then, as far as its pro- duction is concerned, does not differ from other forms of delirium. The dif- ference lies in the peculiar effects arising from the cause. The great interest of medical men in this disease is due to its frequency, through the universal prevalence of drinking habits. There is no disease or injury upon which it may not make its imprint, and give a serious turn to what would otherwise be favorable. In many cases, both medical and surgical, all else has to be abandoned in treatment until the delirium is subdued. Thus delirium tre- mens is not only a torment in itself, but, when it complicates other affeetionsy it is an unbounded torment to all concerned. The cause is nearly always the excessive use of alcoholic drinks. The habitual use of other articles is said to produce it: opium, belladonna, stra- monium, tobacco, cannabis indica, certain fungi, and even tea and coffee are all capable of causing delirium. Of these, it is said that veritable delirium 396 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. tremens is sometimes produced by opium and tobacco, and cases may be found in medical works in proof of the fact. I have seen one case of poisoning with stramonium. There were hallucinations and much severe delirium, with visual anomalies, but, the cause being well known, the symptoms soon sub- sided under treatment with emetics. Overdoses of belladonna produce like effects, and sometimes there is furious delirium. It is not common for either of the two last-mentioned drugs to be used habitually ; a necessity, it would seem, for the production of delirium tremens by any substance capable of causing it. Cannabis indica is habitually used in the East, mostly in the form of the well-known haschish. It is said " to pervert the natural perception of objects and their normal conditions and relations, more than an}^ other agent." If so, one would think that in time phenomena like those of delirium tremens might readily follow its use. I have one observation to record as to its curious power of producing double consciousness, an alter ego. I was giving it to a patient for some chest trouble. He was wholly ignorant of what he was taking. One day he said to me : " Doctor, you will have to stop giving me that medicine ; I don't know what it is, but here am I, John, on this lounge, talking to myself, John, sitting on that chair. I can't stand it, and if you keep on I shall be wild." The symptom disappeared on discontinuing the medicine. Had one side of the brain the power to so project an ego, that the other side could take cognizance of it ? Singleness as to both external objects and ideas, seems to be the result of the actions of our double cerebral organs, or centres, in a normal condition. When perverted by disease or intoxicating agents, this particular property might be disturbed, and such curious results as that just related might be produced. Anaesthetics, such as ether and chloroform, it is well known sometimes cause violent delirium. This may occur at the start, and not return, but now and then a case is met with in which delirium persists after an operation has been performed. I have known it to so continue, and to be apparently the exciting cause of an attack of de- lirium tremens, of which the remote and continuing occasion was an under stratum of rum. It is not my intention to consider here all substances that might possibly cause delirium tremens. The above-mentioned are the most prominent. For practical purposes, delirium tremens caused by the habitual use of alco- holic drinks is what demands the attention of the surgeon. The disease, as proved from post-mortem examinations, and also from the results of various modes of treatment, is one of depression of the organic forces, although it may express itself by intense animal excitement, and hence the source of those mistaken views already alluded to, which regarded it as a true phrenitis. It is thought by many to be caused by the withdrawal of accustomed stimulus. This may sometimes be so, but the truth more likely lies in the fact that, at the time of the attack, there is a rebellion of the overtaxed digestive organs. The stomach becomes sickened, the liver refuses to act properly, the bowels are torpid, the kidneys are irregular in action and, with " old stagers," are often so altered by disease as to give rise to temporary suppression of urine. Thus the various results of vicious tissue-metamorphosis, besides those of alcohol, to which they also are due, poison the blood, and produce through the circulation, and probably by direct contact with the cortex, the peculiar form of delirium under consideration. There is no doubt that in many acci- dent-cases, the sudden stopping of the drinking habit will develop the disease. That is to say that, without the accident, the patient would not have had the attack ; but here the casualty may itself have been a prime cause of depres- sion, and thus have produced that state which allows the effects of the habit to declare themselves and to gain the upper hand. SYMPTOMS OF DELIRIUM TREMENS. 397 Delirium Tremens and Mania a Potu. — It is important to distinguish be- tween delirium tremens proper, and that wild, acute delirium, which is the result of a grand " spree," the delirium ebriosorum, the true mania a potu. The surgeon often meets with these cases, as wounds of all kinds are not unfre- quently received during the debauch. All stages are exhibited by these patients, from the " remorse that weeps, to the rage that roars." They mostly require to be kept from injuring themselves and others, until the immediate effects of the overdoses of alcohol are over, when there is rarely any difficulty in taking care of them. Below is a chart (Fig. 33) of a case of this kind. Fig. 33. "3 a a Temperature. 97 98 99 100 101 102 103 104 105 1 1 1 _l 1 i i i . , ,l 1 1 , l ,i, l 1 . i l , l l_i_L_i 1 f . f 1 1_1_1_J Aug. 12 13 14 15 16 17 18 19 20 21 94 102 108~ 116 106 102 106 101) ibo~ 102~ 20 20 ~2T 22 20 18 124~ M. E. M. E. M. ~ET M. E. M. E. _ m7 E. M. E. N ' / V 22 24 "20 106 ioo 98 100 licT 104~ 112 12CT 136 22 20 22~ 22 24~ 24 j • ' < r i i ? r ( 1 1 1 1 1 1 rill i 1 l'l M. E. M. E. ~m7 28 26 32 ill! till TT— -^~J i E - 97 98 99 100 101 102 103 104 1( 15 Temperature chart of H. M., aged 35. Mania a potu after scalds of face, neck, scalp, fore- arms, hands and ankles. This patient was doing very well, though with high temperature, until twenty-four hours before his death, when, his friends having poisoned him with very bad whiskey which they had smuggled into the hospital, he was attacked with mania a potu, and, after a night and a day of the most acute, active delirium, died from exhaustion. The treatment consisted in the administration of large doses of bromide of potassium, chloral hydrate, and sul- phate of morphia. The cause given, the suddenness of the attack, and the nature of the injuries, also themselves prone to produce delirium, mark it as one of true mania a potu. The chart points almost with certainty to the time when the smuggled whiskey begun its work of death. The rise of temperature was steady," the attack furious, and the termination rapidly fatal. Symptoms of Delirium Tremens. — The trembling, watchful, wakeful, sus- picious, cowardly, busy subject of an attack of delirium tremens, is almost too well known to need description. His hallucinations are without number. He sees rats, rams, snakes, monkeys, cats, bats, bugs, spiders, mice, lice, imps, 398 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. demons and furies, dancers and devils — but not often angels, as the illusions are rarely pleasant. The}' are, however, sometimes comical, frequenly obscene, often sad, but general ly horrible. The patient is subject to attacks from without, and is constantly shrinking from them, having no courage to defend himself. Somebody or something is going to kill him, and fiends are doing their best to prevent him from attending to the most important business, with which he is also constantly occupied. Sometimes this business has to do with the real occupation of the patient, at other times it is wholly im- aginary. I have known a teamster, with a bad fracture, to lie in bed and drive his mules and horses all day, with loud curses and imaginary lashings. A broker will rave of the stocks, and a merchant of the markets; but mostly, when sifted, this all-important business will be found to be about the most trivial and absurd matters. Not unfrequently, and especially in the begin- ning, the delusions are only about one thing, or upon one subject ; thus, an officer who had been through the late war, was perfectly straight as to every- body and everything else about him, except a long tin foot-warmer, which had been placed at his feet in bed and covered up. The mound thus made suggested a body and a coffin, and it was at once converted into the mortal remains of the patient's companion in arms, over which he sat up in bed and gave the most pathetic but maudlin discourse. Again the patient may expe- rience great compunction, and mingle the touching and the sad with the ludi- crous. I call to mind one who, amid his vagaries, stopped to thank the leeches which had been applied to his badly sprained ankle, for drawing different kinds of liquor from him; a lively fellow was taking his fill of champagne, and a sodden chap indulged in ale; while a regular soaker, who fell off motionless, got dead drunk on whiskey. If the attack be not arrested by sleep, the delu- sions are no longer temporary, but continuous, and assume sometimes a dis- tressing, and at other times a violent form. Death is usual]} 7 caused by exhaustion ; always so when there is no complication of organic disease or injury. A layman may imagine how such an interloper as delirium tremens must interfere with satisfactory surgical practice, but no one but a surgeon can appreciate the fact. It plays havoc with all his calculations. It displaces well adjusted fractures, reproduces dislocations, tears open wounds, disturbs dress- ings of all kinds, removes ligatures and sutures, makes simple injuries com- pound and complex, sets up irritative abscesses and exudations, and so opens the door for erysipelas and pyaemia; in fact it is a fiend, sitting like a cormo- rant hard by the surgeon's efforts, and devouring all his measures for good. It might be thought that the pain produced by constant movement of injured parts would be a reminder, as is sometimes the case in traumatic delirium, and call the wandering senses to order. But it is one of the features of delirium tremens, well under way, that the patient is wholly oblivious to pain when injuries arc inflicted upon him by himself. He will often howl with fear or agony at what the surgeon does, but within an hour may be grinding the ends of his broken bones together as though they were mill stones, while at the same lime his busy brain will be working foolishness. I'have known two men with broken legs to get up and have a fight. It is not at all uncom- mon to see a man with a broken leg, whose habits have not been suspected, giving the first signs of an attack of delirium by getting out of bed with his apparatus on, and walking about the room or ward. These facts are explana- tions of the seeming conl radiction, that a man in delirium tremens is an arrant coward, and yet will cut his own throal or shoot himself if he gets a chance. Sometimes he maims himself dreadfully and deliberately, without any idea of suicide. I know of one who coolly cut away his genital organs, DIAGNOSIS OF DELIRIUM TREMENS. 399 piece by piece, and fed the ducks with them. Tain, not being felt, or at least regarded, is no hindrance to the act of self-wounding. I shall illustrate delirium tremens as to its special clinical features in sur- gical cases, by the three following charts (Figs. 34, 35, 36), which may be called typical. Fig. 34. o P a> 3 a p. 6 PS Temperature. Remarks. 98 99 100 101 —t-xJ.-L. J_.l._l I !_.!_.! 1 1 June 21 22 23 90 80 86 "98~ 96 94 89 lif 98 22 20 M ! DrHrium very active both nicrlit and day, requiring mechanical restraint. - Mild delirium. ( Mild delirium ( at night. Quite rational. E. ! M. E. 20 "24" ~22~ "24" 28 30 "26" E. 24 25 26 27 M. M. E. M. E. j 96 80 80 80 82 24 "22" ~24~ 21 22~ M. X i i i E. ! 28 29 98 80" 76" 82 80 80 22 M. "e7 M. E. M. 24 22 24~ 22~ 22 30 July 1 2 E. 78 80 "80~ 22 22" 20 M. E. M. ' ' «■' i r , i i,-ii E. 98 99 100 101 Temperature chart of S. R., aged 38. Delirium tremens following fracture of femur. Delirium appeared the first night after the patient's admission to the hospital. The treatment consisted in the administration of bromide of potassium and chloral hydrate. Recovery. Diagnosis of Delirium Tremens. — From what has been said, it will be seen that the diagnosis of delirium tremens is generally easy, in spite of the misrepresentations which are made, and the absolute lies, as to habits, which are too apt to be told, both by the patient and his friends. Sometimes all are deceived in the matter, and the attack comes on as a surprise. The patient has only been a moderate drinker, and if the additional and depressing effects of an accident had not occurred, neither himself nor his friends would have even thought of him as a subject for the disease. Therefore, it is but justice to say that patients' statements, denying drinking habits to any harmful extent, may be given in perfectly good faith. The ideas of people differ so much as to what is harmful in this matter, that it is important for the surgeon to find oat if possible what are really the facts of the case, both a3 to the amount and as to the kind of liquor used. 400 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. « Fie. 35. 9 a "5 o 'E. Temperature. Eemarks. 98 99 100 101 102 103 104 . . r r I r -i , 1 1 f_i 1 1 1 1 1 !. LJ i TT .. 1 April 90 30 26 M. Mild delirium at night. ' [ring the day. Passive delirium du- Active delirium at [night. Patient quite rational . during the day. Mild delirium at night. Active delirium. • Patient strapped day and night. Delirium continues . violent ; patient has to he strapped night and day. [with no relapse. Patient rational now, 11 95 X E. M. 12 13 14 100 28 98 104 100 "95" Si! 24 30 28 26 E. M. E. M. E. M. i "E7! 28 N 15 16 17 IS SO 92 Te" 85 ~90" 28 "26" i % 26 y M. 1 28 > e. : "m7 26 82 90 24 Till 1 1 1 I ,iii i i.i i 1 1 1 1 E. l 28 M. E. M. E. M. E. "m7 E. M. E. M. E. ~m7 E. 80 26 19 20 21 22 23 24 84 80 1(10 lo.; DS 100 f20" 27 26 22 24 24 "24 24 115 116 120 120" 26 28 26 28 "2fT 1 , , 1 "" 25 2G 27 28 29 30 110 130 112 L15 120 L20 US 120 98 in; llo 112 26 "28 "26 ~28~ 30 30 30 32^ 28 30" 35 36 M. — -~^ IT M. E~ M. E. M. ~ET M. ~E. M. E. M. -E. ^-"-^ . — May 1 • ■ i » 98 99 100 101 102 103 104 Temperature chart of W. II., aged 45, a moderate drinker. Delirium tremens following com- pound fracture of leg and fracture of ribs. The treatment consisted in the hypodermic use of morphia at night, with the internal administration of large doses of bromide of potassium and chloral hydrate. Recovery. TREATMENT OF DELIRIUM TREMENS. 401 The peculiar tremors of delirium tremens are very characteristic ; if I may go express it, they are loose and free, without spasmodic jerkings ; somewhat jelly-like, and giving a general idea of instability. They seem to say " prop me up, prop me up;" if you don't prop me up, I shall die." Fijr. 36. d a a o a a. P4 Temperature. Bemark8. 98 99 100 101 102 103 June 14 15 16 17 18 19 20 21 22 23 84 80 ~8tT 86 86 90 98 105 120 126 124" 108 100 94 —~ 18 18 M. E. M. E. M. E. M. 1 Perfectly 1 rational. J [ p roach ing. Delirium ap- 1 Delirium r very active. 20 v 20 20 ■s 22 24~ 24 28 30 32 30 26 24 E. M. E. ! <-- — T M. ~eT Delirium ' moderating. -i Delirium i absent ; pa- tient much i prostrated ; action of heart rapid and weak. M. E. M. E. M. "ET >> iiii >* 90 92 84 90 86 24 23 20 20 M. 20 X, . * 1 1 1 » i i ._ 1 E - 98 99 100 101 102 103 Temperature chart of A. N., aged 50, a steady drinker but not an habitual drunkard. Delirium tremens following fracture of the patella. During the stage of delirium the patient was treated with morphia hypodermically (a quarter of a grain every six hours), and chloral (15 grains) and bromide of potassium (30 grains) every four hours, by the mouth. The diet consisted of liquid and concentrated food : beef-tea with capsicum, milk, soup, etc. Mechanical restraint was employed from June 17 to June 20. Recovery. Treatment of Delirium Tremens. — The disease being one of depression, it is this " propping up" that is required in the treatment. Nourishment and sleep will bring most cases to a successful issue. Of course the nourishment must be digested, and the digestive organs may not at first be ready for their work. To those who are not too weak, an emetic may be given with most excellent effect. One of the best is mustard and water. Then the bowels may require attention, for often the patient has been very neglectful of him- self in this respect. An enema, a large one, of soap and water, will mostly accomplish the object. This plan may look like reducing the patient. On the contrary, it is simply aiding to bring the digestive apparatus into a recep- tive state. There is no use in cramming down what will not be assimilated, and what will be almost certainly rejected. After the stomach has become somewhat retentive, we may begin with small amounts of hot and well-spiced beef-tea, or soup, repeated at short intervals. If milk can be taken, so much the better. As to medicines, opium, the bromide of potassium, chloral hydrate, the tincture of digitalis, and alcohol, are at the command of the surgeon. vol. i.— 26 402 TRAUMATIC DELIRIUM AND DELIRIUM TREMENS. At times the case is so urgent that these have to be resorted to at once, in order to procure sleep, and other indications may be met afterwards. It is in this state that the surgeon most frequently finds his delirium-tremens patients. Time often will not permit him to take risks. Then hypodermic injections of morphia should be given at once. In cases of fracture, the limb must be so guarded and bound up that it will move as one mass, and not be held by extending bands, or other means, to fixed places. Soft splints padded with cotton should be applied, and then the part may be bound up in a pillow. A suspension apparatus may also be useful. One has to be regardless of the accurate apposition of the fragments ; that is to be attended to after quiet and sense have been restored. Where it is absolutely necessary, restraint by strapping the uninjured parts to the bed may have to be resorted to. Under all circumstances the patient must be most carefully watched, for in some way or other he will manage to disturb his dressings or to injure himself, if this be not done. When sleep comes on, everything to encourage its continuance should be ob- served. When the patient wakes he is always much better, and often perfectly sane. Now is the time to push the nourishment, for it is the true reliance to bring about a permanent cure. The anodynes and stimulants are a weak prop, if food does not go with them. They may be gradually withdrawn, and may be again resorted to in full measure should relapse be threatened. It is not my intention in this article to discuss the relative therapeutic value of the different remedies for delirium tremens. The treatment must be based on the general principle that the disease is one of depression. Nourishment, withdrawal from exciting surroundings, and sleep, are what are wanting. Much may be done to ward off an attack if the surgeon is forewarned as to habits. Early measures to secure rest and sleep, under these circumstances, will often be entirely successful. ANESTHETICS AND ANESTHESIA. BY HENRY M. LYMAN, A.M., M.D., PROFESSOK OF PHYSIOLOGY AND OF DISEASES OF THE NERVOUS SYSTEM IN THE RUSH MEDICAL COLLEGE, CHICAGO. • The term Anesthesia, derived from a privative, and alae^ii sensation, is employed to signify a condition of the nervous system, resulting either from disease or from the administration of certain substances, by which the indi- vidual is rendered incapable of perceiving external impressions. History of Anaesthesia. From the earliest ages attempts have been made to relieve pain by the induction of insensibility. Homer records the use of cataplasms, which doubtless owed a portion of their anodyne efficacy to the products of fermen- tation which they contained. The Egyptians were acquainted with the soothing etfects of nepenthe, a drug probably identical either with Indian hemp or with opium. Herodotus refers to a practice among the Scythians of inhaling the vapors of hemp for the purpose of intoxication. The Chinese were also accustomed, as early as the third century, to produce insensibility during surgical operations, by the use of Indian hemp. There is a tradition to the effect that, among the ancient Assyrians, the pain of circumcision was prevented by compression of the veins in the neck, during the time of opera- tion. Pliny and Dioscorides relate that the Egyptians possessed a species of rock, brought from Memphis, which they were accustomed to apply in the form of a powder, moistened with sour wine, to painful wounds. This was probably a primitive method of producing local anaesthesia with carbonic acid gas. The most potent anaesthetic known to the ancients was the drug mandragora. Its infusion in wine was known to the Greeks by the name of ^morion. Apuleius states that half an ounce of this preparation would render one insensible even to the pain of an amputation. The sleep thus produced might continue for several hours; hence, no doubt, the origin of the story of the sleep of Juliet, as recorded by Shakespeare. The Jewish women were accustomed to give this anesthetic wine to the victims of crucifixion ; hence the record of the "wine mingled with myrrh," in the gospel of St. Mark. The practice of inducing annesthesia by inhalation, may be traced from the Scythians of the age of Herodotus, through the middle ages. "While Dante was writing the Inferno, Theodoric, a surgeon of Bologna, taught the art of producing insensibility by inhalation of the vapor yielded by a medicated Bponge that had been steeped in a decoction of opium, belladonna, hyos- cyanms, mandragora, hemlock, ivy, and lettuce. It is probable that the (403) 404 ANESTHETICS AND ANESTHESIA. anaesthetic properties of ether and alcohol were known to the alchemists. Giambattista della Porta, in a volume on Natural Magic, described the pre- paration and administration of certain volatile substances which were to be kept hermetically sealed in leaden vessels, to preserve their virtues. The effects of their inhalation appear to have closely resembled those of ether. Albertus Magnus (A. D. 1193-1280) taught the art of distilling fire-water (aqua ardens) from red wine and common salt. May not this have produced a mixture of ether and alcohol capable of producing anaesthesia by inhalation? The closing years of the last century were marked by a remarkable apathy regarding the use of anaesthetics. With the exception of opiates, the majority of the drugs upon which the ancients relied had gone out of fashion. James Moore, in 1784, proposed to effect anaesthesia in surgical operations by com- pression of the principal nerves of the affected limb. John Hunter had observed the production of local anaesthesia by refrigeration of the tissues of animals, and Baron Larrey had remarked the same thing among his patients upon the icy held of Eylau. The newly discovered gaseous elements had attracted the attention of chemists, and the vapor of sulphuric ether had been inhaled by Dr. Pearson, of Birmingham, as early as 1785, but without prac- tical results. In the year 1799 (April 9), Humphry Davy, then laboratory assistant of Dr. Beddoes, in the Pneumatic Institution at Clifton, near Bristol, discovered the exhilarating properties of nitrous oxide gas. Shortly after- wards, having inhaled the gas while suffering from the eruption of a wisdom tooth, he observed that the pain was relieved while under the influence of the gas. He recorded his experience, with the following comment : " As nitrous oxide, in its extensive operation, seems capable of destroying physical pain, it may probably be used with advantage in surgical operations in which no great effusion of blood takes place." Though widely circulated, this paragraph seems to have produced no prac- tical result until the Hartford dentist, Horace Wells, turned his attention to the subject in the year 1844. During this long period of time, no systematic research had been undertaken with a view to the discovery of a method for the production of artificial anaesthesia. The anaesthetic properties of sulphuric ether were, however, being gradually ascertained in an empirical way. In the year 1785, it had been employed by Dr. Pearson, in Birmingham, as an inhala- tion for the relief of spasmodic asthma. Dr. Warren, of Boston, had likewise used it, in 1805, for its anodyne effects in the later stages of consumption. In the year 1818, Michael Faraday published a brief notice of the anaesthetic properties of ether vapor, which he considered a dangerous substance. Ex- perimental physiologists also became acquainted with its stupefying effect upon animals ; and, in the year 1836, Christison recorded, in his work on Poi- sons, the case of a young man who had been rendered completely insensible by the vapor of ether. Among drug clerks and reckless young people, the practice of inhaling the vapor of ether was a favorite mode of dissipation in certain parts of the world. In the year 1839, a young negro was thus stupe- fied, to the great alarm of his companions, in the village of Anderson, South Carolina. Tins incident served to encourage Dr. Long, then residing in Jef- ferson, ( Georgia, to administer the vapor to a patient who was accustomed to 1h'' practice of inhaling ether. He was thus rendered insensible, and a tumor was removed without pain, March, 1K42. Three or four other patients were. anaesthetized with similar success during the years 1842 and 1843, but as the doctor resided in a remote and isolated portion of the country, and as he published no statement of his experience, his discovery remained unknown to the scientific world. During the month of December, 1844, an itinerant lecturer on chemistry, named Colton, undertook to exhibit the exhilarating properties of laughing- HISTORY OF ANESTHESIA. 405 t gas before a popular audience, in the city of Hartford, Connecticut. The dentist, Horace Wells, who was present, observed that the person to whom the gas had been administered seemed quite insensible to the pain of the bruises which he had sustained by reason of a fall while under the influence of the gas. He at once imagined that a tooth might be extracted without pain from a person whose sensibilities were thus temporarily obtunded. The very next day he performed the experiment upon himself, inhaling a quantity of the gas, which had been prepared by Dr. Colton. The success of this attempt was complete, and in a few weeks he had in like manner removed teeth from the mouths of a dozen different patients. Visiting Boston for the purpose of introducing his method in that city, he undertook to extra* -i a tooth from a patient to whom the gas had been administered before the students of the Harvard Medical School. The experiment was unsatisfactory, as the patient uttered a cry at the moment of extraction, though he afterwards asserted that he had felt no pain. So great was his chagrin at this failure, that Dr. Wells ceased to interest himself in the subject of anaesthesia, and his death occurred not long afterwards (Jan. 14, 1848). Before this event, how- ever, one of his former pupils, a young dentist in the city of Boston, William T. G. Morton by name, had made known the anaesthetic properties of the vapor of sulphuric ether. At the suggestion of a noted chemist, Dr. Charles T. Jackson, lie had experimented with ether, inhaling its vapor until insensi- bility had been induced. This event occurred during the evening of Septem- ber 30, 1846. On awaking from an artificial sleep which had endured for eight minutes, Dr. Morton resolved to administer the anaesthetic vapor to the first patient who would submit to its use. A man named Eben Frost pre- sently applied for relief from an aching tooth, and was successfully kept under the influence of ether during the whole time of the extraction. It was at once perceived that this discovery might find a wider range of utility than could be afforded by the practice of dentistry, and on the 16th of October, 1846, Morton was invited to etherize a patient from whom Dr. J. C. Warren was about to remove a vascular tumor of the neck, at the Massachusetts General Hospital. The experiment was attended with such a degree of success that it was again and again repeated, until a number of capital operations had been thus performed with the most satisfactory results. Intelligence of the great discovery reached England, December 17, 1846, and was speedily diffused throughout the civilized world. During the fol- lowing year, the celebrated physiologist, Flourens, described the effects of chloroform upon the lower animals. A medical student in London, Furnell by name, about the same time accidentally discovered its anaesthetic proper- ties by inhalation of its vapor, and at his suggestion it was several times employed in St, Bartholomew's Hospital by Sir "William Lawrence and Mr. Holmes Coote. In the mean time a hint regarding this substance had reached Dr. J. Y. Simpson, of Edinburgh, and after testing the drug in his own per- son he administered it with the greatest freedom. "On the 10th of November, 1847, he published the details of not less than fifty cases in which he had used chloroform with perfect success. The agreeable qualities of the new anaesthetic led to its speedy adoption in preference to ether. The occasional occurrence of death from its effects has caused much debate regarding the comparative dangers from the use of different anaesthetic agents, and the superior safety of ether has in England and in the United States produced a very important reaction in favor of the original agent introduced by Morton. Germany and the greater portion of France still. prefer chloroform, a sub- stance which by its energy, its concentration, and its agreeable effects, will always commend itself to those who are inclined to place vigor and precision before safety. Many other substances have been experimentally tested as 406 ANAESTHETICS AND ANESTHESIA. anaesthetic agents, but the majority of them are either too dangerous or too costly to admit of general use. Phenomena of Anesthesia. Certain minor peculiarities characterize the anaesthetic effects produced by inhalation of the different anaesthetic gases and vapors. The principal phe- nomena, however, are common to all. A description of the symptoms occa- sioned by the inhalation of the vapor of ether or of chloroform, will convey a sufficiently accurate idea of the manner in which artificial anaesthesia ordi- narily supervenes. The first effect of the inhalation of an ethereal vapor is a local excitement of the nervous apparatus of the respiratory passages. The senses of taste and smell, and the naso-pha^ngeal branches of the fifth pair of nerves, are powerfully excited. The activity of the salivary glands is aroused, and acts of deglutition are stimulated. Sometimes a disagreeable tickling is experienced in the larynx, and the patient coughs. A sense of suffocation may be expe- rienced, and the patient assumes an attitude of resistance, struggling to free himself from the inhaler. Animals, confined in a retentive apparatus, often endeavor to prevent the entrance of the anaesthetic vapor by restricting their movements of respiration within the narrowest possible limits. These first effects of local contact are soon succeeded by the more extensive results of general saturation of the tissues with the stupefying agent. The vapor rapidly passes into the blood, and is conveyed to every living element of the body. The initial effect is disturbance of function ; the subsequent effect is paralysis of function. Disturbance usually assumes the form of ex- altation ; it is also always marked by perversion of the normal intensity of physiological sequences. The special senses give evidence of this agitation. There is a humming sound in the ears, and subjective impressions of light flash in varying forms across the visual field. The pulsation of the heart can be felt, and the vermicular movements of the intestines can sometimes be perceived. The arteries throb, the brain seethes, waves of heat flush the sur- face of the body, perspiration appears upon the face, and may become gene- ral, the pulse rises, respiration is accelerated, the pupils contract, the eyes close, reflex irritability is exalted, and in his general appearance the patient resembles a person in the earlier stages of alcoholic intoxication. To this period of excitement succeeds the stage of diminishing function. The cuta- neous sensibility grows less, the temperature falls, the pulse recedes towards the normal standard, the blood pressure diminishes, the respiratory move- ments become deep and full, like those in profound sleep, voluntary move- ments cease, consciousness gradually fails, reflex movements are abolished, and the patient becomes utterly insensible. If the act of inhalation be urged beyond this point, syncope may occur, and a cessation of respiration and cir- culation may terminate the life of the patient. During the act of inhalation the eyes are generally closed. The eyelids often move as if winking. At first, the pupils are variable in their diameter. When anaesthesia is fully declared, the pupils are contracted; but if the con- dition of stupefaction is carried to an extreme, dilatation takes place, and persists till death. During the period of complete insensibility, the eyeballs arc frequently turned upwards and inwards, sometimes assuming the position of con jug: i ted deviation. General sensibility is disturbed at a very early stage of the anaesthetic process. After the brief period of initial exaltation, cuta- neous sensibility diminishes at a rapid rate. This diminution is first mani- fested u] ion the least sensible portions of the surliice. Sensibility persists PHENOMENA OF ANESTHESIA. 407 longest upon the anterior surfaces of the trunk, about the eyes, at the tips of the lingers and toes, and especially in the neighborhood of the anus and the organs of generation. The initial effects of inhalation are manifested in the brain by a great exaltation of the powers of perception and reasoning. Ideas are quickened, but, with a diminution of the powers of sensation, the sphere of vivid perception is correspondingly narrowed. Consciousness remains per- fect as long as it exists, but its held progressively contracts to a vanishing point, around which seems to gather an atmosphere of half formed and ever fainter perceptions. The powers of attention, memory, reasoning, judgment, and volition, can be exercised with perfect precision as long as the formation of ideas persists, but the progressive movement towards severance of the brain from all contact with the external world through the medium of the senses, becomes at length so complete that consciousness can deal only with ideas which originate within the brain itself. In this condition the patient seems to dream, and the memory of these dreams may be preserved after awakening. Sometimes all avenues of communication with the external world may be closed but one — usually the sense of hearing — and the patient experiences a feeling as if separated from his body ; as if occupying the position of an im- passive spectator of the scene in which his material organization forms a con- stituent part. In such cases volition has ceased ; perception, memory, imagi- nation and consciousness, alone remain. But, as the anaesthetic process advances, these functions also lapse into the potential state, and the patient passes into a condition of vegetative existence. The effects of anaesthetics upon the powers of volition are somewhat variable. Children and adults of an impressible temperament are more easily overcome than patients of a vigorous, intellectual character. By an effort of the will, the progress of anaesthesia may be delayed, and a mind trained in habits of introspection and analysis will retain consciousness longer than if less happily organized. A similar phenomenon is often remarked during the progress towards alcoholic intoxication, when a sudden and powerful act of volition, exercised, perhaps, as the result of some unexpected stimulus from without, serves to restore the condition of sobriety. By such effort, and even without apparent effort, perfect intelligence may often be maintained for a consider- able period after the loss of the power of perceiving painful sensations. The patient may be conscious, intelligent, and capable of conversation, yet almost wholly insensible to pain; and, on recovery, quite oblivious of the passage of time, and of the majority of the events that have transpired. During the initial stage of anaesthesia, the power of muscular movement is usually exaggerated. Such voluntary movements as may be put forth, are performed with unwonted vigor and celerity. The patient may raise his hand or move his foot without willing the act, yet with perfect knowledge of what is done. The involuntary muscles exhibit the general disturbance with the greatest uniformity. The heart beats more rapidly, and sometimes more violently ; the temples throb ; the movements of respiration are accelerated. Sometimes cough will be excited, the patient vomits, the bladder and the rectum may be evacuated. Convulsive phenomena sometimes appear. They may be limited to insignificant fibrillary twitchings of the facial muscles, or the patient may be shaken as if in an ague-fit. "Epileptic patients may be roused by the anaesthetic to the manifestation of a complete convulsion, from which they will pass into a condition of the most profound insensibility — a combination of coma and anaesthesia. Sometimes the convulsive movement assumes the tonic form. This is said to be more frequently witnessed as a result of chloroform than of ether. An arm or a leg, one half of the body, or even the entire frame, may become perfectly rigid as if fixed in a tetanic 408 ANAESTHETICS AND ANAESTHESIA. spasm. Such conditions indicate a profound and dangerous implication of the most important nervous centres. As the process of stupefaction advances, reflex action diminishes, the power of voluntary movement ceases, and the patient enters upon a condition of perfect repose, in which the only movements that persist are those which sus- tain the functions of respiration, circulation, and unconscious life. By careful administration of the anaesthetic this condition may be maintained without danger for a considerable period of time. The respiratory movements are accelerated, even before the commencement of inhalation, when the patient is agitated by nervous apprehensions. Ether tends to quicken respiration during the early and middle stages of inhalation, and to depress its rate slightly below the normal when the stage of insensi- bility has been reached. Chloroform tranquillizes the initial agitation at an earlier stage of the process, and produces the same final result during the period of unconsciousness. Causes dependent upon the age, sex, temperament, and previous life of the individual, disturb the general course of respiration to such a degree that it is almost impossible to include all cases in a general description. Sometimes the respiratory movements succeed each other with the utmost irregularity, and may even be suspended altogether for a consider- able time. Such patients are said to be intolerant of the anaesthetic, and are liable to pass into a condition bordering on the convulsive state. In certain cases, the patient, though quite conscious and capable of intelligent utterance, seems to have forgotten to breathe. From this condition he may be aroused by the voice of the surgeon, or by a sudden pressure upon the thorax or abdo- men. During the stage of general muscular relaxation, respiration becomes deep and regular, being less frequent but more profound than during the waking state. The exhalation of carbonic acid gas is increased during the period of excitement, and it is diminished during the period of tranquil anaesthesia. The action of the heart corresponds closely with the conditions of respira- tion. During the occurrence of tetaniform rigidity, the pulse may become almost imperceptible. When respiration is slow and feeble, the heart beats in a faint and sluggish way. Again, it may suddenly start off at a very rapid rate, only to sink suddenly into a condition approaching syncope. Such inor- dinate fluctuations and rapid variations should excite grave apprehensions for the safety of the patient. In the normal course of inhalation, the pulse at first is small and frequent, increasing its rate as respiration becomes accelerated, until the stage of muscular resolution is approached, when it begins to recede. With the approach of this stage the arterial coats relax, and the pulse grows soft. When complete unconsciousness supervenes, the volume of the pulse is considerably enlarged, and its rate may tall below the normal standard. As the pulse falls, the general circulation improves. Turgid veins subside ; the cutaneous vessels resume their normal calibre. The face may even become pale, and the mucous surfaces exchange their lively color for a fainter tinge. Extreme pallor, or a dusky hue, should be viewed with alarm. The temperature of the body is generally diminished during the time of anaesthesia. At first, the temperature of the surface is elevated by reason of the increased afflux of blood; but as inhalation progresses the liberation of heat diminishes, and the temperature of the body exhibits a considerable fall. This becomes more notable when the more energetic a naesthetic substances are employed. The function of secretion is at first augmented, and finally diminished by the action of anaesthetics. The degree 01 augmentation depends considerably upon the character of the anaesthetic that is employed. PHYSIOLOGY OF ANAESTHESIA. 409 The time during which anaesthesia may persist after the cessation of inhalation, is quite variable, being dependent upon the volatility of the agent. It is visually three or four minutes after the use of ether, and a little longer after that of chloroform. Recovery is almost immediate after the employment of nitrous oxide or ethyl bromide. When the patient has been made insensible, the condition of anaesthesia may be indefinitely main- tained by the continuous administration of relatively small quantities of the drug. A condition in which the patient continues to moan and to cry, per- haps even resuming a feeble struggle with the attendants, is an evidence That the anaesthetic is either not properly inhaled, or that the individual is in a situation not wholly free from danger. Careful administration will generally overcome the difficulty, but certain patients are especially refractory. Drunk- ards, by reason of long established tolerance of the anaesthetic effects of alcohol, require large and sometimes dangerous quantities of ordinary anaesthetics to effect resolution and insensibility. Mental agitation may produce a temporary tolerance. Operations about the anus and genitalia generally require an unusual quantity of anaesthetic vapor for the production of complete anaes- thesia. The phenomena of recovery ordinarily consist in a regular inversion of the manifestations which have marked the process of induction. If the patient has been previously exhausted by any cause, the period of recovery may be greatly prolonged, and symptoms of prostration may appear. After a long and difficult operation, it may be difficult to distinguish between the effects of shock and those of the anaesthetic. Brief operations, on the contrary, seem to produce less depression when the element of pain is abolished. Physiology of Anesthesia. The action of anaesthetic substances is exerted through the blood upon the nervous system. They operate by contact, rather than by chemical union or decomposition. This mode of action is exhibited by many of them in connection with non-vital processes of a chemical character. A taper will he extinguished in a jar containing one part of carbonic anhydride mixed with seven parts of oxygen, just as readily as in an atmosphere deprived of oxygen. The anhydride effects an arrest of the process of oxidation by its mere presence, without in any way taking the place of either oxygen or oxidizable substance. In like manner, the luminous oxidation of hydrogen phosphide may be arrested by the presence of a very small quantity of "the vapor of ether, or turpentine, or naphtha. The luminous glow that is visible around a stick of phosphorus in a darkened room, will at once disappear if a drop of ether or chloroform be introduced into the container. As the ethe- real vapor is dissipated by evaporation, oxidation begins again, and the phos- phorus glows once more as perfectly as at first. Upon the more complicated processes of vegetable life, these substances exert a similar inhibitory influence. The addition of ether to an infusion containing yeast, at once arrests the pro- cess of fermentation. On removal of the anaesthetic, by evaporation or by filtration, the activity of the yeast fungus is renewed, and fermentation is again resumed. If an aquatic plant be placed in a watery solution of ether or chloroform, its absorption of carbonic anhydride and its exhalation of oxygen cease. The plant does not die ; it merely sleeps. On replacing it in pure water, its natural respiration is immediately resumed. The germination of seeds may also in a similar manner be arrested by surrounding them with an anaesthetic atmosphere. The irritability of the protoplasm in the cells at the base of the petiole, in the leaf of the sensitive plant, is in like manner 410 ANAESTHETICS AND ANESTHESIA. inhibited by anaesthetic vapors. A vigorous specimen of this species, placed for half an hour under a bell-glass with a sponge saturated with ether, will no longer exhibit any irritability. Its healthy appearance remains unchanged, but it no longer absorbs carbonic anhydride, and its leaflets will not shrink when touched. Restoration of the plant to a pure atmosphere is soon fol- lowed by complete recovery of all its natural functions. Each one of these experiments illustrates the tendency to inhibition of cer- tain molecular movements in the presence of an anaesthetic substance. All molecular movement is not thus arrested. Alcoholic fermentation ceases in a solution of ether, which still permits the transformation of cane-sugar into grape-sugar. It is at present impossible to describe the essential nature of the inhibitory process. The only thing beyond dispute is the fact that anaes- thetic substances tend to restrict the ordinary freedom of chemical exchanges in living matter. In the animal body, while all parts are thus modified by the anaesthetic, certain tissues are more than others affected by its presence. To this fact is due the progressive character of artificial anaesthesia. The more highly differentiated the tissues of an animal, the more evidently suc- cessive and complex the phenomena of anaesthesia. Consequently it is in the higher animals, with an elaborate nervous apparatus, that these phenomena are most conspicuous. The action of anesthetic vapors and liquids is exerted through the medium of the circulating fluids of the body upon the cellular units of which it is composed. Introduced into the blood by passage through the walls of the pulmonary air-cells, absorbed by the surfaces of the alimentary canal, or con- veyed directly into the current of the blood by intra-venous injection, it is only when the nervous elements have been reached that the anaesthetic process begins. Primarily local in its action, the effect of the anaesthetic becomes generalized when the central nervous organs are invaded. Numerous experi- ments have thus shown that the local action of chloroform upon the substance of the spinal cord is sufficient to abolish peripheral sensation and muscular movements, even though the peripheral organs have been sheltered from its action. In like manner, the functions of the brain having been abolished, all those peripheral functions which depend upon the integrity of the cerebrum are, for the time being, incapable of performance. When freely circulated through all parts of the body, the anaesthetic produces local effects throughout the whole mass of the body, but the consequences of its action upon the principal nervous centres are the most conspicuous of the resulting phe- nomena. The condition of artificial anaesthesia presents many points of resemblance to natural sleep, but there are also certain important points of difference. The advent of normal sleep is heralded by a gradual failure of the special senses. The eyes close, general sensibility fails, and, finally, the sense of hearing is abolished. In the locomotive apparatus, the voluntary muscles of the limbs are the first to yield ; then follow the muscles of the trunk. The power of reflex movement is not abolished. Respiration and circulation continue, though with a slightly diminished rate. As sleep invades the brain, percep- tion of the external world is gradually diminished by the failure of the external senses. But this arrest of communication does not at once prevent the development of ideas within the brain. Certain groups of cortical cells may remain active after the establishment of sleep in certain other groups. 1 >eprived of that guidance which is derived from the impressions of sense, the attention of tin ■ waking portions of the brain is attracted to such impressions of internal origin as may arise in the territories of the pneumogastric and sympathetic nerves. Hence a succession of erratic ideas, attended with varying degrees of consciousness, dependent upon the degree of uniformity in PHYSIOLOGY OF ANESTHESIA. 411 the condition of the cortical portion of the brain. Or disturbing causes may be originated in the cerebral centres themselves. Groups of cells which have acquired an excessive or morbid irritability, may still continue to perform a certain amount of functional Work as a consequence of previous impressions that have not yet been effaced, and this work will produce results in the field of consciousness. But, through lack of a simultaneous production in consciousness, of that vast complex of associated perceptions and conceptions which is occasioned by the coordinated activity of all parts of the brain during the waking state, this isolated cell-work excites only imperfect trains of thought, which must necessarily progress after a very imperfectly ordered fashion. Such processes constitute what is called a dream. When the special function of the cortical cells is rapidly, uniformly, and completely arrested, sleep is profound and dreamless. The development of this condition is accompanied by a comparatively anemic condition of the cerebral substance. This comparative anaemia is the result, rather than the cause, of sleep. It is effected by the intervention of the nerves which regulate the supply of blood for every organ, in strict accordance with the degree of its functional activity. Quite unlike the advent of natural sleep is the stormy introduction to the sleep of artificial anesthesia. This is due to the fact that the anesthetic sleep is produced by the action of a foreign substance of a paralyzing nature, to which the tissues are wholly unadjusted. The initial effects of contact with such a substance, are contraction of irritable protoplasm, liberation of motion, phenomena of excitement. This produces an increased circulation of blood, and all the functions of the nervous system are momentarily exalted by the combined action of increased blood-supply and local irritation of nervous matter. But the conspicuous and characteristic phenomena of anesthesia are caused by the paralyzing energy of the anesthetic. At first the vascular walls contract, as a consequence of their local irritation by the medicated blood. But, almost immediately, they begin to relax under the paralyzing influence of the drug, and an increased supply of blood reaches the muscular and nervous substance of the heart. This organ contracts more vigorously, and propels through the dilating bloodvessels a larger amount of blood, to stimulate the brain, the spinal cord, and every portion of the body. A gene- ral though temporary increase of function iS the result. Muscular movement and reflex action are exaggerated. The sensory apparatus is in like manner rendered more efficient. Painful sensations, may thus be briefly intensified by the means that are employed for their abolition. But this stage of ex- citement is soon passed. Transported by the blood, the anesthetic soon per- vades the higher nervous ganglia, and depresses their activity. The action of the heart is thus retarded, and the pulse recedes. In like manner the movements of respiration are again brought down to the normal rate, or even belt >w it. The circle of the intellectual functions is progressively narrowed by the progressive paralysis of the cortical cells, and the connection of ideas is disturbed by the increasing disconnection of the centres in which they arise. Complete paralysis of these organs is followed by loss of consciousness and anesthesia. If, now, an equilibrium be established between the 'intro- duction and the elimination of the stupefying vapor, the anesthetic process may be continuously sustained. But if its introduction be urged beyond the power of the tissues to free themselves, they become supersaturated, and systemic death is the final result. Reasoning from analogy, it has been suggested that anesthetic substances modify nervous tissue by a sort of coagulation of its protoplasm. But coagu- lation is incompatible with life. Keeping in mind the tact that the effect of anesthetic substances is temporary, it seems more probable that they operate by inhibition of those chemical processes which are associated with the libe- 412 ANESTHETICS AND ANESTHESIA. ration and diffusion of motion throughout the system. Among the proto- plasmic molecules, the substance acts the part of a screen, like a cloud between the sun and the earth, hindering the energies of one from acting upon the susceptible matter of the other. Too frequent repetition of this action, how- ever, eventuates in the production of certain permanent modifications in the constitution of living matter. These are best illustrated by reference to the permanent alterations of nervous tissue which are produced by the immode- rate use of alcoholic anaesthetics. Mode of Administering Anesthetics. The patient should occupy a recumbent position in order to facilitate the circulation of blood between the heart and the brain. Clothing should be adjusted in a way to permit the freest respiratory movements. The anaes- thetic substance may ordinarily be inhaled as it evaporates from a napkin placed over the mouth and nostrils. Innumerable forms of more or less com- plicated apparatus have been contrived for the administration of graduated quantities of anaesthetic vapor ; but the majority of these inhalers are dirty, cumbrous, disappointing, and unsafe. For ordinary use nothing has yet been found better than the simple napkin or its equivalent. For the administra- tion of nitrous oxide gas, a special form of inhaling apparatus is necessary, since it is important that all air be excluded during the act of inhalation. (Figs. 37, 38.) A very ingenious and useful inhaler has been contrived by Mr. Clover, an English surgeon of large experience with anaesthetics, for either the successive or the simultaneous inhalation of nitrous oxide gas and ether vapor. (Fig. 39.) With these exceptions, the simplest means of introducing the anaesthetic vapor into the lungs are always the best. During the whole time of inhalation, the condition of the patient should be continually observed by an experienced physician, and the earliest symptoms of danger should be immediately noted and opposed by vigorous treatment. 1 Accidents of Anesthesia. In certain rare cases, death may occur suddenly during the act of tranquil inhalation. The movements of the heart and of the respiratory organs seem to be almost instantaneously arrested; this accident seldom occurs unless the patient has been greatly enfeebled by previous disease or by hemorrhage. Death by asphyxia may occur during the act of inhalation. This accident might be occasioned by the use of a badly-adjusted inhaling apparatus, or by suffocation with numerous wet napkins crowded upon the face; but this must lie ;iu exceedingly unusual event. It is when the trachea has been mechani- cally obstructed by tin* entrance of blood from a wound, or by the intrusion of fragments vomited from the stomach, that asphyxia is beyond doubt the cause of death. Asphyxia may occasionally be produced by the induction of tonic convulsion of the respiratory muscles, as a reflex consequenceof the local irritant action of chloroform vapor when brought in contact with the laryngeal mucous surfaces. Ordinarily, however, the consequences of such local irritation are confined to the production of a tumultuous cough. More frequently the intervention of danger manifests itself by prolongation of the Btage of excitement. The muscles may finally pass into a condition of rigid- 1 [Further remarks upon the administration of special anaesthetics will be found under the head of the different agents employed. Bee pp. 424 et seq.~\ ACCIDENTS OF ANESTHESIA. Fig. 37. 413 Codman and Shurtleff 's inhaler for nitrous oxide gas. A, metallic hood ; B, flexible rubber hood ; C, exhaling valve ; 1), two-way stop-cock ; E, sliding-joint ; J, inhaling valve. Fie. 38 The same apparatus adapted for the inhalation of ether. F, ether reservoir. Fie. 39. Rc= -lover's apparatus for inhalation of nitrous oxide gas and ether. E, ether reservoir : F. fare-piece j G, caoutchouc bag for mixture of vapors ; R Kl, nitrous oxide reservoir ; Re, regulator. 414 ANESTHETICS AND ANAESTHESIA. ity, during which the pulse suddenly disappears, respiration ceases, and death occurs. Death in all such cases, and they form the vast majority of the examples of death during the anaesthetic process, is the direct result of the toxic effects of the drug upon the nervous centres which preside over the acts of circulation and respiration. It is, therefore, impossible to employ any anaesthetic agent without, in some small degree, at least, approaching the con- fines of danger. All diseases which diminish the energy of the heart and of the lungs, tend to increase the dangers of anaesthesia. Hemorrhage, intem- perance^ cold, hunger, want, misery, mental anxiety, loss of sleep, fatigue, are all causes of danger, because they serve to depress the vital energies. Since suffocation by the passage of food into the trachea has occurred during the ace of vomiting excited by the anaesthetic, it is advisable to administer the vapor at a time when the stomach is probably empty. The rate of inhalation may become a source of danger. Hasty saturation of the tissues with a powerful anaesthetic may cause speedy death. The primary stage of anaesthesia is a period of excitement, during which it is not impossible that fatal syncope may result from over-stimulation of the cardiac inhibitory apparatus before the fully toxic action of the drug has been dis- played. Convulsions may thus be aroused, and may produce death by arrest of respiration, or they may be the forerunners of fatal syncope. Sudden excitement of the reflex apparatus, by incision of the skin before complete abolition of sensibility, may in like manner become a cause of death. It is for this reason always best to produce complete insensibility before the com- mencement of an operation, even though a certain slight risk of over-satura- tion of the tissues be thus incurred. As a general fact, children are remarkably tolerant of anaesthesia. The rapid rate of circulation and respiration, and the larger relative surfaces of their bodies, provide for a speedy elimination of the anaesthetic substance, so that cumulative effects are almost out of the question. Aged jiersons, also, have been claimed as more than ordinarily favorable subjects for artificial anaesthesia. Few old people, however, become the objects of such experiment, and the fatality among them must therefore seem to be less than among the middle-aged who form the mass of patients. To such elderly patients, anaes- thetics should be administered with more than ordinary care, for with them the phenomena of anaesthesia are liable to assume an adynamic character. Women resemble children in the rapidity with which they yield to inhalation. It has been thought that they are less liable than men to the accident of syncope during anaesthesia. At the menstrual epoch they are more than usually liable to nervous excitement and to hallucinations, but are otherwise not excessively exposed to- danger. During the period of pregnancy, aside froi ii the risk of injury through violent muscular efforts in the stage of excitement, there seems to be no unusual risk from artificial anaesthesia. The act of parturition seems to confer almost absolute immunity from danger through anaesthetic inhalation. Peculiarities of temperament and constitution appear to exereise no appreciable effect upon the course of anaesthesia. A predisposition to syncope does indeed furnish a contra-indication to the use of anaesthetics. Various diseases of the brain and spinal cord, especially such as encroach upon the. medulla oblongata and its neighborhood, increase the danger of accident. Epileptics are very liable to convulsion during the stage of excite- ment, but the immediately subsequent stage of resolution is sufficiently favor- able to warrant the administration of anaesthetics to such patients. The same thing is true of hystero-epilepsy. Alcoholic intoxication and delirium tremens prohibit inhalation, because of the existing tendency to death from exhaustion and syncope. Surgical shock, for the same reason, constitutes a ACCIDENTS OF ANESTHESIA. 415 condition unfavorable to the employment of anaesthetics. Gunshot wounds seem to form an exception to this rule, probably because of the great nervous exaltation which usually precedes their infliction. All forms of "pulmonary and intrathoracic disease add to the risks of artificial anaesthesia, not through any increased liability to asphyxia, but by reason of the greater probability of the occurrence of syncope. For the same reason, organic diseases of the heart or the larger bloodvessels, overloading of the heart with fat, and fatty degeneration of its muscular structure, should preclude the use of anaesthetics. A slow, irregular, and feeble pulse, associated with precordial pain, difficult respiration, general lassitude, and evidences of degeneration in tissues accessi- ble to observation, should excite suspicion of this form of morbid change. The violent palpitations of anaemia should exclude the more potent anaes- thetics. A condition of excitement and terror, preceding the act of inhalation, may increase the risks to which the individual is subjected. A certain amount of encouragement and reassurance of the timid patient, together with repeated stimulant doses of alcohol, should always precede the exhibition of the anaes- thetic in such neurasthenic cases. The risk of accident varies greatly in accordance with the nature of the substance selected for the production of insensibility. It should, however, always be remembered that no anaesthetic agent is absolutely free from risk. Every patient should, therefore, be made an object of special study before the commencement of inhalation, and all possible contra-indications should be fully considered. Treatment of the Accidents of Anesthesia. — Irritation of the respira- tory passages caused by inhalation of anaesthetic vapor, soon subsides after the occurrence of complete anaesthesia, or after removal of the cause. If it per- sists, the purity of the substance should be determined. Vomiting not un- frequently occurs, especially if food has been recently taken. It is, therefore, expedient to defer inhalation for three or four hours after a meal. The sen- sation of suffocation which often oppresses the patient during the earlier stages of inhalation, maybe relieved by larger dilution of the vapor with air. If the anaesthetic is given upon a napkin, the cloth should be raised from the face for a few seconds. Tolerance of the vapor will soon be established, and inhalation may then be rapidly conducted. The principal dangers during inhalation are the arrest of respiration, and the cessation of cardiac movement. As a general thing, if respiration can be sustained the heart will continue to act. It is, therefore, important, whenever alarming symptoms appear, to guard the breathing — even to the extent of producing artificial respiration. This may be effected, preferably, by the methods of Sylvester or of Howard. The tongue may be drawn forward, not because the glottis can be thus opened, but for the sake of the reflex actions of respiration which may be excited. Faradaic stimulation of the thoracic surface may also be attempted. A powerful current should, how- ever, be avoided ; and the application should be restricted to the right side of the body, in order to escape the risk of arresting the movement of the heart by the passage of electricity through the enfeebled organ. For the use of electricity, the best method consists in placing one electrode over the track of the right phrenic nerve, in the neck, while the other electrode is applied to the wall of the thorax over the sixth intercostal space on the right side of the body. Electrical stimulation should be associated with the attempt to pro- duce artificial respiration by Howard's method — the electrical circuit being completed during the elevation of the ribs, and interrupted during the time of their descent. Insufflation has been recommended as a means of filling the 416 ANAESTHETICS AND ANAESTHESIA. lungs with air ; but if performed in the ordinary way, it is likely to distend the stomach rather than the lungs. If a flexible tube be passed through the glottis into the trachea, or, more easily, through a tracheal opening, the lungs may then be easily tilled with air. But such manoeuvres consume valuable time. Complete inversion of the body, so that the head shall be thoroughly depressed, affords the most speedy and, certainly, one of the surest means of relief when cardiac syncope is exhibited. Tested in the physiological labora- tory upon the lower animals, in whom chloroform had produced apparent death, this method of resuscitation has in numerous cases yielded very con- spicuous results. Unfortunately, however, the energy of certain anaesthetic substances is so great that no degree of vigilance can obviate danger, nor can the most scientific methods of relief always effect a restoration when the patient has ceased to breathe. The only real approach to safety, the only irreproachable course of action, lies in complete abstinence from these potent drugs. The administration of atropine previous to the commencement of in- halation has been recommended with a view to protection against syncope by its stimulant effect upon the heart. Though it be a fact that the drug serves to accelerate the cardiac contractions, it certainly has a paralyzing effect upon the pneumogastric nerve connections of the heart ; so that, while it may theo- retically protect that organ from violent inhibitory shocks transmitted through the vagi, it is doubtful whether, in medicinal doses, it can effect any benefit greater than may result from the action of the anaesthetic itself. Employment of Anaesthetics. Artificial Anaesthesia in Surgery. — Briefly, it may be assumed that every painful and long-continued operation, upon a patient who presents none of the contra-indieations already considered, constitutes an occasion for the induction of artificial anaesthesia. By the aid thus procured, many ope- rations in surgery are rendered feasible which otherwise could rarely be pro- posed. It has, moreover, been asserted that by the use of anaesthetics the mortality after surgical operations has been considerably reduced. Without undertaking the discussion of a question into which numerous other elements must in fairness be admitted, it may safely be conceded that the removal of that dread of pain which was always so formidable an obstacle to early ope- ration for the relief of disease, and the diminution of the danger of exhaus- tion by pain during the time of operation, have largely contributed to an in- crease of safety in surgery. It should not be forgotten, however, that loss of blood may be favored by the action of anaesthetics. The depressing effect of the more powerful anaesthetic substances may sometimes exercise a prejudicial effect upon the convalescence of exceptional individuals. Death may occur during the act of inhalation. But, notwithstanding all these possibilities, it can scarcely he doubted that the sum of human misery has been considerably reduced by the employment of anaesthetics in surgery. Artificial Anaesthesia in Obstetrics. — The employment of ether for the relief .,1' | he pains of child-birth soon followed its introduction in surgery. Sir J. Y. Simpson becameat once a most enthusiastic advocate of the new. method, whichsoon became naturalized throughout the greater part of the civilized world. Objections to (he practice have been raised on the ground of inter- ference with a natural process. It may be conceded that in all truly natural Labors the use of anaesthetics is superfluous ; but, since the abnormal condi- tions of a partial civilization have introduced so large an element of pain into a naturally laborious, hut not necessarily painful, process, the employment of EMPLOYMENT OF ANESTHETICS. 417 artificial means of relief is thoroughly justified. Painful parturition is as proper a subject for relief as painful menstruation. The proper stage of labor for the use of anaesthetics may be allowed to depend upon the degree of pain by which it is characterized. Inhalation may be employed during any stage of confinement. It is, however, desirable to avoid the induction of profound insensibility during the earlier portion of a labor which may be prolonged for many hours. A parsimonious use of the drug should be the rule, in fact, during the whole course of parturition, unless instrumental interference be- come necessary for the purpose of completing the delivery. For the produc- tion of anaesthesia, any one of the numerous substances used for this purpose may be employed ; but the obstetrical anaesthetic par excellence is chloroform. Its convenience, its agreeable properties, and the remarkable degree of safety which has attended its exhibition under such circumstances, have all com- bined to give it the preference before all other anaesthetics. For the graver operations of midwifery, however, when complete insensibility is desired, sulphuric ether should be used. When administered for the purpose of mitigating the severity of painful uterine efforts, it is not necessary to reduce the patient to a condition of silent insensibility. A few drops of chloroform vaporized from a handkerchief, and inhaled at the commencement of each pain, are usually sufficient. Thus employed, it is no unusual thing to hear a woman declare, at the close of a tedious labor, during which her complaints have been most volubly uttered, that the whole period has not seemed longer than fifteen minutes. By this intermittent method of inhalation, the stimulant effect of the drug is main- tained. If complete insensibility be induced during the expulsive stages of labor, it may happen that muscular contraction is diminished, or even com- pletely arrested. This is the consequence of over-saturation of the reflex spinal centres with the anaesthetic. The voluntary muscles are the first to yield ; then follow the muscles which are employed in semi-voluntary expul- sive acts; finally, the purely involuntary muscular fibres of the uterus. Ex- cepting only cases of operative interference, it is desirable that during the concluding efforts of parturition the patient should sufficiently possess her senses to assist the involuntary uterine efforts by those powerful voluntary exertions which are most efficient in a state of consciousness. If, however, the sufferings of the patient combine with the effects of partial anaesthesia to render her uncontrollable, it is better to produce complete insensibility at the moment of delivery. With the birth of the child, inhalation should cease, unless some unusual operative interference should be required. The patient soon recovers consciousness, and ordinarily suffers very little pain or discomfort during the succeeding day. For the relief of after-pains, chloroform is un- necessary, opiates and chloral hydrate usually sufficing for that purpose. The new-born infant rarely exhibits any unfavorable consequences from inha- lation by the mother. It is, nevertheless, possible for chloroform to enter the blood in the placenta, and to find its way into the foetal circulation. Hoppe- Seyler has demonstrated the presence of chloroform in the urine of a new- born child. Long-continued inhalation of large quantities of chloroform are, therefore, not without danger to the life of the infant. Puerperal convul- sions require the induction of complete insensibility, in connection with other appropriate medical treatment. Chloroform is ordinarily employed for this purpose, but when prolonged anaesthesia is required, ether should be given. The contra-indications to the use of anaesthetics during labor are the same that should preclude their use under other circumstances. Artificial Anesthesia in Dentistry. — The search for means of obviating the pain attending the extraction of teeth, was the prime cause of the utiliza- vol. i. — 27 418 ANAESTHETICS AND ANAESTHESIA. tion of nitrous oxide and of ether. The defective apparatus employed at that time was doubtless one of the causes which led to the disuse of Dr. Wells's discovery. It was nearly twenty years after the experiments of the Hartford dentist, before nitrous oxide was finally established as the dental anaesthetic. During the interval, ether had been introduced into the operations of den- tistry by Dr. Morton, but its place was soon taken by chloroform. The great mortality consequent upon the use of this agreeable substance, produced a reaction of feeling against its use, but it was only after Colton had shown the superior safety of laughing-gas that chloroform was tinally abandoned by the dental profession. The brevity of the period of insensibility produced by nitrous oxide, especially commends its employment for all operations as short as the extraction of a tooth. For the major operations of dentistry, ether is generally preferred. Local Anesthesia. Numerous attempts have been made to escape from the dangers of general anaesthesia, by the substitution of local anaesthetic and refrigerant applica- tions, for inhalation of generally stupefying vapors. The well-known effects of cold were thus utilized by James Arnott. Freezing mixtures of ice and salt (two parts of pounded ice and one of salt), applied to the surface of the body, soon produce congelation of the part. The skin turns white and tal- lowy, and the part becomes completely insensible. It is necessary to apply the mixture in a gauze bag, to permit the free escape of the resulting liquid. Unfortunately, the great difficulty of limiting the extent of refrigeration must always serve to restrict the usefulness of this method. If it be desired to produce insensibility extending to the deeper parts of a limb, it will be difficult to dispense with a degree and a duration of cold which must en- danger the vitality of the superficial tissues. Arnott's method, therefore, has found comparatively little favor, and local anaesthesia was not generally em- ployed until 13. W. Richardson (in 1866) introduced to English surgeons the method of producing local anaesthesia by the concentration of an ethereal spray upon the part to be deprived of sensibility. This operation is easily performed with an ordinary hand-ball atomizing apparatus. The rapid evaporation of ether thus pulverized, produces refrigeration of the tissues with which it is brought in contact, by abstraction of the heat which they contain. For this reason the more volatile ethers are to be preferred. Richardson employed a mixture of anhydrous ether, sp. gr. 0.720, and amylic hydride. Henry J. Bigelow, of Boston, recommended the use of rhigolene, one of the products resulting from the distillation of petroleum. Its specific gravity is only 0.625, and the liquid will boil in the palm of the hand. Com- plete congelation of the tissues lenders it difficult to operate upon them in the usual way. Richardson finds it necessary to discard the knife, and to supply its place with curved scissors. It is not easy to discover the severed bl (vessels in a mass of frozen hYsh, and their ligation after the parts have thawed is always painful. For all the graver operations of surgery, general anaesthesia must therefore be preferred. Carbonic acid gas has been used from time immemorial as a local anodyne. The stone of Memphis, and the familiar yeast poultice, owe their virtues to 'la' local anaesthetic effect of this gas. The good effects of aerated waters, effervescent wines, kumyss, and fermenting paste, in irritable conditions of the gastric mucous membrane, arc in great measure due to the carbonic acid which they contain. For a brief period the pains of uterine cancer have been alleviated by injection of water charged with this gas. OTHER MODES OF PRODUCING ANESTHESIA. 419 The effect of the local application of the ethereal anaesthetics is exceedingly variable, depending chiefly upon the degree of volatility of the substance. Chloroform is for this reason, as well as for its own intrinsic qualities, more potent than ether. When hindered from evaporation by covering the part with oiled silk, the local effect of the anaesthetic is greatly intensified. As a general rule, the more rapid the evaporation of the substance, the less per- sistent is its anaesthetic effect. Diluted with oil, or combined with unguents, the powerful agents, like chloroform, may be employed with excellent effect for the relief of dermal pains and superficial neuralgias. Pure chloroform applied to the skin produces a powerful counter-irritant effect by virtue of its directly stimulant action upon the cutaneous nerves and capillaries. The burning sensation thus aroused is soon succeeded by cessation of pain, due in part to the local stimulation, and in part to the subsequent diminution of sensibility in the affected nerves. Relief thus obtained is, however, not very permanent, and is restricted to superficial neuralgias alone. For the induc- tion of insensibility sufficient for the painless performance of the major opera- tions of surgery, general anaesthesia must be employed. Other Modes of Producing Anesthesia. Anesthesia by the Aid of Electricity. — An American dentist, Dr. J. B. Francis, attempted, in 1857, to annul the pain of extracting teeth by passing an electrical shock through the tooth at the instant of its evulsion. After numerous trials, it became clearly evident that this method could avail nothing except by substitution of one form of pain for another. The opera- tion was soon abandoned, and the success of nitrous oxide in dentistry has nearly obliterated the recollection of electrical anaesthesia. The attempt to produce local anaesthesia in surgical operations, by connecting the knife with one of the rheophores of an electrical apparatus, fared no better. The com- bined action of electricity and local anodynes has been proved to owe all its efficacy to the action of the drugs placed in contact with the skin, and not at all to the electrical current. Anesthesia by Rapid Respiration. — A method of producing insensibility by rapid breathing, sufficient for the painless performance of minor surgical operations, has been suggested [by Dr. Bonwill and Dr. A. Hewson]. Since the partial anaesthesia thus induced is largely dependent upon accumulation of blood in the veins, overcharging the vessels of the brain with imperfectly oxygenated blood, the method cannot be commended. In elderly subjects with brittle bloodvessels, cerebral hemorrhage might thus be occasioned. Local anaesthesia should be preferred to this method. It is not improbable that some of the cases of insensibility to pain which are placed in this cate- gory, may be really examples of self-hypnotism. Anesthesia by Intra-venous Injections. — Ether, chloral, and chloroform, have been frequently administered by hypodermic injection as remedies for neuralgia, and their effects have been highly esteemed by certain observers. The pain which attends the act of injection, and the subsequent danger of abscess, or worse, has prevented the wide extension of this method. Dr. Ore, of Bordeaux, consequently (1872) recommended the use of chloral by intra- venous injection, as a means of producing surgical anaesthesia. By the aid of a properly adapted canula and syringe, he slowly introduced into a superficial vein four to ten grammes of chloral hydrate, dissolved in three to five parts 420 ANESTHETICS AND ANAESTHESIA. of water. After a period of time varying from six to forty minutes, the patient became completely insensible, and continued in this state for a con- siderable time. In fifty-three cases reported, the shortest period of anaesthesia was ten minutes ; the longest was three hours. Two deaths occurred — one without any visible lesion, the other in consequence of suppurative phlebitis. The difficulties and the danger of this method are thus sufficiently indicated. Use of Anesthetic Mixtures. — The risks of cardiac syncope and respira- tory paralysis which attend the use of chloroform and the stronger anaesthetics, have occasioned the suggestion of various mixtures designed to stimulate the cardiac and respiratory nervous centres during the act of inhalation. Oil of turpentine has been added to chloroform with alleged successful results. At- tenuations of chloroform with alcohol and sulphuric ether, have been extensively employed. Billroth uses a mixture containing three parts of chloroform and one part each of sulphuric ether and alcohol. The London Chloroform Com- mittee recommended (1864) a mixture composed of ether three parts, chloro- form two parts, and alcohol one part. Experiments with frogs were said by Sansom to prove that these animals could not be killed with chloroform after they had inhaled the vapor of alcohol. These mixtures, however, do not obviate all danger in the human subject. Several deaths have occurred during their administration. A mixture of amylic nitrite and chloroform, in the proportion of sixteen drops to the ounce, has been recommended. Amylic nitrite stimulates the heart, and produces a special impulsion of blood to the head. It has, therefore, been urged that medullary paralysis cannot occur while under its influence. For brief operations this method has been satis- factory, but it is an open question whether the prolonged inhalation of such a mixture may not be quite as dangerous as the use of chloroform alone. Successive inhalations of nitrous oxide and of ether vapor have been em- ployed, chiefly in England, by Mr. Clover. The patient is rendered insensible with laughing-gas, and the condition of anaesthesia is then maintained by the substitution of ether or any other anaesthetic vapor. This method has given good results, but it necessitates the use of a complicated inhaling apparatus. Belladonna, or atropine, has been administered, in concurrence with the inhalation of chloroform, to counteract the tendency to syncope while in the anaesthetic state. Theoretically useful, it is hardly probable that a medicinal dose of atropine would be sufficient to protect against a fatal dose of chloro- form. The similar employment of morphine was introduced in 1863 by Nuss- baum, who discovered that surgical anaesthesia could thus be prolonged for several hours. Bernard soon observed the same phenomena in the lower animals. Extending these observations to the human species, he determined the fact that moderate doses of morphine, injected hypodermically half or three-quarters of an hour before inhalation, rendered the induction of anaes- thesia less difficult, and caused it to be attended with less than ordinary excitement. Injection immediately before inhalation augmented the period of excitement. Large doses of morphine caused danger of death by asphyxia while under the influence of chloroform. This method of treatment is espe- cially useful in the management of drunkards and other patients who are unduly excited by anaesthetics. When small doses of morphine are employed, the danger of death during anaesthesia is not materially affected ; but large doses of the drug mU\ greatly to the peril of this condition. Chloral hydrate has sometimes been administered previously to the inhalation of chloroform. The period of excitement is thus abolished ; but opinions are divided con- cerning the safety of patients thus exposed to the concurrent action of two such potent drugs. Claude Bernard and others have observed that when morphine is injected HYPNOTISM. 421 hypodermically, before the inhalation of sulphuric ether, the period of excite- ment is prolonged and rendered more tempestuous, and the subsequent head- ache and nausea are greatly aggravated. A similar association of chloral hydrate and sulphuric ether gives a less unpleasant result. Insensibility endures for a longer time than when ether alone is employed. Vomiting, however, is very common, and the subsequent prostration and headache are considerably aggravated. Hypnotism. — Certain persons are physically constituted in a manner which leaves their nervous system extraordinarily liable to disturbance of the co-or- dinating and connective portions of the apparatus. Accidentally observed at intervals during all ages of the world, this fact has been made the basis of numerous forms of superstition. Brought into notoriety by Mesmer, the phenomena of hypnotism were carefully investigated by Dr. James Braid, of Manchester, between the years 1843 and 1852. Recently his experiments have been repeated by the German phj'siologists, Heidenhain and Weinhold. By causing a susceptible person to gaze intently for several minutes upon any bright object placed before the eyes, within the limits of distinct vision, a condition of somnambulism, or even of catalepsy, may be induced. In this condition the body becomes insensible to painful impressions, and the volun- tary functions of the brain may be completely inhibited. The patient becomes reduced to the condition of an automaton, evolving reflex actions in obedience to the will of the operator. JSTot all individuals are thus susceptible. Some experimenters have concluded that one person in five was capable of hyp- notism. Heidenhain, who experimented only upon males, found that one in twelve could be thus influenced. It is not necessary to address the brain through the eye alone. Gentle friction of the finger tips, or similar stroking of the scalp, or passes of the hand near the surface of the patient, will pro- duce the desired result. A monotonous and continuous sound may also induce this peculiar state. In certain cases a cataleptic state may be set up by simply rubbing or pinching the limb which is to be affected. The patient may retain, in certain cases, the faculty of speech and the power of motion, and yet be insensible to every painful impression. It is while in this con- dition that surgical operations may be endured without any experience of pain. The susceptibility of the patient to the influence of the operator usually increases with practice, until, at length, a touch with the finger upon some particular portion of the body, or even a glance of the eye, may suffice to reproduce the hypnotic phenomena. This degree of susceptibility is so frequently associated with ill health, that indulgence in hypnotic sleep has been generally considered injurious to the patient; but the observations of Heidenhain indicate that this is not necessarily the case. The nervous susceptibility may coexist with vigorous health. The duration of the hypnotic paroxysm is quite under the control of the operator. A smart tap upon the shoulder, friction in a direction op- posite to the original course, a puff of air in the face, are sufficient to restore the conscious sensibility of the patient. Perrin relates a case in which the patient, from whom a cancerous breast had been removed during the hypnotic trance, was permitted to sleep for forty-eight hours before she was awakened. She had given no evidence of pain at the time of operation, and retained no recollection of anything that had occurred. But, though it is certain that the anaesthesia which forms one of the phenomena of the hypnotic state is sufficient to admit of painless surgery, it is also a fact that the comparatively limited number of individuals who are susceptible must always preclude the general employment of hypnotic anaesthesia as a surgical resourca 422 ANAESTHETICS AND ANESTHESIA. Anaesthesia by Compression. — James Moore (1784), and other surgeons since his clay, have sought to produce local insensibility sufficient to abolish pain, by compressing the nerves of the part to be operated upon. For this purpose a species of tourniquet has been employed by some, while simple ligation of the member has been proposed by others. Though it is possible thus to produce a certain degree of numbness, the success of the method has been very imperfect, and the whole subject has become a matter of purely historical interest. [Aug. Waller produced muscular relaxation and anaes- thesia by compressing the cervical portions of the pneumogastric nerves.] Mortality consequent upon Artificial Anaesthesia. It is impossible to reach any degree of certainty regarding this matter. The number of administrations since the discovery of Morton cannot be esti- mated, and the number of cases which have resulted fatally cannot be ascer- tained. Hundreds of such cases have been recorded in the medical journals, but many hundred other cases have never been thus reported. All estimates based upon medical literature must, therefore, be regarded as approximations merely. Sufficient, however, is known to enable the surgeon to speak with great assurance regarding the relative dangers which attend the employment of different anaesthetics. Thus, it is certain that chloroform has occasioned the vast majority of deaths which have occurred in connection with artificial anaesthesia. But chloroform has been so much more generally employed than any other anaesthetic, that its mortality, other things being equal, should present a figure greater than that of any other substance. In Europe, the vast majority of surgeons have used chloroform alone. It is in America, where ether has been more generally employed, that a comparison of mor- tality is more likely to give definite information. Here, however, complete statistics are wanting. A combination of statistical tables is not likely to give additional information, because many of the reported cases of death are repeated in the different tables, while the sum total of inhalations is largely imaginary. The following estimates may illustrate the present condition of our knowledge on the subject. Dr. J. J. Chisolm, of Baltimore, estimates (1877) that among over 250,000 recorded administrations of chloroform, only twelve deaths had occurred. But, since over three hundred fatal cases — Dr. Turnbull (1879) gives a total of three hundred and seventy — have been recorded, if these had been added to Dr. Chisolm's collection, his estimate of the ratio of mortality would have been seriously affected. Prof. E. Andrews, of Chicago (1870), collected 117,078 cases of chloroform inhalation with 43 deaths, giving a ratio of 1 to 2723. Among 92,815 cases of ether inhalation were 4 deaths, giving a ratio of 1 to 23,204. A mixture of chloroform and ether, used in 11,17(3 cases, caused 2 deaths, giving a ratio of 1 to 5588. Bichloride of methylene, used in 7000 eases, caused one death. 7>. Coles, of Virginia, reported, on the basis of Eng- lish and American statistics, the following figures: Ether, 4 deaths in 92,815 inhalations ; ratio, 1 to 23,204. Chloroform, 52 deaths in 152,260 inhalations: ratio, 1 to 2873. Mixture of chloroform and ether, 2 deaths in 11,176 inhala- tions ; ratio, 1 to 5588. Bichloride of methylene, 2 deaths in 10,000 inhalations; ratio, 1 to 5000. Richardson collected from English hospital statistics, between the years 18 18 and 1869 inclusive, a report of 35,165 administrations of chlo- roform, with 1 1 deaths, giving a ratio of 1 to 3196. Squibb has estimated the ratio of deaths by chloroform published in American journals at 1 to 11,764. Assuming thai only half the fatal cases are reported, this would give a ratio of 1 to 5882. A more favorable showing is made by the Royal Infirmary of DEATH FROM ANESTHESIA. 423 Edinburgh, where it is reported that during a period of ten years only one death occurred in an estimated total of 36,500 administrations of chloroform. Rendle estimates that in twenty of the principal London hospitals chloroform is administered about eight thousand times each year, with a mortality oi three per annum. This would }'ield a ratio of 1 to 2666, which agrees very closely with Richardson's later estimates. The well-known assertion that, during the Crimean war, not a single fatal ease of anaesthesia occurred among the 20,000 patients who were chloroformed in the French army, may be received with a certain degree of reserve, for, in military practice, it is not always easy to assign due weight to the different causes which may co-operate to produce a fatal result. It is admitted by the highest American authorities that, during the war of the rebellion, seven fatal cases resulted from eighty thousand inhalations of chloroform, giving a ratio of 1 to 11,448. Kappeler reports for himself and for three other Ger- man surgeons — Billroth, Xussbaum, and Konig — about thirty-nine thousand administrations of chloroform, with but two fatal cases. This would give a ratio of 1 to 19,500. The same author admits the insufficiency of German re- ports concerning the mortality after use of chloroform. Much allowance must be made for the personal equation of each surgeon in estimating the value of individual experience in this matter. If now the above statistics, excluding the earlier tables of Andrews and Coles, be consolidated, a total of 218,165 inhalations of chloroform gives a mortality of twenty-four cases. This yields a ratio of 1 to 9090, which is probably the most favorable award that can be made to chloroform. (See Note, p. 433.) Information regarding the actual mortality caused by sulphuric ether, is no more easily discovered than in the case of chloroform. Kappeler could dis- cover only thirteen fatal cases assigned to ether, and of these thirteen, only four could without contradiction be ascribed to the influence of ether alone. Turnbull has collected the histories of eighteen cases which proved fatal after the inhalation of ether ; but of these only nine cases can be fairly charged to the anaesthetic. It is probable that the ratio fixed by Dr. Andrews (1 to 23,204) expresses very nearly the actual risk from ether inhalation. It should be observed in this connection, that such statistical estimates take no cogniz- ance of the innumerable cases in which alarming symptoms, rarely noted after ether, present themselves during the course of anaesthesia from chloroform. Very little is known regarding the comparative dangers which attend the use of the majority of • anaesthetic substances. Many of them have caused death at an early period in the history of their employment, so that they have been laid aside before their fatality could be justly estimated. There appears to be good reason for the belief that the lethal energy of an anaes- thetic is closely related to the molecular weight of the substance — increasing directly as its weight increases. The presence of the haloid elements also adds greatly to the deadly efficiency of an anaesthetic compound. Nitrous oxide, in spite of its asphyxiating property, is the safest of all ana?sthetics for brief operations. This gas has been administered more than a million times, with but seven fatal cases. Used according to the method of Bert [admin- istered in a chamber of compressed air in mixture with oxygen gas], it is theoretically as harmless as atmospheric air. Post-mortem Appearances after Death from Artificial Anesthesia. Excluding the rare cases of asphyxia in which death has been occasioned by the intrusion of a foreign body into the larynx or trachea, and the equally rare cases in which suffocation may have been caused by the use of an ill-con- 424 ANESTHETICS AND ANESTHESIA. structed inhaler, the autopsies of the victims of anesthesia present nothing positive or characteristic. In such cases, death is the consequence of disturb- ance of the nervous apparatus concerned in the acts either of respiration or of circulation. The changes which have produced the result are intra-niole- cular, and are consequently beyond the reach of our senses. Anesthetic Substances. The majority of alcohols and ethers are probably endowed with anaesthetic properties. The number, however, of such compounds which are capable of use in a manner to exhibit this quality, is comparatively limited. The fol- lowing; list includes all that have been tested with any degree of precision. Besides these, a variety of substances which do not belong to the class of alcohols and ethers, are known to possess anaesthetic properties. Nitrous oxide, carbonic anhydride, and various hydrocarbons, are examples of these bodies. It is not unlikely that all substances which possess antiseptic qualities are also capable of producing artificial ansesthesia, if sufficiently diluted. There is wide room for experiment and observation in this field of investiga- tion. The classification here adopted is furnished by Miller's Elements of Chemistry (fifth edition). The formula? and the descriptions of the different substances are derived either from the same source or from Watts's Dictionary of Chemistry. I. Hydrocarbons and their Derivatives. From petroleum and from coal, certain binary compounds of carbon and hydrogen may be separated by distillation. These are either gaseous and present in illuminating gas, or liquid and separable by fractional distillation from the kindred compounds with which they are associated in crude petro- leum. A number of these substances have been isolated, and separately tested in the production of artificial anaesthesia. Others, like keroselene, have been used in their natural combinations. The lowest member of the series is Methane, CIT 4 , sometimes called meihylic hydride, marsh gas, or light carburetted hydrogen. It is one of the products of the destructive distillation of w^ood, peat, soft coal, and other allied sub- stances. It is one of the principal constituents of illuminating gas. It is a colorless, inodorous, tasteless gas, sp. gr. 0.5576, respirable with safety if diluted with air. It is never thus used, unless by accidental breathing of coal gas. The derivatives of this radical are among the most important an;esthetics. Ethane, C 2 II fi , Ethylic hydride, or Dimethyl, is a tasteless, and odorless gas with a specific gravity of 1.075. It is chiefly interesting as the radical of the ethylic scries of alcohols, aldehydes, ethers, etc. Tetrane, C 4 H I0 , Butane, Diethyl, Butylic hydride, is a liquid derived by fractional distillation from petroleum. The vapors must be condensed at a low temperature, for the boiling point of the liquid is 1° C. (33°.8 F.). Dis- solved in naphtha, the solution constitutes rhigolene, a colorless liquid which evaporates with great rapidity, boiling in the palm of the hand. It has been used tor the production of local ansesthesia by the evaporation of its spray. Keroselene is a colorless liquid, with a. variable composition, derived by dis- tillation from petroleum. It is chiefly composed of higher members of the paraffin series, such as amylic, caprylic, cenanthylic, laurylic, myristilic and palmitylic hydrides. Inhalation of its vapor produces disagreeable ant I ANESTHETIC SUBSTANCES. 425 alarming symptoms, so that it may be justly discarded from the list of useful anaesthetics. Pentane, C 5 H is , Amylic hydride, is a colorless liquid, boiling between 37° and 39° C. (98°.6 and 102°.2 F.). Its specific gravity is 0.626. It is one of the constituents of naphtha and of rhigolene. Inhalation of its vapor is fol- lowed by speedy anaesthesia, without disagreeable consequences. It has been successfully used in dental surgery, but its extreme volatility is an objection to its general employment. Octane, C 8 H 1s , Caprylic hydride, has also been isolated from keroselene or from petroleum. It is a colorless liquid, with a specific gravity of 0.728. Its boiling point is uncertain; 115°-125° C. (239°-257° F.). Administered to animals, it produces a long period of excitement, often accompanied by vom- iting. The substances above mentioned belong to the paraffin series of hydro- carbons. The olefin series of hydrocarbons has yielded two substances whose anaesthetic properties have been recognized — ethylene and amylene. Ethylene, C 2 II 4 , Olejiant gas, Heavy carburetted hydrogen, Elayl. This is one of the most important luminous constituents of coal-gas. It is a trans- parent, colorless gas, with a faint, sweetish, alliaceous odor, and is soluble in about 12 times its bulk of cold water. Its specific gravity is 0.978. Liquefied under great pressure, it remains unfrozen at — 110° C. ( — 166° F.). Asso- ciated with methane, butylene, acetylene, hydrogen, carbonic oxide, and a variable volume of impurities, it constitutes a part of the gaseous mixture used for illuminating purposes. Illuminating gas, when inhaled in consider- able quantity, produces muscular rigidity, contraction of the pupils, injection of the cutaneous vessels, rapidity of the pulse, snoring respiration, and com- plete insensibility. Continued inhalation produces dilatation of the pupils, muscular relaxation, vomiting, and death. The fatal issue results in part from the asphyxiating property of the impurities contained in the gas, and in part from the directly toxic effect of its various ingredients. Amylene, C s H 10 , Pentylene, or Pentene. Sp. gr. 0.6549. Boiling point, 39°-42° C. (102°.2-107°.6 F.). A transparent, colorless, mobile liquid, with an offensive, cabbage-like odor. It burns with a luminous flame, is almost insoluble in water, but mixes in all proportions with alcohol or ether. It may be distilled from a mixture of zinc chloride and amylic alcohol, and it also exists as a constituent of petroleum. The condition of insensibility pro- duced by inhalation of its vapor is less persistent than the effect of chloro- form. Muscular spasms are likely to occur under its influence. Snow administered it in more than one hundred cases ; but, two deaths occurring as a consequence of its use, it was entirely abandoned. Hydrocarbons of the Terpene Series are represented by Tuiycntine oil, C 10 II 1V This is a colorless, mobile liquid with a peculiar, aromatic odor, and is obtained by distillation of the oleo-resinous juices of certain species of Pinus. Its specific gravity is 0.86, and it boils at 150°-160° C. (302°-320° F.). It has been recommended in combination with chloroform as a means of preventing syncope during anaesthesia. Administered to animals, it pro- duces complete insensibility without unfavorable consequences. Its effects are slowly evolved, and it sometimes produces local irritation of the respira- tory and urinary passages. Hydrocarbons of the Benzene Series. Benzene, C fi H 6 , Benzol, Phem/lic hydride. Sp. gr. at 0° C. (32° F.), 0.8995. Boiling point, 80°.5 C. (176°.9 F.). A colorless, limpid, strongly refracting liquid, of a peculiar and rather agreeable odor. Its vapor is very inflammable, burning with a luminous and smoky flame. The substances generally sold under the names of benzine and benzoline are chiefly mixtures of paraffins, and do not contain benzene. It 426 ANESTHETICS AND ANESTHESIA. may be obtained by the distillation of benzoic acid with calcic hydrate at a dull red heat, but on the large scale it is prepared from the portion of coal- tar oil which boils below 100° C. (212° F.). As an anaesthetic it may be used to produce insensibility when inhaled, but it produces disagreeable sensations, muscular twitching, and even convulsions. Haloid Derivatives of the Hydrocarbons. — Monochloromethane, CH 3 C1, Methylie chloride. Sp. gr. of gas,1.736. Boiling point, —22° C. (— 7°.6 F.). A colorless gas, prepared by passing hydrochloric acid into a boiling solution of zincic chloride in twice its weight of methylie alcohol. A solution of this gas in ordinary ether has been employed experimentally as an anaesthetic. It is an agreeable but not very efficient substance. Dichloromethane, CH„C1 2 , Methylenic chloride, Methylene bichloride. Sp. gr. 1.36. Boiling point," 40°-42° C. (104°-107°.6 F.). A colorless liquid, with an odor resembling . that of chloroform. Prepared by acting upon monochloromethane with chlorine in bright sunshine, or by treating di-iodo- methane, CH 2 I 2 , with chlorine. Its effects are very similar to those of chloroform inhalation. Owing to the low boiling point of the liquid, it can- not be economically employed during very warm weather. Its effects are for the same reason very evanescent. Four cubic centimetres are sufficient to produce insensibility. No unpleasant sensations ordinarily accompany the return to consciousness. Vomiting is less frequent than after chloroform or ether. This anaesthetic has been extensively employed by Spencer Wells, in England, but other surgeons have been less enthusiastic, and numerous deaths caused by its administration have been reported in the English medical journals. It is, probably, little less dangerous than chloroform. Trichloromethane, CHC1 3 , Chloroform. Sp. gr. 1.497. Boiling point 61° C. (142° F.). A colorless, volatile liquid, with high refracting power, an agree- able, ethereal odor, and a sweet, penetrating taste. Very sparingly soluble in water, it dissolves in every proportion in alcohol or in ether. Set on fire with difficulty,' it burns with a greenish, smoky flame. Pure chloroform should communicate no color to sulphuric acid when agitated with it. The liquid should be colorless, and destitute of any chlorous odor. When evapo- rated from the hand, no unpleasant odor should remain. Chloroform is an excellent solvent for sulphur, phosphorus, iodine, fats, and resinous bodies. It is the most perfect solvent for caoutchouc. Chloroform is manufactured by acting upon dilute alcohol with chloride of lime. Wood spirit, acetone, oil of turpentine, and many essential oils, likewise yield it when treated with bleaching powder. It may be administered internally in the liquid form, largely diluted, in doses not exceeding four cubic centimetres. Administered by inhalation, it may be evaporated drop by drop from a napkin placed be- fore the face. The vapor must be largely diluted with air. More than five per cent, of the vapor in the air of respiration is liable to produce alarming symptoms. The agreeable odor of chloroform, its pleasing effects upon the brain, the energy and rapidity of its action, and the concentration of the liquid, have rendered it the favorite anaesthetic. The high rate of mortality which accompanies its use has rapidly depressed its value in the estimation of an increasing number of surgeons, and has greatly stimulated the search for a safer an;csthetie which shall still possess the admirable qualities of chlo- roform. Tetrachloromethane, CC1 4 , Carbonic tetrachloride. Sp. gr. 1.509. Boiling point 78° C. (172°.4 FA A colorless liquid, obtained from wood spirit and chloroform by the action of chlorine in bright sunshine. It is insoluble in water, but soluble in alcohol and in ether. Employed as an anaesthetic, its action is less rapid and more persistent than the action of chloroform. Its sensible effects are less agreeable, and its effect upon the heart is more energetic ANAESTHETIC SUBSTANCES. 427 than that of chloroform. It is powerfully irritant to the nervous system, pro- ducing tonic and clonic convulsions, rapid and irregular action of the heart, and arrest of respiration. Its general action is similar to that of chloroform, but its depressing action upon the heart is much greater, so that it must be considered a more dangerous substance. Iodomethane, CII3I, Methylic iodide. Sp. gr. 2.2. Boiling point 42° C. (107°. 6 F.). Vapor density 4.833. A colorless, mobile liquid, of peculiar ethereal odor, insoluble in water, prepared by distillation from a mixture of 100 parts of iodine with 50 parts of methylic alcohol and 7 parts of amor- phous phosphorus. Chemically pore, its vapor is respirable and anaesthetic; but it is exceedingly unstable, yielding excessively irritating fumes, and pro- ducing very disagreeable effects. Tri-iodomethane, CHI 3 , Iodoform. Melting point, 120° C. (248° F.). A product of the action of iodine, in presence of potassic or sodic hydrate or carbonate, on ethylic alcohol, aldehyde, acetone, and many other substances. It exists in greenish-yellow, scale-like crystals, with a sweetish taste, and a peculiar odor which may be masked by the oil of peppermint. Its properties are discutient, antiseptic, and anaesthetic. Applied locally, it diminishes the sensibility of the skin, and of irritable surfaces generally. All varieties of unhealthy, offensive, and painful ulceration are benefited by its topical ap- plication. Administered internally, in small doses, it is rapidly eliminated without producing any signs of irritation. Doses of half a gramme (eight grains) produce in man a diminution of the frequency of the pulse. If con- tinued for any considerable period of time, somnolence may result. Given to animals — four grammes to a dog — it produces muscular relaxation, anaesthe- sia, insensibility, and death. Muscular rigidity may also be observed. Moxochlorethane, CLH/31, Etkylic chloride, Hydrochloric ether. Sp. gr. 0.920. Boiling point, 12°.18 C. (53°.92 F.). Vapor density, 2.219. A thin, colorless liquid, with a pungent, ethereal odor, and a sweetish, aromatic taste. It is very inflammable, evolving hydrochloric acid from a brilliant, green- edged flame. It is the first product of the action of chlorine upon ethane in disused daylight. In spite of its remarkable volatility, this substance has been employed as an anaesthetic in a number of operations. Its general effects correspond very closely with the effects produced by ordinary ether. Given to rabbits, it produces rapid anaesthesia, but it has caused in these animals cessation of respiration, and general convulsions. Dichlorethane, C 2 H 4 C1 2 . Two isomeric dichlorethanes are known: (a) di- chlorethane, or ethylenic chloride, CII 2 C1.CII 2 C1 ; and (0) dichlorethane, or ethyli- denic chloride, CH 3 .CHC1 2 . (a) Mhylenic chloride, Ethylene dichloride, Dutch liquid. Sp. gr. 1.256. Boiling point, 84° C. (183°.2 F.). Vapor density, 3.4434. A colorless, neu- tral, oily liquid with a fragrant, ethereal odor and a sweetish, aromatic taste. It is formed by the action of chlorine upon ethylene. The resulting compound is anaesthetic, but its vapor is irritating, and sometimes causes vomiting. In the lower animals it may produce convulsive movements without anaesthesia. It possesses no advantages over chloroform. ((3) Ethylidenic dichloride, JEthylidene chloride, Ethidene dichloride. Sp. gr. 1.174. Boiling point, 60° C. (140° F.). Vapor density, 4.954. A colorless, oily liquid, resembling chloroform in taste and odor, produced by acting on monochlorethane with chlorine, and also by treating aldehyde with phosphoric pentachloride. Its anaesthetic action is very rapid, producing insensibility in one minute — seldom requiring to be inhaled as long as three minutes. Ke- covery is speedy, and disagreeable after-effects are rarely experienced. The heart is less liable to depression under the influence of ethylidenic chloride than when chloroform is employed. It is, nevertheless, a cardiac poison, pro- 428 ANAESTHETICS AND ANESTHESIA. ducing death by syncope. Administered by Mr. Clover in one thousand eight hundred and seventy-seven cases, it caused one death ; and on three other occasions the patient was only saved by inversion and artificial respiration. Trichlorethane, C 2 H 3 C1 3 , exists in two isomeric forms — (a) trichlorethane, CH 2 C1.CHC1 2 , and (?) trichlorethane, CH 3 .CC1 3 . (a) Trichlorethane, Monochlorethylenchloride. Sp. gr. 1.422. Boiling point, 115° C. (239° F.). A liquid, having an odor like chloroform, formed by the action of chlorine on dichlorethane, or by the action of chlorovinyl (C 2 H 3 C1) on perchloride of antimony. It is readily decomposed with potassa into potassic chloride and dichlorethylene. The vapor of a few drops is sufficient to pro- duce rapid anaesthesia in frogs, pigeons, guinea-pigs, and rabbits. Dogs weighing five or six kilogrammes are rendered insensible in three to seven minutes by the vapor of thirty to fifty drops of the liquid. The duration of such anaesthesia varies from eleven to nineteen minutes. In one case, reported by Tauber, of Jena, the pulse was considerably accelerated; slightly in three others. In no instance was it retarded. Respiration was either accelerated or but very slightly diminished. The kymographion exhibited no diminu- tion of blood-pressure. (j3j Trichlorethane, MonochlorethyUdenchloride, Methylehloroform. Sp. gr. 1.372. Boiling point 75° C. (167° F.). A liquid, resembling chloroform in odor and appearance, produced by the action of chlorine on monochlorethane. With this substance, Tauber, of Jena, has recently experimented upon animals and upon himself. Frogs and rabbits were quickly rendered insensible with- out special modification of either circulation or respiration. A dog, weighing five or six kilogrammes (ten or twelve pounds), was rendered completely in- sensible for nineteen minutes by the vapor of forty or fifty drops of the liquid. Respiration was somewhat accelerated during the period of most profound insensibility, but the pulse was very slightly disturbed. The vapor of two hundred drops (twenty grammes), administered to Dr. Tauber, caused anaes- thesia in five minutes and thirty seconds. It continued for ten minutes. There was no preliminary stage of excitement. Respiration remained quiet and normal. The pulse did not exceed 84, and continued undisturbed throughout the experiment. Recovery was attended with vomiting, and with a feeling of discomfort which lasted for an hour. Aran's Ether, C 2 H 3 C1 3 + C 2 H 2 C1 4 , Ether ancesthetie.us, is a mixture of tri- chlorethane and tetrachlorethane. Its specific gravity varies from 1.55 to 1.6. Its boiling point is about 130° C. (266° F.). In appearance and prop- erties it resembles chloroform. Monobromethane, C 2 H s Br, Ethylic bromide, Bromide of ethyl, ITi/drobromic ether. Sp. gr. 1.4733. Boiling point, 40°.7 C. (105°.26 F.). 'Vapor density, 3.754. A colorless, neutral liquid, with ethereal odor and a disagreeably sweetish taste. Sparingly soluble in water, it mixes readily with alcohol and ether. It is ignited with difficulty, giving a green flame without smoke, evolving a strong smell of hydrobromic acid. Its vapor is powerfully anaes- thetic, producing insensibility in animals in less than a minute. Its effects pass off very rapidly. Circulation and respiration are profoundly modified by its depressing action. To adult human beings it may be administered upon a napkin in doses of four cubic centimetres (one drachm) at once. The excessive volatility of the liquid requires almost total exclusion of air during inhalation. Owing to the instability of the- substance, it is liable to become contaminated with carbon bromide and free bromine. Great irritation may be excited by inhalation of these impurities. This fact, in connection with the recent occurrence of death in two instances of its use, has led to the almost total abandonment of the drug as a general anaesthetic. ANAESTHETIC SUBSTANCES. 429 Iodethane C 2 H 5 T, Ethylic iodide, Iodide of ethyl, Hydriodic ether. Sp. gr. 1.97. Boiling point 72°. 5 C. (162°. 5 F.). Vapor density, 5.475. A colorless, ethereal liquid, prepared by distillation from a mixture of ethylic alcohol, amorphous phosphorus, and iodine. It soon decomposes, turning red or hrown from the liberation of iodine. Its vapor is useful in chronic bronchitis and in certain cases of asthma. It has been occasionally employed as a gene- ral anesthetic, but its instability is sufficient to disqualify it for such use. Monochlorotetrane, C,H C1, Butylic chloride. Sp. gr. 0.88. Boiling point, about 70° C. (158° F.). An ethereal liquid, with an odor recalling that of chlorine, may be obtained by distilling amylic alcohol with calcic hypo- chlorite. Its vapor, administered to rabbits, overpowers respiration and weakens the cardiac pulsations until they cease altogether. Isobutylic chloride, CH(CII 3 ) 2 CH 2 C1, is a compound isomeric with the pre- ceding substance. Its specific gravity is 0.895; its boiling point is 60° C. (140° F.). Prepared by treating isobutylic alcohol with hydrogen chloride, or with phosphorus pentachloride, it is a limpid liquid, with a pleasant, ethereal, but slightly alliaceous odor. Administered to frogs, rabbits, and dogs, it produced anesthesia in from three to five minutes. Respiration was unaffected, and cardiac pulsation was not weakened. Monochloropentane, C 4 H n Cl, Amylic chloride, Chloride of amyl. Sp. gr. 0.699. Boiling point 101° C. (213°.8 F.). Vapor density' 3.8. ' Three iso- meric monochlorinated compounds of pentane exist, differing slightly in specific gravity and boiling point. The substance which is employed as an anesthetic has been tested by Snow and Richardson. It is administered in quantity similar to chloroform, and produces a gradually developed and long- continuing anesthesia, without specially disagreeable consequences. aIono-iodopentane, C 5 H n I. Amylic iodide, Iodide of amyl. Sp. gr. 1.511. Boiling point 146° C. (294°.8 F.). 'Vapor density 6.675. A colorless liquid, with faint odor and pungent taste, turning brown on exposure to light. It is prepared by treating amylic alcohol with iodine and phosphorus. Though possessed of anesthetic properties, its instability disqualifies it for practical use. Xitropentane, CjHjjXO^ Amylic nitrite, Nitrite of amyl. Sp. gr. 0.877. Boiling point 96° C. (205° F.). A clear, colorless liquid, prepared by heat- ing pure amylic alcohol with nitric acid. It has a peculiar odor, suggestive of apples and bananas. Administered drop by drop, in vapor, it powerfully excites the heart, and dilates the bloodvessels, especially of the head. The stage of excitement is followed by diminution of cardiac energy and collapse of the terminal vessels. Consciousness disappears before death when the drug is given in poisonous doses. Complete anesthesia does not occur until shortly before death. The use of this substance is specially indicated in diseases characterized by spasmodic or excessive, tonic contraction of the vascular coats in any part of the body, such as the angiospastic variety of hemicrania, angina pectoris, or epilepsy. Its stimulant effect upon the heart has led to its employment in the syncope induced by chloroform. _ Pyrrol, C 4 H 5 N. Sp. gr. 1.077. Boiling point 133° C. (271°.4 F.). A nitro-hydrocarbon found "in coal tar. It is produced whenever animal or vegetable substances containing nitrogen are subjected to destructive distilla- tion. It is a colorless, transparent liquid, with a delightfully fragrant odor, resembling chloroform, but softer and less pungent. Its taste is hot and pun- gent. Administered to small animals, its vapor produces great excitement and muscular spasms, succeeded by imperfect anesthesia. 430 ANAESTHETICS AND ANAESTHESIA. II. Alcohols. Methylic Alcohol, CH r OH. Wood spirit, Pyroxylic spirit. Sp. gr. 0.8142. Boiling point 58.6° C. (137°.4 F.). A limpid, colorless, inflammable liquid, with a penetrating, spirituous odor, and a disagreeable, burning taste. It is usually prepared from the crude wood vinegar obtained by the dry distilla- tion of hard wood at a high temperature in closed vessels. Its vapor pro- duces headache, dizziness, and nausea. Taken in the liquid form, it may pro- duce intoxication and insensibility resembling that produced by ordinary alcohol. Ethylic Alcohol, CH 3 .CH 2 OII. Alcohol. Spirit of vine. Sp. gr. 0.8095, 0.7938 at 15°.6 C. (60° F.). Boiling point, 78°.3 C. (173° F.). Vapor den- sity, 1.613. A colorless, volatile, inflammable liquid, with an agreeable, spirituous odor and burning taste, obtained by distillation from saccharine solutions which have undergone fermentation. A stimulant in small doses, large quantities of the liquid produce depression of temperature, enfeeblement of the heart, general anaesthesia, unconsiousness, and even death itself. Phenol, CgH 6 .OH, Oxybenzene, Phenylic hydrate, Carbolic acid. Sp. gr. 1.056. Boiling point, 182° C. (359°.6 F.). Obtained by purification of the product of distillation of the dead oil of coal tar. It crystallizes in long colorless needles which melt at about 39° C. (102°.2 F.). Its odor is charac- teristic though not disagreeable. It is moderately soluble in water, and does not redden litmus. It is extremely soluble in alcohol, ether, acetic acid, carbon disulphide, chloroform, and hydrocarbons of the benzene series. It coagulates albumen, and prevents fermentation and putrefaction. Applied to the healthy skin it excites a burning sensation, whitens the surface, and produces local anesthesia sufficient to render superficial incisions painless. Administered internally it produces acceleration of the circulation and respi- ration, followed by more or less general ansesthesia. Poisonous doses — thirty grammes (an ounce) or more — produce caustic effects in the mouth, oesopha- gus, and stomach, followed by feeble pulse, livid skin, insensibility, collapse, and death. Fatal consequences have followed the external use of this sub- stance when used in large quantities with surgical dressings. TrichlorethaldeHydrol, CC1 3 .CII(0II) 2 , Chloral hydrate. Boiling point, 96° C. (204°.8 F.). Produced by the action of chlorine on a well cooled aqueous solution of aldehyde. It crystallizes in large monoclinic prisms, soluble in water. Administered by the mouth, or injected into a vein, it produces deep sleep. This action has been attributed to its conversion into chloroform and formic acid in the blood. There is, however, not sufficient reason to accept this explanation. It reduces the temperature, lessens blood pressure, lowers the rate of respiration and circulation, relaxes spasm, and induces sleep, but does not produce complete ansesthesia unless administered in dangerous doses. It is a powerful irritant when applied locally to the skin or mucous membranes. Its hypodermic use is liable to cause pain and sloughing. As a hypnotic, it may be given in doses of one or two grammes (fifteen to thirty grains). Death has been known to result from ten grains, but recovery has nlso occurred alter taking 165 grains, or even 350 grains. As an anodyne, chloral hydrate is inferior to opium. Trichlorobutaldehydrol, (yi 4 01 3 .(TI(01i) 2 , BvtylcUoral hydrate. A snb- stuiicc closely resembling chloral hydrate in appearance, crystallizing from water in thin, glistening, white plates which melt at 78° C. (172°.4 F.). It is prepared Prom ethvlic aldehyde by the action of chlorine, which first pro- duces trichlorotetraldchyde. The addition of water occasions the formation of butylchloral hydrate. The effect of this substance closely resembles the ANAESTHETIC SUBSTANCES. 431 effects produced by chloral hydrate. It, however, produces marked insensi- bility of the nerves of the head and face. This has given the drug a certain reputation in the treatment of facial neuralgia. The ordinary soporific dose is about gm. 0.20 (three grains), repeated at intervals of an hour. Excessive doses may prove fatal by arresting the movements of respiration. III. Ethers. Methylic Ether or Oxide of methyl, CIT r O.CH 3 . A colorless gas, with a pleasant, ethereal odor, it may be condensed by cold or by pressure to a liquid boiling at about — 21° C. ( — 5°. 8 F.). It is not used in surgery, but its solution in ether has been tested under the name of methyl-ethylic ether. The vapor of this substance produces anaesthesia without agitation, spasm, or convulsion. Small animals killed by its inhalation die from paralysis of respiration. Its odor and its extreme volatility furnish the principal objec- tions to its use. Ethylic Oxide, C 2 H 3 .O.CJI s , Ethylic ether, Ether, Sulphuric ether. Sp. gr. 0.736. Boiling point, 35°.5"C. (95°.9 F.). Vapor density, 2.586. A colorless, transparent, mobile liquid, with a peculiar, exhilarating odor and sharp, burn- ing taste, with a cooling after-taste. It is formed by the action of sulphuric acid upon ethylic alcohol. The primary effect of ether inhalation is excite- ment. The pulse and respiration are accelerated ; the mucous surfaces are irritated ; there is a disposition to muscular movement ; the brain is excited. This stage is soon followed by a diminution and perversion of general sensi- bility. The sense of pain is overcome before the sense of touch. The special senses soon yield ; the muscular apparatus is relaxed ; the pupils are con- tracted ; the face suffused ; the skin becomes moist ; consciousness ceases. In this stage the circulation and respiration recede towards the normal standard, and tend towards a uniform rate. In profound anaesthesia the respiration may become stertorous and slow ; the pulse falls and weakens ; the skin is cool, moist, and pale — sometimes cyanotic. In the rare instances of death from inhalation of ether, the fatal result is due to arrest of the func- tions of respiration and circulation. [Under the name of "first insensibility from ether," Dr. Packard, of Philadelphia, has described a condition of brief duration in which certain operations, such as opening an abscess, can be per- formed without pain to the patient, though the administration of the anaes- thetic has not been pushed to the extent of producing complete insensibility. A similar condition of "primary anaesthesia" from the use of chloroform, has been noticed by Dr. Gibney, of New York.] Methylal, CH 2 (OCH 3 ) 2 , Methylene dimethyl ether. Sp. gr. 0.8551. Boiling point, 42° C. (107°.6 F.). Vapor density, 2.625. A colorless, ethereal liquid, obtained in small quantity by distilling methylic alcohol with sulphuric acid and manganic peroxide. It possesses decided anaesthetic properties, but is less agreeable and less manageable than chloroform. IV. Ethereal Salts. Ethylic Nitrate, C 2 II s .N0 3 , Nitric ether. Sp. gr. 1.112. Boiling point, 85° C. (185° F.). Vapor density, 3.112. A colorless liquid with an agree- able odor, and a taste at first very sweet, but followed by a bitterish after- taste. It is obtained by distillation from a mixture of alcohol and nitric acid with urea. The vapor of fifty or sixty drops produces anaesthesia, followed 432 ANESTHETICS AND ANESTHESIA. by such disagreeable dizziness, headache, and general discomfort that its use cannot be recommended. Ethylic Formate, C 3 H a 2 , Formic ether. Sp. gr. 0.918. Boiling point, 54°.9 C. (130°.8 F.). Vapor density, 2.573. A colorless liquid with an agreeable, pungent odor, formed by distilling a mixture of formic acid and ethylic alcohol with sulphuric acid. It is supposed to act by decomposition into alcohol and alkaline formiates in the blood. Upon animals its effect is similar to that of alcohol. Doses of six or eight cubic centimetres (a drachm and a half to two drachms), given to the human subject, produce only drowsi- ness. Ethylic Acetate, C 4 H 8 2 , Acetic ether. Sp. gr. 0.906. Boiling point, 77° C. (170°.6 F.). Vapor density, 3.047. A colorless liquid which has a pleasant, fruity odor when diluted with alcohol or water. It is obtained by distilling a mixture of ethylic hydric sulphate and sodic acetate. Less volatile and less inflammable than ordinary ether, it produces anaesthesia in small animals with less previous agitation than when ether is used. It may be employed in doses similar to those of sulphuric ether. V. Aldehydes. Ethaldehyde, CH 3 .COtI, Acetic or Ethylic aldehyde, Aldehyde. Sp. gr. 0.801. Boiling point, 22° C. (71°.6 F.). Vapor density, 1.532. Produced by the action of nearly every oxidizing agent on ethylic alcohol, this substance is a colorless, mobile, inflammable liquid, with a characteristic, pungent, not dis- agreeable odor. Inhalation of its vapor produces a sense of constriction about the chest, and distressing irritation of the respiratory passages, with a marked tendency to arrest of respiration. It is a powerful anaesthetic, producing insensibility in about two minutes ; but its effects are disagreeable and dangerous. VI. Ketones. Dimethyl Ketone, CII 3 .CO.CH 3 , Acetone. Sp. gr. 0.814. Boiling point, 56°.3 C. (133°.3 F.). Vapor density, 2.0025. A limpid liquid possessing an agreeable odor, and a biting taste like peppermint. Prepared by various processes, it is most conveniently obtained by the dry distillation of calcic acetate. Its vapor is slightly anaesthetic to frogs. Inhaled by the human subject, it produces soporific effects associated with dyspnoea and irritation el' the air-passages. VII. Inorganic Substances. Nitrogen, N. Sp. gr. 0.971. A colorless, tasteless, odorless gas. Its reac- 1 ion is neutral with litmus, and it is neither inflammable nor a supporter of combustion. It may be readily inhaled in an undiluted form. It thus pro- duces simple, uncomplicated asphyxia. Such insensibility as follows its inha- lation is merely one of the preliminaries of death by asphyxia. For this reason, oitrogen cannol strictly be considered an anaesthetic substance. Nitrous Oxide, N 2 0, Laughing gas. Sp. gr. of gas, 1.527. Sp. gr. of liquid, 0.908. Boiling point of liquid, —88° C. (— 126°.4 F.). A transpa- rent, colorless gas, with a faint, sweetish smell and taste, prepared by heating ammonium nitrate. It may be liquefied by a pressure of fifty atmospheres at ANESTHETIC SUBSTANCES. 433 7° C. (45° F.). Inhalation of the gas produces both asphyxia and anaesthesia ; hence it can be respired with safety for a brief period only. It rapidly dis- charges oxygen from the blood, and produces death by asphyxia. The con- vulsive phenomena which ordinarily accompany that state are suppressed by the anaesthetic action of the gas upon the convulsive nerve centres. If mixed with atmospheric air during inhalation, great nervous and cerebral exhilara- tion is produced, without loss of consciousness. The action of the undiluted gas is very prompt, and recovery is equally rapid. Faul Bert has shown that an equal mixture of nitrous oxide and common air, or an equivalent quantity of oxygen, inhaled under a pressure of two atmospheres, will produce com- plete anaesthesia without asphyxia. Inhalation of the mixture may be safely continued for an indefinite period. By this method the blood receives enough oxygen to sustain life at the same time that it is sufficiently charged with nitrous oxide to produce anaesthesia. Carbonic Oxide, CO. Sp. gr. 0.967. A transparent, colorless, inflammable, almost odorless gas. It is ordinarily produced by the combustion of coal with a limited supply of oxygen. Its action is exceedingly energetic. The presence of one tenth of one per cent, of this gas in the air is sufficient to destroy a bird, and two or three tenths of one per cent, will kill a dog. It forms a permanent combination with the haemoglobin of the blood, expelling oxygen, and producing insensibility and death by asphyxia. Resuscitation is rendered almost impossible by the stability of the compound which it forms with haemo- globin. The stupefying energy of the smoke of burning puff-ball (Lycoperdon proteus) is due to the presence of this gas. Carbonic Anhydride, C0 2 , Carbonic acid gas. Sp. gr. of the gas, 1.529; sp. gr. of the liquid, 0.83. Boiling point, —78° C. (—109° F.). A colorless, transparent gas, with a slightly acid taste and smell. It may be liquefied and frozen by pressure and cold. It may be liberated from any carbonate by the action of a stronger acid. The gas causes speedy death by asphyxia, if inhaled without dilution. If it exceed three or four per cent, of the air that is breathed, giddiness, dyspnoea, muscular weakness, and feeble and rapid move- ments of the heart appear. Any considerable increase of the gas intensifies these phenomena, and will destroy life, even though a considerable amount of air be present. Death results partly through exclusion of oxygen from the blood, partly from retention of carbonic acid in the blood, and partly from the directly amesthetico-toxic action of the substance upon the nervous tissues. A few surgeons have attempted to combine the action of carbonic acid with the vapor of ether, by causing the patient to respire from a closed receiver containing the vapor, thus consuming his own breath until rendered insensible by its carbonic acid mingled with ether. This practice cannot be too strongly condemned. Carbonic Disulphide, CS 9 , Bisulphide of carbon. Sp. gr. 1.269. Boiling point, 47°. 7 C. (117°.8 F.). A colorless, volatile liquid, with a pungent aro- matic taste, and an agreeable odor when pure. It is formed by dropping pieces of sulphur upon red-hot coals in a retort. The general anaesthetic eti'ects of the vapor resemble those produced by chloroform, but it also pro- duces great depression, sometimes followed by coma. \Yorkmon exposed to its fumes in certain factories experience great depression, weakness, and loss of memory. The liquid has been used externally with some degree of success for the relief of neuralgia; but the offensive odor if impurities are present, and the disagreeable effects of the resulting vapor, have led to its complete abandonment. Note. — Additional statistics show 84 deaths in 492,235 chloroform inhalations, or one in 5860. (See p. 423.) VOL. I. — 28 OPERATIVE SURGERY IN GENERAL. BY JOHN H. BRINTON, M.D., lecturer on operative surgery in the jefferson medical college and surgeon to the jefferson medical college hospital, surgeon to the philadelphia hospital, and to st. Joseph's hospital, Philadelphia. Submission to a surgical operation is at all times, and to every one, a for- midable trial. It is not the pain alone which affrights, but it is the absolute self-surrender from which the patient shrinks, conjoined to the uncertainty which attends the issue of even the most trilling operation. An operation, therefore, should not be lightly undertaken, but should be well considered, and should only be resorted to in the interests of the patient's life or comfort. It has been the custom to speak of operative surgery as a mere art, and its achievements have been looked upon by some as detrimental to the science of surgery — " opprobria." This is, however, but a narrow view, for in the adaptation of surgical means to the ends desired, in the selection and prepa- ration of cases, in the operation itself, in the after-treatment, in combating all evil influences, and in conducting the sufferer to a state of renewed health, surely Operative Surgery may justly share the honors of the "Science and the Art." Qualifications of a Surgeon. In all matters in life, the every-day test of excellence is success. So, too, the measure ot the surgeon's abilities, in the long run, is his success. He may be never so brilliant an operator, yet, lacking other essential qualities, the record of his work may be against him. On the other hand, no man can be a good surgeon without manual dexterity, be his judgment and other acquire- ments what they may. The qualifications, therefore, of an operative surgeon appear to be varied and comprehensive. In the first place, he must be thoroughly honest; he should operate only in the interests of his patient's highest good, where life is to be saved, or discomfort or deformity relieved ; he ought never to be tempted even by importunity to perform an unnecessary operation ; nor to operate for the sake of display, nor in the desire of acquiring notoriety or fame, nor for the sake of linking his name with this or that procedure. In doubt, he should try always to place himself, as it were, in the patient's place, and, before deciding upon an operation, at all times be able to answer distinctly and affirmatively the self-directed question — Is the proposed surgical interference really for my patient's good ? ( 435 ) 436 OPERATIVE SURGERY IN GENERAL. The surgeon should be adroit, and possessed of manual skill and dexterity. He must be a good workman, and his work must be thorough and exact. He should guard against precipitation, for in every mechanical art hasty work means bad work ; and in operative surgery this is sure to be the case, and it is here that the old motto, " festina lente," so strongly applies. A hasty operator will often do too much, and yet leave undone something which may affect the issue of the case. Every operation must, therefore, be performed with deliberation and in an orderly manner. Each step ought to be well thought over and planned beforehand ; and whilst there must be no undue haste, neither should there be unnecessary delay. The universal use of anaesthetics has long since removed from operations alike the necessity and temptation of hurry ; at the same time, it has imposed upon the surgeon the duty of quiet, prompt procedure, in order that the patient may be released from the anaesthetic influence as soon as possible. A knowledge of anatomy is essential to the operating surgeon. By some its importance has been decried, and it has been regarded as a stumbling-block, rather than an assistance, to the operator. For them, the old maxim of "cut and tie what bleeds" has been sufficient. But at the present day, in view of the frequent performance of operations of the most delicate nature, and of the invasion by the knife of regions once sacred and undisturbed, where the only safeguard is the surgeon's anatomical knowledge, it is useless to enter upon any discussion of this subject. It may then be assumed, not only that the surgeon should possess a knowledge of anatomy, but also that this infor- mation must be of a peculiar kind. The mere acquaintance with muscular origin and insertion, with the direction of vessels and nerves, and the like, is insufficient. The operating surgeon wishes, and the claims of his art demand, more than all this. His comprehension of anatomy must embrace the tissues in disease as well as in health. He must know them topographically, singly, and in groups and layers, and must be able to recognize them when trans- formed by morbid action. An appreciation of tissues is in fact one of the very highest and most practical of the accomplishments of the surgeon, and by this is meant the power to recognize the living tissues under all circum- stances. It seems, in truth, as if there were two varieties of anatomical knowledge : the knowledge of the anatomy of the dead subject — cadaveric anatomy — as scon by the pure anatomist ; this is well enough in its way, and answers sufficiently as a basis for the other, to wit, a knowledge of clinical anatomy, which alone can serve the purposes of the surgeon — the anatomy of the living tissues. It is only this knowledge of applied anatomy which confers upon the educated and practised operator that skill which leads up to great suc- cesses. It is this alone that enables him to recognize tissues, however masked, or changed, or hidden. It is this which gives his hand dexterity, and almost endows his knite with vital consciousness. Without this power of discrimi- nating tissues, tin; operations of the surgeon must be at best gropings in the dark ; with it, on the other hand, they will be characterized by skill and certainty, by safety for his patient, and by satisfaction for himself. The acquisition of this knowledge of anatomy is no easy matter ; it cannot be gathered from books, nor can it be arrived at to best advantage by the ordi- nary methods of dissection. It can only be learned by dissections practised by regions, and with a true surgical intent, and these must be repeated again and again ; for, as Pare tells us in his chapter on " Chirurgicall Operations," "Thou shall far more easily and happily attain to the knowledg of these things by long use and much exercise, than by much reading of Books, or daily hear- ing of Teachers. For speech, how perspicuous and elegant soever it be, QUALIFICATIONS OF A SURGEON. 437 cannot so vively express anything, -as that which is subjected to the faithfull eyes and hands." 1 This knowledge, once acquired, must lie kept up by dis- sections repeated from time to time, and especially ought the surgeon to refresh his memory when about to venture upon any new or delicate pro- cedure. Many blunders happen during an operation from a defective ac- quaintance with anatomy; none because the operator knows too much. Re- peated practice upon the cadaver cannot be too heartily enjoined ; and this will at all times prove of advantage to the surgeon, whatever his years may be, and however ripe his experience. The demeanor of the surgeon is a matter of no little importance. On the eve of operation, his every look and movement are closely watched, and a patient will often derive much comfort from noting the composure of the surgeon, his coolness and evident self-reliance. In his manner he should be kind and sympathizing, dignified, and free from ill-placed levity. Above all things let him try to foster in his patient that faith and confidence in him, which go so far to soothe the spirit and strengthen the resolution of one about to place himself in the surgeon's hands. It is not, however, alone upon the patient and his friends, that the happy effect of the surgeon's mental composure is produced. It intiuences too his assistants and the lookers-on at the operation ; and these are sometimes many, for the work of the operator is often done in public, where he stands in full view of critical eyes, and not unfrequently exposed to carping tongues. The surgeon ought not to present a mere out- ward composure ; but in reality he should possess it. Sangfroid, intrepidity, and the power of self-support are absolutely essential to his success. His presence of mind should never desert him. He must train himself to think, during operation, of his work, and of his patient; and not of the bystanders. If things go wrong, he must preserve his coolness, and not suffer himself to fall into that condition of mind which has been described as " surgical deli- rium" — in which the operator loses his head, and strives to extricate him- self from embarrassment by ill-directed and often aimless efforts. For it must be here observed that, while the surgeon may, year after year, pass along with little seriously amiss in his operative practice, yet, sooner or later, trouble and accident may, and indeed must, come. Startling vicissi- tudes, catastrophes which can neither be anticipated nor prevented, are sure to happen. These are the incidents of human life, and the professional man who deals so largely with life itself cannot expect to escape them. It is im- possible to conduct an active surgical practice for a long period without meet- ing with occurrences which Paget has justly called " surgical calamities ;" with every care it is not possible to foresee such contingencies, and the sur- geon must stand prepared to meet them as they come. Let him then train himself in habits of independent thought, action, and self-reliance. Let him stand strong in the best knowledge of his profession, and in the firm determi- nation to act for his patients' good, and for that alone; then, if ever these dreaded calamities shall fall upon him, his shoulders will prove strong enough to bear them. The success of the operation is undoubtedly influenced by manual dexterity in its performance, but beyond the mere mechanical skill are other factors. The proper selection of cases, Awe preparation for the operation, and careful nurs- ing, feeding, and after-treatment, have very much to do with the welfare of the patient. Indeed it may be said that the exercise of a wise and sound judg- The works of that famous cliirurgeon Ambrose Parey, translated out of Latin, and compared with the French by Th. Johnson. Book I., Chap. II. London, 1049. 438 OPERATIVE SURGERY IN GENERAL. ment, in these respects, bears greatly upon ultimate success or failure. It is the observance and enforcement of all precautions, before, during, and after an operation, which give the sufferer his best chances, and it must never lie forgotten that the latter is entitled to all the chances which operative skill and the exercise of sound judgment can possibly afford. It is a mistake to look upon the failure of an operation simply as an untoward accident to the operator ; we must recollect that there is another party to the transaction, the patient ; and if harm befall him, either from deficient skill, lack of pru- dence, or too biased convictions on the part of his surgical attendant, surely there is matter of self-reproach for him in whom he trusted. If, on the other hand, the surgeon acts on full consideration of the facts attending each individual case, with a wide knowledge of the general practice of others, with proper reliance on his own experience, and an earnest seeking after his patient's good ; then indeed he has done all that man can do, and may humbly await the issue from the hands of the Almighty Arbiter of all things human. While it is incumbent upon the surgeon to do much that is merely mani- pulative in character, it must not be forgotten that, besides the operation, he must perform many duties which demand the exercise of the highest func- tions of the medical mind. He must be a good diagnostician, medical as well as surgical, and possess an accurate knowledge of morbid anatomy, and of general pathology. He must, above all things, exercise skill in searching for, and in detecting, visceral disease, for here a broad field has been opened to the view of the practical surgeon. In times past, it was perhaps too much his custom to confine his study to that only which was evident to the eyes and touch. He did not trouble himself greatly with those morbid processes which were developing in organs, it might be somewhat removed from the local seat of disease, but which were often related to or influenced by the proposed operation. Pathology has, however, made fast onward strides, and no operation can now be undertaken without a careful examination of the internal organs ; since the presence of lurking visceral disease, often unsus- pected, may forbid or modify surgical interference. The surgeon must more- over be a good therapeutist, and an expert clinical observer — ever prompt to catch the passing indication, ever ready to interfere on just occasion, or, with wise caution, patient to hold his hand. He should be sharp-witted in emer- gencies, and quick in his decisions ; for the tide of surgical accident runs fast, and if he falter or delay, precious moments may be forever lost. In short, the surgeon should be an Accomplished Physician as well as a Skilful Operator, possessing a comprehensive knowledge of diagnosis, pathology, and therapeutics ; with less he can neither do justice to his patient, nor satisfy the demands of his own conscience. Preparation for an Operation. A certain amount of risk to life accompanies all surgical interference. It is present in a marked degree in serious operations, and is not absent from those of apparently the most trifling character. Death may and has followed the simple introduction of a sound, the slitting of a contracted meatus, or the ligation of an apparently insignificant pile. It is, therefore, fit that the surgeon before operating should bear in mind the possibility of an untoward result, and that lie should seek by every means in his power to guard his patient against unfavorable chances. 1 1 is wisdom and judgment will be never more apparent than in the care and skill he may exercise in preparing the patient tor operation. Each case should be to him a study, and he ought PREPARATION FOR AN OPERATION. 439 carefully to investigate its characters. His conclusions should be deliberately arrived at, and the propriety of an operation must be quite clear to his own mind, before any announcement is made of its necessity. "When, however, it is evident to the surgeon that an operation should be done, it becomes his duty to state the facts to the patient, if he is of sufficient age, and in a pro- per state of mind, or, if not, to his family or friends. This should be done gently, and not abruptly, nor in a manner calculated to alarm. The necessity of the operation ought to be clearly explained to those concerned, and the chances of success and recovery fairly laid before them. It is also right that the surgeon should add to these statements the weight of his professional opinion, and he must not shrink from the responsibility of so doing, nor speak with hesitation or doubt. He must remember that the persons interested look to him for advice, and that as consultants they are fairly entitled to whatever help he can so render them. It is not to be ex- pected that the public can always decide wisely in matters affecting life or health; they must in the end depend upon professional judgment ; aud the professional utterance ought to be positive and unmistakable. It becomes, therefore, the duty of the surgeon to neither exaggerate nor underrate the possible peril of an operation ; he must think for his patient, and by his sym- pathy and the kindness of his manner win the confidence of the latter, so making him to feel that the arm of his surgical adviser is in truth one of strength, upon which he, in his own weakness, may safely lean. All this the surgeon may rightly do, not endangering his professional position, but rather strengthening it by his services as counsellor and friend. To the question which is so often put in minor cases, "Is there any danger in the operation?" he can truthfully answer, " Xot greater than in the chapter of the ordinary accidents of life, and whatever risk there is, I advise you to take it." The ultimate decision thus rests with the patient himself, but he may be fortified in mind, and upheld in a correct judgment, by the judicious and wise words of his professional attendant. In a general way, it is customary to divide surgical operations into two great classes. The first comprises operations of necessity, where life is at stake, and where surgical interference to be of avail must be immediate. Ope- rations for strangulated hernia, or for hemorrhage, or for foreign bodies in the air passages, or for many surgical injuries, are examples of this nature. The second class comprises operations of expediency, in which a slight delay in performance does not materially atfect the result. The removal of morbid growths, the correction of deformities, and many other operations in the great category of surgical diseases, are examples of the second order. In de- ciding upon operations of the first class, the surgeon must often assume a great responsibility. His professional duty demands that he should act deci- sively and promptly to save life ; and, in the absence of friends, or where the patient is very young, or from the very nature of the case incapable of being consulted, the surgical attendant must take the burden upon his own shoul- ders. Sometimes, in such capital cases, the advice of colleagues may be obtained, but where the urgency is very great, the surgeon shoald learn to depend fearlessly upon his own judgment, and to act in accordance with it. Time for Operation. — In ordinary cases, not those of immediate necessity, where an operation has been decided upon, the first question which presents itself to the mind is the time for its performance. Broadly stated, the answer to this question is, "As soon as the patient can be brought into the best state of mind and body." The first of these conditions must depend somewhat upon the patient's morale and his confidence in his surgeon. Many sufferers 440 OPERATIVE SURGERY IN GENERAL. are nervous and timid ; they dread the future, and shudder at the thought of an operation. Delay in these cases often makes matters worse ; the mind re- acts upon the body ; and, for them, the sooner an operation can be performed with safety the better. Other patients may be less fearful of results, and may seem to be stoical, almost indifferent. These not unfrequently ask time for consideration, and, having reflected, come calmly to a decision, and place themselves in the hands of the surgeon with quiet confidence and bravery. Preparation of Patient. — The general bodily health of one who is to undergo an operation must always be most carefully looked to, and all pre- cautions taken to bring it into the best possible condition. Every operation, no matter how slight it may be, presupposes some extra strain upon the con- stitutional powers, and the resources of our art should be taxed to meet this demand. Unfortunately, it often happens that the very occasion for surgical interference is in itself a cause of impairment of vital strength, and unneces- sary delay in operation is therefore to be deprecated. In hospital practice this is especially the case. Patients* enter the wards with impaired nutrition, enfeebled by pain and suffering, and exhausted by chronic suppuration. The effort to improve their general state seems to be a laudable one ; but even here mistakes may be committed ; for it is undoubtedly true that too pro- longed a residence in hospital is often productive of injury rather than of benefit to the patient. For the first week or ten days, he may seem to im- prove, but it is a matter of common experience that after that period much change for the better is, as a rule, scarcely to be looked for. It would seem therefore wise, in such cases, not to defer unduly an inevitable operation, but to proceed to its performance, in the absence of positive contra-indications, as soon as the secretions have been brought into tolerable condition. The re- moval of a source of irritation, or of a drain upon the constitution, will often do more to bring up a patient than any prolonged course either of dietetics or of therapeutics,"and that this is true, is amply shown by the success which proverbially follows secondary operations. Rest. — The influence of rest of mind and body, in fitting the latter to pass safely through the perils of an operation, must not be overlooked. The quiet of a day or so in bed permits the patient to recover from the fatigues of his daily work, and to obtain that necessary sleep which has sometimes been cur- tailed by the exigencies of labor. Overworked organs, and notably the heart, pass into a condition of repose ; excited or perverted functions are soothed or corrected ; local congestions are relieved ; and, in short, body and mind are alike benefited by the state of true physiological rest thus brought about. Pain, which may have been aggravated by locomotion, becomes less, or disappears : and the patient acquires that custom or ability to remain tranquilly in bed which may become essential to his future welfare. Nothing is more detri- mental to the success of an operation than after-restlessness and jactitation, and the exercise of patience, and practice in remaining still in bed, is a matter of more importance than it is usually considered. During this period of rest, too, the medical attendant has ample opportunity for familiarizing himself with his patient, and for acquiring that knowledge of him which may have a direct bearing on the after-treatment. lie is enabled also to judge of his con- stitutional condition, byrepeated physical examinations, and to form thatcor- iv. t estimate of his strength or weakness which may prove of so much value in the future conduct of the case. It is a matter of everyday observation that where operations arc hurriedly undertaken, without due investigation of the patient's condition, they are apt to be attended by perils which might have been avoided by more careful examination. The writer can recall case upon ANESTHESIA. 441 case, where the happy results of serious operations have heen attributed to mere skill at the time of performance, when in truth they were not a little due to the previous painstaking and repeated examinations of the patient, and to the careful and watchful study of his idiosyncrasies. Preliminary Treatment. — Deferring for a moment the subjects of the risks of operations, and the causes influencing their results, it ma} 7 be well to inquire what preliminary steps must be taken to put the patient in the best condition for the operation, when the latter is imperative, or when it has been decided upon as judicious. If the operation be one of emergency, such as herniotomy, or tracheotomy for urgent cause, preparation in a general way can scarcely be attempted. The surgeon must do his best to save life already endangered, and the patient must take his chances, such as they are. On the other hand, if the case be one of a chronic nature, certain useful precautions before opera- tion may be attempted. If the patient is in poor condition, and if time admits, the requisite diet, stimulus, and tonics may be employed, and the rest already referred to enjoined. The secretions may be attended to, and the bowels regu- lated as demanded. All previous medication, which may be inappropriate to the time of operation, should be stopped ; and a sufficient interval allowed for the elimination from the system of such drugs as digitalis, arsenic, the iodide of potassium, and the like. If the case is one of injury demanding amputation, and the patient has not yet reacted, the bleeding should be con- trolled, and such stimulus administered as will bring about reaction, and re- lease the sufferer from the state of shock. The advisability of administering stimulus just before operation is a ques- tion which has been much discussed, and on which different opinions are now entertained. By some, a parallelism has been affirmed between the effects of alcoholic stimulus and those of the anesthetic, especially sulphuric ether; both being regarded as agents which secondarily depress the action of the heart. Yet it is probable that the great majority of practical surgeons look favorably upon the administration of whiskey a short time prior to operation, especially if with the stimulus a small amount of opium is ad- ministered, either by the mouth or hypodermically. Clinically speaking, this conjoined exhibition of alcohol and opium is probably judicious, since it would seem to exercise a triple influence : In the first place it appears to lessen the shock of operation ; in the second it tranquillizes the patient after the operation, and prevents or soothes the subsequent pain ; and in the third place it expedites anaesthesia, and lessens the amount of ether necessary to be given. The testimony of many excellent surgeons seems to be conclusive in this direction, and in such a matter mere theoretical opinions cannot have weight when opposed to the direct results of clinical experience. In admin- istering stimulus, care should be taken to give it three-quarters of an hour or an hour before operation. If given later than this, it may cause nausea and vomiting as the inhalation of the anesthetic progresses— always an annoying complication, and peculiarly so at the beginning of an operation. Anaesthesia. It would be out of place in this article to enter upon the history of surgical anesthesia, or to discuss the priority of claim of those with whom it origi- nated. It is sufficient to say that its discovery originated in Hartford, Con- necticut, in 1844, and that its first practical application for surgical purposes was made in Boston about the year 1846 — the agent then employed being sul- phuric ether. In the following year the anesthetic qualities of chloroform 442 OPERATIVE SURGERY IN GENERAL. were announced by Professor Simpson, of Edinburgh. Since that time, the value of these two agents has been universally recognized. Throughout Europe, until quite recently, chloroform has been preferred by surgeons*; while in America the professional mind has been greatly divided as to the relative value of the two agents. In the northern portion of the country, ether is probably the favorite agent, while in the south and west the predi- lection is in favor of chloroform. The merits of the rival agents may be thus briefly summed up : Both produce complete anesthesia, but ether is un- doubtedly the safer agent. It is, however, far more bulky, and consequently more difficult of transportation. It is, therefore, not so well adapted as chlo- roform for use in military or country practice. It is slower in its action, and more disagreeable than chloroform ; and its use is attended by more strug- gling and rebellion on the part of the patient. The stimulating action of ether is felt largely by the nervous and respiratory systems, and on the latter it sometimes produces much irritation. The action of the heart is also stimu- lated by ether, and in this respect it differs from chloroform, which is apt to cause cardiac sedation. It seems, therefore, that the use of ether as an anaes- thetic is indicated in cases attended by nervous shock, and also where there is cardiac weakness, the result of fatty changes or of ventricular dilatation. Comparison of Ether with Chloroform. — The primary excitant effects of ether are shortly followed by secondary sedation. This is at times aggra- vated by the tendency to nausea and vomiting, which occasionally is persist- ent, and which it is not always easy to check. Chloroform, on the other hand, is free from most of these objections. Its odor is agreeable, and its first effects sedative ; it acts promptly, and, as a rule, without causing that degree of excitation and muscular action which is so characteristic of ether. It proba- bably causes less nausea and gastric irritation, and it acts kindly and safely upon children. The great matter, however, in the choice of an anaesthetic is that of safety, and the one question to be answered is simply this : Which carries with it the least peril to the life of the patient, ether or chloroform ? — and here it must be stated that the condition of anaesthesia is always one of some danger, and that no anaesthetic is altogether safe. A patient in a con- dition of absolute anaesthetic unconsciousness, is necessarily in more or less jeopardy of life, and it is incumbent upon the operating surgeon never to lose sight of this fact. It is to be feared that the comparative impunity which has attended the long-continued use of anaesthetics, tends to beget in the mind of the surgeon too great a confidence in their safety, and that he sometimes realizes only when it is too late that this blind confidence may be unfounded. Especially is this the case when the exhibition of the anaesthetic is submitted to unskilled hands, and that this is very often done it is impos- sible to deny. In reality, the assistant who has charge of the ether or chloro- form, plays a part in the operation scarcely secondary to that of the surgeon himself, for on his skill, watchfulness, and judgment, the welfare of the pa- tient to a great extend depends. It is, therefore, incumbent upon the operator to devolve this important duty only upon one who is qualified to undertake it ; and the assistant himself must devote his whole mind to this given task. lie ought to do nothing else, and should not permit his attention to wander for a moment from the patient before him, nor attempt to render any other assistance in the operation than that to which he is particularly assigned. He must carefully watch the breathing of the patient, and moderate or sus- pend the anaesthetic on the slightest evidence of its irregularity. He should be on the watch against retraction of the tongue, and, if this happens, he must blatantly draw it forward with a hook or forceps, and see to the removal of mucus from the mouth or fauces. Not unfrequently, spasm and closure of ADMINISTRATION OF ETHER. 443 the larynx occur, evinced by the lividity and discoloration of the lips and ears. This can usually be relieved by turning the head, or by pushing for- wards the angles of the jaws, and by making pressure upon the chest, thus exciting afresh the respiratory efforts. The pulse must be watched as well as the breathing, especially if the patient have a fatty heart, or any other form of organic cardiac disease. While, in the great majority of cases, ether will accomplish all that chlo- roform can do, and indeed all that can be desired, and, as we think, with a greater degree of safety, there are nevertheless instances in which it seems proper to employ chloroform,. As is well known, ether vapor acts as an irritant to the lungs even when healthy, and its use is sometimes followed by more or less bronchitis. It should not, therefore, be resorted to when any pulmonary irritation or inflammation already exists, but preference should be given to chloroform. Acute oedema of the lungs, terminating fatally in a few hours, has occurred after, the inhalation of ether to the writer's knowledge, and it is probable that most of the few deaths charged to the use of ether have in reality been due to this cause. An examination of the lungs and of the heart must consequently be made before ether is given. The use of ether in cardiac disease has also been questioned, but here hesitation need only be felt when there is a tendency to overloading of the right heart ; and there does not appear to be any reason for not giving ether when the heart is weak or tatty. Indeed, its action as a cardiac stimulant would rather favor its employment in these cases, but under such circumstances its effects must of course be carefully watched. Chloroform is peculiarly adapted for children ; upon them it acts readily, and, as far as is known, safely. First Insensibility from Ether. — Before describing the mode of adminis- tration of ether and chloroform, it may be well to allude here to one of the effects of ether inhalation which is not as widely known as it deserves to be namely, the transitory state of first insensibility produced by a few whiffs of ether, originally pointed out by Dr. Packard, of Philadelphia, 1 who has noticed that, if, when a patient begins to inhale ether, " • • • • lie be told to hold up his hand, and the direction be repeated as often as necessary, for a little while he will obey, but soon there will be a failure of voluntary power, and the hand will drop. At this instant there begins a very brief period less than a minute — of total insensibility. If the inhalation be now suspended, conscious- ness will return at once, and the patient will come to himself without headache, nausea, or any other of the disagreeable effects so commonly experienced after the prolonged administration of the anaesthetic. During this brief period of ana3sthesia, the 'first insensibility,' as I have called it, any operation may be performed as painlessly as if the inhalation had been carried to the fullest extent I feel warranted in asserting that this first insensibility invariably occurs ; that it is absolute and profound, though brief; and that it may always be detected and taken advantage of by careful observation and prompt action." From a personal experience, the writer can testify to the entire accuracy of Dr. Packard's statements, not only as to the occurrence of this short in- sensibility, but also as to its thoroughness and completeness as regards any sensation of pain from cutting operations. Administration of Ether. — In obtaining anesthesia from ether, not a little depends upon the skill of the administrator. If the patient be frightened or roughly handled, he naturally rebels, and the process is necessarily pro- longed, and therefore to a degree imperfect. Here, as in all other surgical 1 American Journal of the Medical Sciences, July, 1877, and April, 1878. 444 OPERATIVE SURGERY IN GENERAL. procedures, the first step should he to win the confidence of the patient, and to impress him by gentleness rather than by force. In the early days of ether, various complicated forms of apparatus and mouth-pieces were con- structed to assist the inhalation. In America these have given way to methods of greater simplicity — the employment of the folded towel or the sponge. Perhaps the simplest plan is the use of a towel folded and pinned in the shape of a cone ; the sides of the cone may be stiflt'ened by placing within the folds of the towel a layer or two of newspaper. A chamber is thus formed for the retention of the ether vapor, the base of the cone being sufficiently large to thoroughly cover the mouth and nostrils, and to include the lower jaw. The eyes of the patient should be covered with a light nap- kin or handkerchief at the beginning of the inhalation. This precaution shuts out the observation of external circumstances, and has a very marked effect in hastening the period of insensibility. It is well also to divert the attention of the patient by directing him to count slowly "one, two, three," and so on, following the lead of the administrator. The expiratory effort thus induced is followed by a corresponding inspiration, and full inhalation of the ether is thus greatly favored. Few persons can count as high as twenty-five or thirty without feeling the effect of the agent, and scarcely any can reach sixty or seventy without becoming unconscious. The best test of the proper period for operation having arrived is insensibility of the eyeball and general muscular relaxation. The ether can then be withheld or pushed, as the cir- cumstances of the case may indicate. The unconscious occupation of the mind by the counting method will be found preferable to the usual coaxing attempts, or the futile advice to the patient that he should try and go to sleep, which is commonly under the circumstances very .difficult for him to accomplish. Ether can also be administered from the folds of a tow r el with- out the formation of the cone described. This is not so perfect a method, lacking, as it does, the formation of a true ether atmosphere, and is accom- panied by more resistance and struggling of the patient; nor does it seem to possess any of the advantages of the method already described. When the patient is inclined to resist, or takes ether badly, the resistance can usually be overcome, if the exhibition of the vapor be begun slowly, and if the cone, towel, or other vehicle, be gradually brought nearer to the face, as he becomes accustomed to the ether odor. The patient should always be placed in the recumbent posture before etherization is commenced ; it is a mistake, not unaccompanied by risk, to attempt anaesthesia in the sitting or semi-re- cumbent posture. Of course, all constraint of clothing should be removed from the neck and waist, and false teeth should be taken out, as they are lia- ble to become displaced; and instances have occurred in which they have been swallowed during insensibility. If any operation is to be attempted within the mouth, involving the separation or holding apart of the jaws by corks or like substances, the latter should be controlled externally by strings. An in- stance occurred not many years since in Philadelphia, in which a cork used as a gag was drawn into the larynx by violent inspiration, producing an im- mediately fatal result. In using ether it is well to watch the pulse carefully as well as the breath- ing. If the pulse is good, the patient is doing well. If it becomes feeble or infrequent, the ether should be withdrawn and the access of air permitted. So also if the lividity of the face increases, or if laryngeal spasm occurs, more aii- must lie given. When mucus collects in the mouth and fauces, and there is usually a, good deal, it must be removed; and if from any cause the breath- ing seems to be interfered with, or deficient, access of air must be allowed by opening the mouth or drawing the cheek out, and seeing that the tongue is not retracted. Vomiting when it occurs should be met by turning the head AFTER-TREATMENT OF ETHER ANESTHESIA. 445 to one side, so that the mouth may be dependent, when the vomited matters may easily be gotten rid of. In using ether at night, care should be taken to keep the lights above the level of the patient's body, so as to prevent ignition, the ether vapor being heavier than air. So also in operations demanding the application of the actual cautery, the possible ignition of the ether vapor should be carefully guarded against. By practical experience, it has been shown that this acci- dent may be prevented by tanning the air in front of the patient's mouth for a moment or so before the approach of the hot iron. Nevertheless, the utmost care in this respect must be observed. The same remarks apply to the careless use or too great proximity of the spray-producer in Lister's method, which has also on more than one occasion set fire to the ether. Indeed, it may be questioned whether, in operations where ether is employed, the steam atomizer should be used at all, unless in those upon the trunk or extremities. The powerful atomizer arranged by Dr. J. Solis-Cohen is free from this objection, since in it the spray is produced under atmospheric pressure, without the employment of a name. The exhibition of ether by means of a large sponge, once so universally adopted, is not now generally resorted to. It accomplishes the purpose well enough, but is attended by wasteful expenditure of the anaesthetic, and by too great an impregnation of the air of the room. The amount of ether which it is proper to use in an operation, of course varies greatly. When it is judiciously administered, when its effects are carefully watched, and when its exhibition is relaxed from time to time upon the appearance of too marked a lividity of face, its influence may be continued for a very considerable time. In the treatment of a subclavian aneurism by compression exerted by a tourniquet, to the extent of cutting off all arterial impulse, the writer has, on several occasions, kept the patient well etherized for six, seven, or eight hours at a time. But it must be remembered that no anaesthesia is altogether safe, and the risks in such a case must be deliberately weighed against the possible advantages to be gained. Occasionally patients are met with who seem to have an intermittent respiration, with a tend- ency to lividity. With such persons extraordinary care must be used in the administration of an anaesthetic, and atmospheric air must be freely admitted. After-treatment of Ether Anaesthesia.— A matter not to be overlooked in the use of anaesthetics, ether as well as chloroform, is the after-care. A patient should not be left by himself, or unwatched, until he has regained his consciousness, or until the respiration, circulation, and color of the skin have been fairly established. Very frequently, anaesthesia is followed, particularly in children, by prolonged sleep, but the surgeon will feel more comfortable in his own mind if the patient has once fairly reacted into consciousness, before being allowed to pass into slumber. Sponging the face with cold water, or slapping the face and chest gently with a wet towel, will usually bring the patient to himself, and when once he has been sufficiently aroused to answer questions put to him, immediate danger may be regarded as having passed away. In etherization, however, there is always the possibility of the subse- quent pulmonary complications already alluded to, and it is difficult to say what precautions can be adopted to prevent the development of the acute cedema of the lungs, -which, once established, is usually so destructive to the patient. Fortunately, however, looking at the vast number of cases in which ether is given, with an almost absolute impunity, this accident is very rare ; yet it is still a contingency which may occur. In cases in which prolonged etherization is necessary, Dr. John Ashhurst directs the subsequent adminis- tration of carbonate of ammonium in doses of five grains every half hour, 446 OPERATIVE SURGERY IN GENERAL. hour, or two hours, according to circumstances, until all risk of pulmonary congestion and oedema has passed away. There is one other untoward effect of etherization, which is sometimes met with, and which does not appear as yet to have been fully studied. It is the suppression of urine, and uraemic poisoning, met with in cases where disease of the kidney has been pre-existent. To what extent this condition is charge- able to the ether used, or whether it is rather the result of the operation itself, is not altogether clear. It is nevertheless probable, that prolonged anaesthesia, * or perhaps we should say etherization, may interfere with the due elimination of the urinary constituents. A proper examination of the urine should, of course, be made before any serious operation is attempted, and, if organic dis- ease of the kidney be manifest, the operation if done at all should be accom- panied by as short a duration of anaesthesia as is consistent with the circum- stances of the case. Administration of Chloroform. — In Europe, and in a large section of America, and in the military and naval services of different countries, chloro- form is the favorite anaesthetic agent. In the late civil war in this country, it was employed by both combatants almost to the exclusion of ether in armies in the field, and in very many of the large hospitals in the rear. The convenience, portability, prompt action, and pleasant effects of chloroform are everywhere admitted, and have already been referred to. It remains to consider its clanger ; and that it is dangerous is. conceded by all, even by those who are loudest in its praise. Very many excellent surgeons can be found who have used chloroform for years, without an accident, and who have never witnessed an accident at the hands of others from its employment. Yet the surgical mind is undoubtedly being influenced by the growing death-roll which has marked its use. In Great Britain especially, where chloroform has for so many years been the favorite anaesthetic, a distrust of the agent is springing up, and the employment of sulphuric ether is becoming daily extended. The pages of the medical press evince this altered opinion most distinctly, and that it is a judgment based upon conviction, no one can doubt who is conversant with the honesty, good faith, and wide experience of the British medical profession. The administration of chloroform by surgeons in this country, and prob- ably by the major portion of those who use it abroad, is effected by pouring a drachm of the drug upon a piece of lint, or a folded towel of two or three thicknesses. This is at first held three or four inches from the face of the patient, and gradually approximated until within an inch of the nose. Tree circulation and admixture of air with the chloroform are thus permitted. The defect of this mode of administration, as stated by Mr. Erichsen, is that there is no possibility of estimating the true proportion of the admixture of air and chloroform, and that the administrator can only judge by his observa- tion of the resulting effects. To remedy this uncertainty, various inhaling apparatuses have been designed, the best of these, to quote the same authority, being those of Messrs. Shaw and Clover. In that of the latter, the mixture of 30 to 40 minims of chloroform with 1000 cubic inches of air is ingeniously accomplished, and from a bag charged with this mixture, the inhalation by the patient is effected through a tube and mouth-piece. The first effect of chloroform is an excitant one upon the nervous system, and upon the action of the heart. This is soon followed by motor and sensory paralysis, by insensibility, and by a sedative effect upon the heart, with feeble respiration, and a state <>i' greater or less asphyxia. At this time, if the chloroform be unduly pressed, there is danger of death resulting. LOCAL ANESTHESIA. 447 The occurrence of stertorous breathing indicates that the administration ot the chloroform should cease. The exhibition of chloroform is often followed by effects of an annoying character. Thus gastric irritability, accompanied by nausea and vomiting, may supervene ; this does not happen as often as after the inhalation of ether, but, when it does occur, it is apt to be severe and depressing. Slight congestion of the lungs is also met with, as in the case of ether administra- tion, but it is not so common, nor, as a rule, so irritating. Cephalic troubles also occasionally take place. The evil effects of chloroform are, however, not to be found so much in its secondary consequences, as in the liability to death at the time of administration, or during or after an operation. When death thus occurs, it is usually immediate, and cannot be prevented ; and it may be charged either to asphyxia, to coma, or to syncope. It has taken place not unfrequently in those who seemed to be the most healthy, and after the performance of the slightest operations and surgical procedures, such as the amputation of a finger or the passage of a catheter. It is impossible from any previous examination to predicate with certainty the chances of danger, and it would seem also equally difficult to treat them when once fairly developed. As we have already said, in all anaesthesia there is some danger, and in the anaesthesia from chloroform the chances of danger are greater than those attendant upon the use of its rival — ether. Should it unfortunately happen, during the administration of chloroform, that any of the dangers referred to are present or threatening, the most active measures must be adopted to check them or ward them off. The chloroform should be immediately withdrawn ; fresh air admitted ; cold water dashed upon the face ; the tongue, if retracted, drawn forward ; and prompt efforts at artificial respiration instituted. If the effect of the drug fall chiefly on the heart, as evinced by the state of syncope, its action should be stimulated by electro-galvanism, the poles of the apparatus being applied on the chest and diaphragm and over the spine. Mr. Erichsen, in his valuable remarks on this subject, speaks of the use of nitrite of amyl, referring to the . experiments of Dabney. From what I have seen of the effect of this drug as an antidote to an overdose of bromide of ethyl, an agent which is certainly as sudden and fearful in its action as chloroform, and probably much more so, it would seem that the nitrite of amyl exercised a most powerful influence in raising the patient from a condition of syncope or asphyxia, and in establishing reaction. The quantity employed in the cases referred to was twenty or twenty-five drops, and its action was immediate. Local Anaesthesia, the result of extreme cold produced by different methods, may sometimes be advantageously employed in slight operations, such as the opening of abscesses or the removal of a toe-nail. It is, however, not applicable to operations in which deep tissues are divided, but is limited to skip-deep incisions only. It can be conveniently brought about by the appli- cation of a piece of ice on which a little common salt has been sprinkled, covered by a single layer of a towel, and kept steadily upon the part for three minutes. It can also be obtained more perfectly by the spray of pure ether, or by that of rhigolene. The latter will freeze the tissues to some depth, but perfect congelation, at times, renders it difficult to distinguish, during operation, abnormal from healthy tissues. This excessive freezing is also sometimes followed by too great a reaction, and by sloughing. For these minor operations, when merely a temporary and, as it were,"local insensi- bility is desired, the transitory effects of the inhalation of ether already described may be preferably substituted. 448 OPERATIVE SURGFRY IN GENERAL. Other Means of Producing Anesthesia. — Allusion has already been made to the use of the vapor of bromide of ethyl as an anaesthetic agent. Its properties in this respect were first demonstrated by Mr. Nunnery, of Leeds, who, in 1865, used it in surgical operations. The difficulty of its prepara- tion and its great cost led, however, to its abandonment, especially as at that time it did not appear to possess any qualities which rendered its employ- ment more advantageous than that of other substances. In 1879, its use was revived by Drs. Levis and Turnbull in Philadelphia, and a wide application of its powers was speedily made. At a first view, it seemed that the long- desired anaesthetic had at last been found in an agent which was not disagree- able to inhale, which produced anaesthesia with great promptness and without much nausea or vomiting, and from the effects of which the patient recovered as rapidly as he had passed under them. More extended observation, how- ever, showed that the employment of the new agent was fraught with danger, and that its seductive qualities were more than counterbalanced by their attendant perils. Its exhibition was marked by rapidly developed anaesthesia, accompanied by much muscular rigidity and spasm, apparently of a tetanic character, and, at times, reaching almost to opisthotonos. While in the great majority of cases patients did well, still, instances occurred in which they w T ere rescued from the combined condition of coma and asphyxia only by the most active measures, including the use of the nitrite of amyl. Excellent and powerful as the agent was in many respects, its continued use seemed to be undesirable on account of the certain peril which attended it. Its em- ployment has, therefore, been abandoned, and, as we think, wisely. The employment, under the name of chloric ether, of a mixture of ether and chloroform, has been strongly advocated by many surgeons. It has been stated that, by the admixture of one part of chloroform to five of ether by weight, a compound agent is obtained which combines the advantages of ether and chloroform, and is yet free from the objections to both — the stimulating effects of the former counteracting the depressing influences of the latter. By some the proportion of chloroform in the mixture is greatly increased. There is no doubt that "chloric ether" acts promptly and effi- ciently, but it is questionable whether the dangers incident to chloroform do not still exist, since it is probable that the chloroform acts in its characteristic manner, unchanged by its combination, or rather mixture, with ether. From a prolonged experience with this compound agent, the writer believes that the alleged immunity to danger is not obtained, and that the chloroform still exerts its effects as chloroform per se. Nitrous oxide is occasionally employed as an anaesthetic. Its use is, how- ever, greatly restricted by its transitory effects, and by the rapidity with which the patient emerges from its influence. It is only suitable for the slightest operations, and possesses no advantages over ether employed as already described. Mode of Conducting an Operation. In the performance of the operation itself, the skill, readiness, and self-com- mand of the Burgeon are tested to the utmost. He should always be master of the situation, and should stand prepared for every emergency. Order must characterize all his arrangements, and every step must be well considered beforehand, and executed with promptness — free from hesitation, and yet de- void <>)' all appearance of haste. The same deliberation should characterize the liual as the initial *\v\)* «.f the operation. Sir James Paget, in his admi- rable chapter on the "Calamities of Surgery," has so vividly portrayed that MODE OF CONDUCTING AN OPERATION. 449 condition of mind which every operator must have felt towards the close of a serious operation, that his words deserve to be indelibly imprinted on the mind of the surgeon. He says : — " Be quite clear about carrying out carefully the last stages of all operations. I sus- pect that everybody in operating, when he has passed through the sort of mental tension in which he performs the most difficult part of what he has to do, when his attention has been completely occupied in some difficult task to be achieved, next feels his mind relaxed, his attention less keen, less ready for exercise than it was before. Be sure that these are times of danger to your patient ; as soon as the attention ceases to be as keen as possible, you are in risk of doing some mischief." Few operations can be performed by the surgeon alone. In most cases he requires professional aid, and this should be rendered by trained assistants, accustomed to operations, and, if possible, in the habit of assisting the indi- vidual operator. These gentlemen should be efficient but not officious. Their duties should be assigned to them 03' the surgeon himself, and should be per- formed by them in perfect quiet, and in a manner calculated to assist and not to embarrass the operator. An able assistant is of the greatest use, while an inefficient one is only a source of annoyance to his principal. The time most suitable for operation is near the middle of the day, as the light is then at its best. Care should be taken that the patient's breakfast has been a simple one, and that his stomach is not overloaded when the period for operation has arrived. For most operations the patient should be in the recumbent posture, as loss of blood is then more readily borne, ana?sthesia can be best effected, and there is much less chance of syncope. He should be placed on a table of proper height, and one can usually be formed by utilizing articles of room furniture, such as two small tables, or a table and washstand, and then covering them with blankets. The improvised table can then be brought near to a window, and in full light. Attention to the matter of the operating table is of more consequence than is usually supposed ; for it enables the surgeon to discharge his duties in comfort to himself, and without that strain and weariness in the back which is invariably felt when the operator is obliged to bend down in a constrained position over a low bed. Attention at the same time must be paid to the patient's comfort, or rather to his well-being, while on the table and under the anaesthetic. He ought not to be unnecessarily exposed to the air, but should be kept warm. The trunk and the lower extremities must be carefully covered, since there is always, during an operation, a tendency to a decrease in the temperature of the body. In operations upon the urinary and genital organs, when the lower part of the body must be uncovered to a certain extent, the legs of a pair of drawers, divided in the crotch, can be drawn over the lower limbs. If laxity be permitted in this respect, and the temperature of the body be allowed to fall unduly, an additional element of shock is created. Too much precaution cannot be exerted in this matter, particularly in the case of delicate persons, women, and children. The immediate dangers of operation are hemorrhage and shock. The former must be prevented by every possible means, as the loss of an extra ounce or so of blood is often the turning point in a case. In children particularly it should be guarded against, since they bear bleeding very badly. Fortunately, in Esmarch's elastic bandage we have a means of practising many serious ope- rations without the loss of blood. A new department of surgery has thus been created — bloodless surgery — which is applicable not only to amputations, but indeed to all operations upon the extremities. It is scarcely necessary to describe the apparatus here. As is well known, it consists of two elastic ban- dages, one of which is wound around the limb from its distal extremity to vol. 1.— 29 450 OPERATIVE SURGERY IN GENERAL. above the point of operation, thus expelling the blood from the part, and leaving the tissues completely exsanguine. The second rubber band, thicker and stronger than the former, is then carried two or three times around the part, with sufficient tension to thoroughly compress the soft tissues, and cut off the circulation in the arterial trunks. The first band is then removed, when the operation can be performed without bleeding, and with the same facility as on the limb of a cadaver. In applying the second constricting band, care must be taken not to draw it too tightly ; if this be done, there will be danger of sloughing ; this is not an imaginary evil, but has occurred, and the resulting ulcers have been deep, unmanageable, and difficult to heal. The broad thick band is preferable to the tubing, which has been so much used, since the latter on being stretched acts as a cord, and is apt to produce mis- chief. If the reader doubts this assertion, let him try the experiment of the application of these rubbers upon his own person, and he will be quickly con- vinced of the power of their action. There is another precaution which it is well to observe in the use of the upper constricting band ; this is, not to ap- ply it when the muscles and tissues which it constricts are in a state of shortening or flexion. If this mistake be made, and the distal portion of the limb be afterwards extended, as may be necessary during an amputation, injury or laceration of the upper structures may take place, thus causing troublesome after-consequences, or even deep sloughing. A question has arisen as to the propriety of making much pressure, with the first bandage of Esmarch, over suppurating or gangrenous tissues, or even malignant growths, and it has been urged that, by so doing, disorganized and morbid elements might be forced into the general circulation. Whether this be so or not, it is difficult to say ; at the same time, it is a contingency which it is worth while for sur- geons to bear in mind. A plan of emptying a limb of blood by simply elevating it to the highest point, and then stroking it for a minute or more in the direction of the venous circulation, has of late years been practised in Great Britain, and is described by Mr. Erichsen as "Lister's method." It is one, however, which has long been familiar to the American profession, and was witnessed by the writer in the hands of Pancoast of Philadelphia, nearly thirty years since. Before beginning an operation, the surgeon should see that the proper in- struments have been laid out, and that they are in good condition, and, if he intends to employ complicated apparatus, that it is in working order. Neglect of this precaution is often attended with great annoyance, and these matters should not be entrusted to an assistant, but should pass beneath the sur- geon's own eye. If the operation be a cutting one, all incisions must be deliberately planned, and made without faltering. Haste should be avoided, but each stroke of the knife should be an onward step in the operation, and piecemeal or imperfect work ought not to be permitted. The first cut should divide the entire thickness of the skin, and the succeeding one, if the opera- tion be a deep one, as the ligature of an artery, should be of the same length. The division of the deep structures will thus be as long, or nearly so, as the first incision, and full opportunity will be afforded the operator to make the necessary search at the bottom of the wound. When this course is not fol- lowed, the lowest portion of the wound will often be so contracted as to pre- vent full examination. The wound will in fact be a cone, with the apex downwards, a most undesirable result. In making dissections and incisions, if the bloodless method is not adopted, it is well to tie the larger vessels as they bleed, while (lie smaller ones can be left until the conclusion of the ope- ration. For the ligature of vessels, the ordinary silk or linen thread, or the carbolized cat-gut ligatures, may beemployed. Acupressure pins may at times be conveniently substituted for the ligatures, not only for the purpose of con- MODE OF CONDUCTING AN OPERATION. 451 trolling existing hemorrhage, but also for preventing it in regions where Esmarch's bandages arc not applicable. Thus if a pin be passed beneath the facial artery as it mounts over the lower jawbone, plastic procedures may be readily practised on the face with little loss of blood; and in the same man- ner, operations around the mouth and lips may be greatly facilitated by judi- ciously transfixing the adjacent tissues with acupressure needles, around which strong compressing threads are carried. In cleansing the wound, sponges may be used, but they "should then have been previously washed in carbolic acid solution to prevent infection of the wound; or clean napkins may be profitably substituted. In the removal of tumors, as for example of the mammary gland, bleeding can often be prevented to a great degree by tearing the tissues with the end of the finger, rather than by cutting them with the knife. When enucleation is thus effected, the vessels contract, there is but little bleeding, the outlying diseased portions come away with the affected mass, and the operation is quickly over. Under certain circumstances, where the tissues are tight, and bind, and the divulsion cannot be conveniently effected by the end of the fin- ger, knives with silver or rounded blunt steel edges — " dry dissectors" — may be resorted to. When after-oozing takes place, from incised wounds, or from the face of stumps, it may be checked by the use of cold water or ice, or better still by sponges or napkins wrung out of very hot water, or by hot water it- self. In the application of the actual cautery, care must be taken to avoid the ignition of ether vapor, when it is the anaesthetic employed. Deep caute- rization may at times be conveniently effected by Paquelin's thermo-cautery, but this should be tested before operation, since it often fails to become heated at the critical moment. The proper fluid to be used in this instrument is painter's benzine of 0.715 specific gravity. Wounds of operation, particularly when of any extent, should not be closed until all bleeding has ceased, since the presence of blood interferes with immediate union. For drawing the lips of the wound together, sutures of silk, or fine silver, or soft iron wire, may be employed. The latter should not be used upon the face or exposed parts, since the oxidation of the iron leaves a small discolored point which does not disap- pear for some time. When possible, the sutures should be inserted before the patient recovers from the influence of the anaesthetic. Perhaps the most important matter in the healing of wounds is the estab- lishment of free drainage. Surgeons may be greatly divided as to the par- ticular form of after-dressing, but nearly all agree as to the necessity of drainage. It is therefore incumbent upon the operator to see that his wound is not closed too tightly, but that a free escape is afforded for all fluids which may form. In deep wounds, this can be best accomplished by the insertion, lief* >re closure, of a small, perforated, rubber tube, through which these fluids can escape. After six or seven days, the tube can be gradually withdrawn by cutting off half an inch or an inch daily ; when the drainage through its track will be found sufficient to keep the wound free. If the rubber tube be left too long in situ, it may possibly serve to keep up the purulent discharge. The after-dressing of the wounds of operation has been a matter of much discussion, and the surgical world, sometimes influenced by fashion, epidemic opinion, or honest conviction, has been greatly divided. Poultices, water- dressings, dry dressings, earth dressings, cerate cloths, open air dressings, and many other forms of topical application, have all had in their day active .sup- porters, and have doubtless furnished excellent results. At the present mo- ment, the antiseptic treatment of Professor Lister is on trial. It has a host of ardent partisans, many lukewarm supporters, and some, perhaps not a great many, opponents. Whether it has realized, whether it will realize, all that has been claimed, and all that is hoped from it, remains to be seen. But the 452 OPERATIVE SURGERY IN GENERAL. earnest and enthusiastic efforts of Professor Lister have already wrought great good to surgery, in many ways ; not the least heing in the care and cleanliness in the treatment of wounds, which he has taught, and in the personal obser- vation and attention he has enforced by his own example. As the antiseptic treatment of wounds will form the subject of a separate article, it is not neces- sary to -consider it further in this place. Yet apart from the antiseptic method in all its details, it is probable that, in a modified form, it can be made largely and conveniently available in the treatment of wounds of operation, and open injuries. A piece of lint saturated with carbolized oil, or carbolated solution, will answer every practical pur- pose, and may be substituted for the rather cumbersome special dressing of Lister. No matter what dressing may be resorted to, the surgeon must still remem- ber that it should at all times be inspected with repeated and scrupulous care; that soiled cloths, breeders of infection, must be at once removed ; and that absolute cleanliness of the wound and all its surroundings must be rigidly .enforced. If there be much suppuration, the carbolic acid spray from an ordi- nary atomizer can be advantageously employed. All dressings should be light, and in changing them great gentleness should be used to avoid disturb- ing the soft parts, and arresting or interfering with the process of union. If adhesive straps have been laid across the line of the wound, and it becomes necessary to change them, this should be done in accordance with the great indication, the preservation of local rest. Treatment of Patients after Operation. The after-treatment of operations- may conveniently be considered as local, and general. As regards the former, the part must be placed in the position of greatest comfort to the patient, and properly supported, while all strain upon the tissues is avoided. The position, too, should be selected so as to favor drainage, and the dressings should be as light, and as little cumbersome, as possible, while every attempt should be made to favor early union. If the sutures used are metallic, and are productive of little irritation, they may be left until it becomes evident that they are of no further service, or until they begin to cut out, when they may be removed. If the arteries have been tied with thread or silk ligatures, the latter must be left until it is apparent that they are sepa- rating or falling. They must always be handled with extreme caution, and no force should be employed to effect their dislodgment, for fear of pulling them off prematurely, and thus giving rise to bleeding which might prove troublesome. In arranging the threads, before closing the wound, it is well, as a rule, to carry them out either at the nearest point, or at the angles, and they should be laid straight in the wound ; care must also be taken to pre- vent them from felling into loops, or from becoming entangled one with another ; otherwise, in removing one which has fallen, an unsuspected ligature may be unduly pulled upon. It is well, too, to count the ligatures, and to be quite sure as the ease progresses that the full quota of threads has been taken away. Instances are not uncommon, where many ligatures have been applied, in which one or more have in some way or other become buried or hidden in the depths of the wound, and, to the mortification of the surgeon, have made their appearance by ulceration weeks after the wound had been regarded as firmly closed and cicatrized. When the carbolized gut ligatures have been used, their removal will necessarily be spontaneous and by absorption, and the surgeon need not trouble himself as to their coming away. Rest, support, drainage, cleanliness, the avoidance of unnecessary handling, with proper TREATMENT OF PATIENTS AFTER OPERATION. 453 attention to the ligatures and sutures, constitute in short the local after-treat- ment of the wound of operation. To these must be added constant watchful- ness to detect the development of abscesses, and the requisite incisions for their evacuation should any form. In fulfilling the above requirements, the surgeon must bear in mind that, while it is incumbent upon him to do what is neces- sary, and that promptly, on the proper indications, he must nevertheless ab- stain from officiousness or fussincss. After an operation has been finished, and the wound satisfactorily dressed, the patient should be placed in bed, well covered, and carefully watched until he has recovered from the effects of the anaesthesia. Until he has done so, he must not be left alone, or in the hands of an inexperienced assistant, or in those of a nurse. It is the duty of the surgeon himself not to leave his patient until he has recovered at least sufficient consciousness to answer questions. The general after-treatment now begins, and upon it the ultimate issue of the case in no little degree depends. The first general indication is rest: rest to body and mind, relief from excitement, and freedom from pain. There is no doubt that these ends can be best brought about by the exhibition of an anodyne, and in no better way than by the subcutaneous use of morphia. A hypodermic injection of from a quarter to a half grain, will usually be sufficient to prevent pain and soothe restlessness. In excep- tional cases more may be required, but the amount mentioned is usually sufficient, and, if not, it can be repeated. When it acts, the patient passes off into quiet sleep, and thus escapes the shock of pain which would otherwise greet him so unpleasantly on his recovery from anaesthesia. Of course, if an hypodermic have been given prior to the operation, this fact must be remem- bered in apportioning the after-medication. Xot unfrequently after operation a good deal of nausea is present from the effects of the ether or chloroform. This commonly passes off gradually in a few hours, but sometimes continues throughout the night and even into the next day. When prolonged, it is difficult of treatment and not readily amenable to drugs. Occasionally it is relieved by ice in small quantities, by a teaspoonful or so of brandy, by carbonated waters, or by sinapisms to the epigastrium. It is sometimes ameliorated by vomiting, although not always. In most cases of serious operation, especially if the nausea above described be present, the patient does not desire food of any kind, and, indeed, cannot retain it even if he forces it down. Great care must, therefore, be exerted in selecting the proper nourishment. It would seem that the diet most suitable under these circumstances was milk, or milk diluted with lime-water. This can generally be retained, is palatable to the patient, and gratefully assuages the thirst which is often so terrible to bear. Physiologically considered, too, it is that form of nutriment best adapted to cases where there has been much loss of blood ; in fact, it would almost appear to satisfy a natural craving. Few patients object to it ; and even those who at first say that they " cannot bear milk — it does not agree with them," yet take it willingly and even eagerly after the first trial. In administering milk, caution should be exer- cised as to the quantity. Too much should not be given at one time, but small quantities, repeated, and taken slowly. If the stomach be very irritable, an ounce and a half or two ounces every two hours will be sufficient. If the patient be very weak, brandy or whiskey can be given with the milk, or in alternate doses, according to the indications. Beef essence is not always well received by the stomach, nor are soups, however nicely they may be made. They are undoubtedly satisfactory articles of diet after the lapse of a day or two, but are not so well borne immediately after the operation. In many cases, particularly where thirst is annoying, acidulated drinks may be admin- 454 OPERATIVE SURGERY IN GENERAL. istered with benefit. The combination of milk with occasional small quan- tities of lemonade may at first thoughts appear to be somewhat incongruous, yet clinical experience fully asserts their value, especially in operations upon the urinary organs. As the case progresses, and as the patient improves, the diet may be increased in strength and quantity, and richer soups, the breast of a chicken, or the more digestible meats may be given. In every instance, the selection of diet must be governed by the circumstances of the patient. If there is a tendency to inflammation, it must be light ; while for those who are weak, or who have suffered much from shock or hemorrhage, fuller diet is demanded. A good deal can be left to the patient's inclination, for he can sometimes judge better than those who are around him as to what he can most easily retain on his stomach ; and his fancies in this respect should be considered when not obviously objectionable. Before operation, the patient should be instructed to empty the bladder. If this be not attended to, an early use of the catheter may be demanded, since many persons experience great difficulty in voiding their urine after operation. It is, perhaps, unnecessary to state that the bowels should be freely evacuated on the morning before the operation. This is all the more to be insisted upon, since constipation usually follows operation. This may be due in part to the loss of blood, and in part to the opiates given, and the confinement to bed. It is not, however, a circumstance which need give rise to any uneasiness, or indicate hasty administration of purgatives. It is usually corrected by the change of diet, and, if it is not, a little castor oil after a few days will answer evevy purpose. The use of purgatives in any shape too soon after operation is greatly to be deprecated. In the first place, they are unnecessary, and, in the second, too early a movement of the bowels sometimes overtaxes the patient's strength and is followed by exhaustion. Should the bowels act, it is well to give a little stimulus at the time. In rare instances, patients are met with who bear operations with wonder- ful composure and recover with remarkable facility. The writer can recall, as such, a case of secondary amputation at the knee-joint, upon a delicate lady. On the following morning she was found sitting up in bed knitting, and she had insisted upon her customary diet without any abatement. The popliteal ligature separated on the tenth day, the wound healed by first intention, and in reality in less than ten days she was well. Another singular instance occurred in an Irish soldier whose humerus was shattered in action by a ball, and whose arm was removed close to the shoulder-joint immediately afterwards. He walked on the same day, under a broiling sun, fifteen miles, carrying his gun, knapsack, and full accoutrements, and in the evening was found acting as a volunteer sentry on guard. He was with difficulty placed in hospital ; the ligature separated early, and his recovery was as rapid and wonderful as in the case above given. In neither of these instances was traumatic fever developed. There is yet one other matter which it is well for the surgeon to see to, and that is the character of the patient's surroundings. Not only should his room be well ventilated, but it should be light and cheerful ; and, as he convalesces, he should be provided with proper books, and resources to relieve the tedium of confinement, and to occupy his mind. At a later period, and where no positive reason to the contrary exists, if he be a smoker, he maybe permitted his cigar or pipe. Growing flowers and plants in the chamber have been objected to on the ground of their tendency to absorb oxygen and give off carbonic acid. Bui practically this is an error, for in fact the plant lives on carbonic acid, and during daylight, while its nutrition is going on, carbonic acid in large quantities is absorbed and oxygen given off. At night the TRAUMATIC OR SURGICAL FEVER. 455 nutrition of the plant is suspended, and the reverse process takes place in the exercise of its function of respiration, oxygen being absorbed and carbonic acid being given otf, but in quantities so small as scarcely to demand con- sideration. There is, therefore, from a chemical point of view, no question as to the propriety of having living plants and flowers in moderation in a sick room, if proper ventilation of the latter be looked to. JEsthetically considered, nothing can be more delightful and cheering to a convalescent than their presence, since they are always lovely in themselves, and doubly so in their happy influence on a sick man's mind. Traumatic or Surgical Fever. After most operations, especially if they be of any magnitude, the patient suffers from more or less febrile disturbance. This is known as surgical or traumatic fever, and generally makes its appearance a few hours after the operation, or during the ensuing night, or on the following day. It varies greatly in intensity; at times it is very slight, and at times sharply charac- terized from its inception. The patient is at first restless and uneasy, tosses about, and complains of heat and thirst, with more or less headache ; the face flushes at times greatl}-, the pulse is quick and tense, the skin feels hot and dry, there is no appetite, but much thirst, and the tongue becomes dry and furred. If the fever runs very high, there may be some mental disturbance ; the patient is a little flighty, and in extreme cases eVen delirious. The tempera- ture of the body is increased, and rises to 102° or 103° Fahr., sometimes to 104°. The secretions are disturbed, the urine is scanty and high colored, and there is commouly a general exacerbation of all these symptoms in the latter part of the day, or during the evening. In ordinary cases all these s3 T nrptoms lessen about the third or fourth day, and gradually pass away ; their subsi- dence being marked by the increasing comfort of the patient in every respect. Traumatic fever rarely lasts more than a week, and usually only three or four days ; it often assumes a somewhat remitting character. All persons are not equally liable to the occurrence of this fever, nor is its violence always in proportion to the gravity of the operation or injury. As already stated, it may be altogether absent ; in an aggravated form it may follow the slightest operation. Malarial surroundings, exposure, intemperance, mental disturb- ance, and debilitating influences generally, probably act as predisposing causes to its development. The subject of traumatic fever has been carefully investigated by Billroth, who, as the result of his observations, declares that this fever, like any other inflammatory fever, depends upon a poisoned state of the blood, induced by the absorption or passing of various materials from the seat of inflammation, or the surface of the wound. At the same time, it must be observed that the fever in question sometimes makes its appearance very early after operation ; before, indeed, sufficient time has elapsed to permit de- composition to have taken place, which forms so essential a part in the theory of blood-poisoning. It would, therefore, seem likely that the shock of operation, the manipulation of the tissues, the nerve lesions, the swell- ing and resulting tenderness, have just as much to do with the develop- ment of surgical fever as the more obscure causes which have been adduced. Left to itself, this fever in the vast majority of cases soon diminishes, and, by the time suppuration has been fairly established, ceases altogether. Should it reappear, it carries with it the suggestion of fresh local mischief, such as the formation of abscesses, or the extension of the inflammatory process to other parts, neighboring or removed — possibilities which demand careful investiga- 456 OPERATIVE SURGERY IN GENERAL. tion from the surgeon. The occurrence of rigors, in traumatic fever, is not common ; and in this respect it differs, as in many others, from the urethral fever so often encountered after operations on the urethra and bladder. The treatment of surgical fever hinges on the patient's special condition, and must be met by a judicious application of well-known general principles. If he be very weak, he must be supported ; if he be plethoric, and the fever run high, with great increase of temperature, sedative fever mixtures adapted to restore the secretions, with the addition of a little aconite, can be advanta- geously exhibited. Conditions Determining the Results of Operations. In estimating the risks of operations, and in comparing the hazards of those of the past with those of the present day, it is proper to consider the advances which have been brought about by modern surgery. An operation has always been regarded by the community as little short of a catastrophe, even under the most favorable circumstances, and certainly the operation of former times was appalling in its nature when contrasted with the same operation as now practised. For the surgical mind, it is scarcely possible to contemplate anything more terrible than the amputation of a limb before the discovery of anaesthesia. All of the attendant circumstances were calculated to strike terror to the mind of the trembling patient; the mental anguish before being placed upon the table ; the horrid pain of the operation itself ; the loss of blood, and shock, combined, were sufficient to intimidate the bravest, and must necessarily have influenced in no slight degree the issue of the case. But all these horrors have almost vanished since the advent of anaesthesia, hypodermic medication, and the application of Esmarch's elastic bandage. The patient now possesses at least the assurance that whatever may be the surgeon's duty, he himself will feel no pain ; that his condition while under the knife will be one of unconsciousness, and that when he returns to him- self, it will be with but the memory of a dream. It is somewhat difficult to compare accurately the statistics of past operations with those of the present day. By some, the risks of operations have been regarded as increased rather than decreased by the discovery of anaesthesia. But it would seem to be scarcely possible that such in reality could be the case. It is certain, however, that the number of operations has greatly increased ; the surgeon of to-day dares to do far more than his predecessor would have been willing to attempt, or indeed justified in attempting. The elimination, too, of the factor of pain during operation, renders patients more willing to submit to operation than formerly; while, again, it w T ould seem as if the causes demanding operation had increased greatly, not only in number but in gravity. The more ex- tended use of machinery, the high velocities at which it is driven, the in- creased chances of accident attendant upon great engineering projects, the altered means of transportation, the more general use of railway and street cars, have all combined to produce a large class of the " seriously injured" formerly unknown. The shock of accidents resulting from all such violent causes must consequently be necessarily augmented. Granting, however, al- though not proven, that the risks attendant upon operation are now increased, it is but fair to assume that these augmented dangers, if any, may be fairly charged, in part at least, to the changed pursuits and habits of men, rather than to the discovery of the blessing of anaesthesia. Much lias been said and written of lute years concerning "hospitalism," or the gathering of large numbers of patients into one building. Undoubtedly the effects of overcrowding are in the highest degree deleterious, but it must CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 457 be remembered that, during the last quarter of a century, hospital facilities and accommodations, the world over, have been infinitely improved and ex- tended to meet the demands of the growing influx of patients. Far more attention has been paid to the wants and necessities of the latter, and more thought and enlightened study have been paid to ventilation, drainage, and cleanliness. The necessity of increased air space has been recognized, the pavilion system of wards has been adopted, and the diet scale has been changed for the better, and in accordance with physiological teachings. It would thus seem that, while the demands upon the hospital are now greater and more imperative than they once were, at the same time every effort has been made to satisfy these claims, and that the present hygienic surroundings of the hos- pital patient are more favorable than they have ever been before. Before an operation is undertaken, the surgeon should always critically ex- amine his patient, so that he may form a correct estimate of his general apti- tude to undergo operation, and of the ability of his constitution to sustain the fresh weight about to be imposed upon it. This examination must be con- ducted systematically, and must embrace the general condition of the patient's system, his habits, and an inquiry into the state of his special organs, as to whether the latter are, or have been recently, diseased. It is not always easy to decide if a man is or is not a good subject for operation. There are so many factors which enter into the determination of this question, that the surgeon is liable to deceive himself, or to be deceived, unless his study of the case before him is critical and thorough. 1 General Condition op the Patient. — First, as to the general constitution of the patient : what is it which makes, to use the terms of the insurance companies, a "good risk"? Undoubtedly they are the best subjects for opera- tion, in whom nutrition is most thoroughly effected, in whom assimilation is well performed, whose secretions and excretory functions are in perfect work- ing order, and in whom consequently there is no organic disease. Now these conditions may be found both in fat and in lean subjects. Obesity is usually regarded as one of the eontra-indications to operation, but it must be remembered that many persons who are in perfect health are fat, and that any undue falling off from this state is attended with more or less loss of health. On the other hand, there are those who are normally lean. Fat is not in itself an evidence of deranged health, if it be natural or hereditarv ; but excessive fat, or sudden or precocious development in this direction, must be regarded as one of the evidences of something being amiss constitutionally ; especially is this the case if fatness be unaccompanied by a healthy condition of the skin and capillary system, or if the development have occurred sud- denly, or from habits of drinking, gluttony, or indolence, and when the pa- tient is inert, and unwilling or incapable of taking proper exercise, or exertion. Under such circumstances, the person is apt to be flabby or loose in his tis- sues; and there is a want of that firmness and contractility of the skin and subjacent structures which is inseparable from health. This state is not 1 in- frequently observed in women approaching or passing middle a^e, and, when found, unquestionably indicates that the possessor is no longer in the best condition of health, nor well suited to undergo the risks of a surgical opera- tion. In such persons, the wounds of operation do not heal well ; there is 1 For an elaborate and exhaustive study of the risks of operations, and of the causes influ- encing their results, the reader is invited to consult the published lectures of Sir James Paget, who has fully treated of these subjects in paragraphs which have already become classical. So great has been his experience, so close his observation, and so lucid the utterance of his beliefs, that it seems as if little else were left for other pens ; and the writer of the present article has accordingly not hesitated to make free use of the teachings of this eminent surgeon. 458 OPERATIVE SURGERY IN GENERAL. commonly much suppuration and burrowing of matter, and a tendency to sloughing. These conditions all predispose to exhaustion, and to intercurrent diseases of a low type. The state of plethora which is marked in those who are usually spoken of as "full blooded," is also one which requires careful consideration from the sur- geon. If this condition is confined simply to the external surface, and is not accompanied by internal congestions, or derangement of the viscera, and has not been produced by free living, there is no reason why the surgeon should refrain from operating. He must simply be on his guard against the devel- opment of intercurrent affections of an inflammatory type, to which such per- sons may possibly be naturally disposed. Leanness is not a bar to operation, uidess it result from non-nutrition, de- fective assimilation, or excessive excretion, in which case it will probably be found to depend upon some perverted function or organic disturbance. When loss of flesh has occurred from overwork, or too great mental or bodily strain, the surgeon should be careful, and, except in urgent cases, should defer ope- ration, if possible, until the patient has by proper therapeutic and dietetic measures been brought to a better grade of health. In short, it may be re- peated, as already stated, that when the deflections from the standard of health have been produced by impaired nutrition, or organic disease, the patient is not, and will not be, in a suitable state for operation until the exciting cause has been remedied or removed to the greatest degree possible. Habits of Patient. — Habits, bad habits, play an important part in render- ing a patient unfit for operation. The evil effects of the excessive use of stimulus; opium eating; the taking of chloral or other pernicious agents of this kind, are so well known as scarcely to demand more than a passing mention. Drunkenness, too, in its varied forms, is one of the most familiar examples of the contra-indications to operation. But here there is a differ- ence of degree. The quiet drinker, who "soaks" over night, and, while rarely quite drunk, seldom goes to bed really sober, is, perhaps, one of the worst subjects for an operation. In his case there is in all probability more or less organic hepatic trouble, or, if this condition is not yet fully established, there is a tendency in that direction. In him the powers of life are lowered, and there is a lack of that vital resistance necessary to carry him through the perils of an operation. In such cases, too, there is always more or less ten- dency to the development of delirium tremens, and, when this occurs, the prognosis always becomes grave. In confirmed, steady drinkers, the outlook after surgical interference is bad, and more so after accidents which demand amputation. Even here, however, poor as the chances are, the probability is that primary amputations are less dangerous than secondary— the latter when of the severer kind not unfrequently ending fatally. There is another class of intemperates upon whom the effects of operation arc not so disastrous as in the group already referred to. These persons indulge occasionally in fits or bouts of drinking, the duration of the debauch usually lasting from two to six days. These periods of carouse are succeeded by weeks or months of sobriety, during which time the individual attends to his business actively and industriously. Operations performed during these intervals of abstinence, are not necessarily attended Iry any \evy great amount of increased risk to life; nevertheless the surgeon must watch care- fully against the advent of untoward symptoms. It .must also be remarked that, in these unfortunates, the craving for drink is apt to be developed at times until it assumes almost the form of mania. To the practised eye the approach of these drinking periods is unmistakable, the patient's manner being marked at times by tits of irresolution, and at times by a general state CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 459 of exaggeration and excitement of the mental functions — the sure forerunners of coming trouble. During and preceding these attacks no operation should be attempted, unless in the utmost emergency. In close relation to excess in drinking, stands overfeeding, or gluttony. Overindulgence in the pleasures of the table undoubtedly adds to the risk of operation, inasmuch as an abnormal condition is thereby developed, accom- panied by bodily indolence, and by perversion of the natural excretions. This is the case when large amounts of meat are consumed, and when deficient exercise interferes with the proper elimination. Influence of Nervous System. — There is another class of persons upon whom the surgeon at times almost fears to operate, in consequence of the existence of what is ordinarily described as a " nervous" state of mind and body. It is possible, however, that fears in this respect are often exaggerated. A patient may be timid and nervous in the highest degree, with a mind worked up to a point of greatest tension ; his clread of operation may be so intense as to give rise to fears of subsequent shock ; and yet, after all, the operative dangers in such a case may be imaginary rather than real. As long as organic disease does not exist, the surgeon may hope and indeed count upon this depression, dependent upon mental causes, passing away as soon as the contemplated operation has been performed. Here the reaction is not, usually, as quick and marked as was the pre-existent mental prostra- tion, and, the depressing cause once removed, the patient will probably pass to a corresponding condition of contentment of mind in every way favorable to the production of a happy result. Operations are often demanded upon feeble persons in whom, although there are no evidences of positive disease, there is an absence of robust "or even of moderate health. Such individuals are apt to have been overworked or worried. They have been taxed either mentally or bodily beyond their powers of endurance, and are in no condition to sustain the weakening and depressing effects of operation. In such cases, all surgical interference should, if possible, be delayed until, by rest and judicious medical treatment, the general condition has been sufficiently improved. As a familiar example of the class of patients first referred to — the men- tally overtaxed — may be cited the hard-worked man of business, whose mind has long been kept on the strain by the exacting nature of his calling, and whose face betokens the anxiety and harassment of his vocation. His aim is the accumulation of money, and for its accomplishment all other objects must give way — even health itself. Of the latter class — those worked beyond bodily endurance and ill fed — there are in this country fortunately but few, the rate of wages being usually sufficient to provide good food and a home for the poorest laborer, if he be industrious. Age and Sex. — Age exercises a decided influence upon the results of opera- tions. As a rule children bear operations well, and, while they are peculiarly susceptible to pain and shock, they are not liable to the mental depression which acts so powerfully in after life. They are usually healthy, and their internal organs are not so frequently the seat of organic diseases, the result of long-continued or abused action, as those of adults. Their growing con- dition, moreover, favors the process of repair, and the union of wounds." The chief danger to them is shock, consequent upon pain and hemorrhage; the latter undoubtedly acts powerfully in this direction, but, this once overcome, the wounds of children heal kindly and rapidly, and they are rarely sub- ject to the secondary complications of pyaemia or septicaemia ; tetanus may at times occur, but more often as the consequence of lacerated or ragged 460 OPERATIVE SURGERY IN GENERAL. wounds, than of simple operations. Another important feature in the favor of children, as suhjects of operation, is the readiness and comparative comfort with which they bear confinement. Easily satisfied and amused, they soon accustom themselves to their new condition, and pass through a long period of confinement to bed, possibly subject in the mean while to exhausting dis- charges, in a manner unknown to those of more mature age. The tendency of children to suffer from the exanthemata must always be remembered, and no operation should be attempted on them when exposed to these affections. There is also in children, as has been pointed out by Sir James Paget, a special liability to the occurrence of scarlatina after operation. Why this should be so, is not clear, but it seems probable that the shock of operation upon children carries with it a predisposition to the development of this disease, especially if it is epidemic at the time. The same writer also states that the type of the disease, occurring under these circumstances, is somewhat modified, and the period of incubation shortened. In some chil- dren the disease appears on the whole surface at once ; in others, more deci- dedly upon the limbs ; sore throat and desquamation are observed in some, and not in others. The development of this affection necessarily adds to the hazard of operations in childhood. The performance of certain operations upon children is at times difficult, and demands a high degree of anatomical knowledge, in consequence of the contracted space in which procedures, often of a delicate and complicated nature, must be practised. Yet, as a rule, the average child may be regarded as a good subject for operation, and in this respect contrasts strongly with persons of advanced age. In the latter, the powers of life are already weak- ened, and it requires but little to disturb the vital equilibrium. The chances of the existence of organic disease in one or more of the great viscera, and, in men particularly, in the genito-urinary organs, must be considered. No surgeon would deliberately select a very old man as the subject for operation, and yet in many instances such patients will recover from operations wonderfully well. Still, this cannot be anticipated, and must be looked upon as an ex- ceptional circumstance. Age cannot always be measured by years alone ; a good deal depends upon the constitution, and upon pre-existent habits, and they have the best chances of recovery who are in the best general condition of health. When operations are called for upon the aged, every effort should be made to prevent hemorrhage and shock, and such patients should not be kept in bed longer than is absolutely necessary. All depleting measures should be carefully avoided, and the diet should be of the most nourishing, and, if necessary, stimulating kind. Sex. — As far as sex is concerned, there does not seem to be a great deal of difference as to the capacity of men and women to sustain operations. The latter are undoubtedly more patient, more accustomed to endure suffering, and more tolerant of confinement to house and bed. At the same time, there are certain physiological conditions of womanhood which must be borne in mind in the selection of the time of operation. Thus the menstrual period should be avoided. The woman is then in a state of nervous irritability, and often of positive pain. Her mental and physical functions are in a degree perverted, and her judgment and self-control disturbed. In fact, she is not then in a state to l)e exposed to any increased or unnecessary irritation. The best period for operation in women is probably from five to eight days after the cessation of the menstrual How. After operation, it frequently happens that the menses will make their appearance too soon, and in anticipation of the proper period; and the nearer to the latter that the operation is performed, the more apt is this anticipation to occur. CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 461 Operations during pregnancy should be avoided when it is possible." Sometimes this cannot be done, the conditions demanding surgical interfer- ence being imperative. When such is the case, every precaution should be taken to guard against excessive nervous disturbance, and the risks of mis- carriage. It must here be observed that when wounds and accidents do occur during gestation, the healing and reparative processes are usually very rapid. During lactation, operations should also be avoided, as prejudicial alike to mother and child ; nor should surgical interference with the mammary gland be needlessly undertaken. Tumors in this region should never be removed at that time, as much on account of the probable hemorrhage, as for other reasons. Race and Temperament. — The influence of race is potent in determining the results of operations. Strange as it may seem, the black races and the Oriental nations sustain injuries and operations best ; next stand the Anglo- Saxons ; and, according to M. Chauffard, the Latin race is as far behind them as they are behind the black race. The immunity of the Chinese and Japa- nese to mortality after operations is remarkably shown by the various reports of medical officers serving in the East. It is stated that pyaemia is a rare occur- rence among the Chinese, and in a recent report of 138 operations for lithotomy performed on persons of all ages and occupations, from two years old to eighty, but eight deaths occurred. 1 A similar immunity is said to be enjoyed by the Japanese in regard to pyaemia, septicaemia, tetanus, and erysipelas. It is difficult to understand why this should be, unless the explanation is to be found in the fact that the lower classes of these races live chiefly on vegetable diet and fish, and eat but little meat. In our own country, the negro has generally borne injuries and operations well, provided that he has not been exposed to the after vicissitudes of cold and dampness. This was remarkably shown in the experience of the negro brigades during the late American war. According to the observation of the writer, when these soldiers, injured in battle, were cooped up in overcrowded and overheated hospitals, they did well ; when, however, removed to well- ventilated pavilion hospitals, and placed under such hygienic conditions as are most favorable to the white American soldier, they did badly, suffering severely from intercurrent pulmonic and other acute inflammations. In the daily practice of our hospitals, the negro is, we think, regarded as a satisfac- tory patient, and one of whose case a favorable prognosis can usually be formed. Whether this be due to the happy mental condition of his race, and to its characteristic freedom from care, cannot perhaps be clearly shown. The Irish, from their peculiar mental elasticity, also bear operations well, and so do the more phlegmatic Germans. The American is not so good a patient ; his activity of mind renders him restless and impatient of restraint ; he looks anxiously forward to the end of his convalescence, and not infre- quently ventures out of doors too soon, and thus hinders his own recovery. The influence of personal temperament is not less than that of race. A happy and contented disposition contributes greatly to convalescence after operation, for it enables the patient to obtain and enjoy that rest of body as well as of mind which has so much to do in bringing about recovery. Influence of the Seasons and Weather on Operations. — The popular as well as the professional mind has long since recognized the influence of the weather on certain general and local conditions of the body. Its effects upon 1 Imperial Maritime Customs. Medical Reports, 187S-9. 462 OPERATIVE SURGERY IN GENERAL. •rheumatism, neuralgia, diseased bones, and the ends of stumps, are examples in point. But, strange to say, its precise relations to surgical operations, and the influence it exerts upon their results, had never, as far as we know, re- ceived that precise study which they deserved, until the year 1869, when Dr. Addinell Hewson, of Philadelphia, published in the Pennsylvania Hospital Reports for that year, a paper on the " Influence of Weather on the Results of Surgical Operations." This was followed, in 1870, by the published lec- tures of Dr. Richardson, of London, in the Medical Times and Gazette for January and February of that year. The observations of these two investi- gators agree in the main, and may be thus epitomized. It must here be stated that by "the weather" is meant the measure of the changes of the conditions of the temperature, humidity, and pressure of our atmosphere, relatively to each other. Dr. Ilewson's deductions are based upon the observation of 259 ope- rations performed at the Pennsylvania Hospital in the thirty years preceding 1860, during which period a meteorological register had been faithfully kept by Dr. Conrad, the apothecary. Taking, as the expression of the changing weather, the barometrical condition, and regarding it as ascending, stationary, and descending, Dr. Hewson found that, of the 259 operations, 102 were per- formed when the barometer was ascending, 91 patients recovering and 11 dying, giving a death-rate, of 10.7 per cent.; 34 operations were performed when the barometer was stationary, giving 26 recoveries and 8 deaths, a mor- tality of 20.6 per cent. ; and 123 operations were practised when the barometer was descending, with 88 recoveries and 35 deaths, a mortality of 28.4 per cent. In other words, with an ascending barometer the mortality of operations was a little less than eleven per cent., with a stationaiy barometer more than twenty per cent, and with a descending barometer more than twenty -eight per cent. In the same general way, it was observed that the results of opera- tions were most favorable in autumn and winter, and least, so in summer. The most happy month for operating was October, then January, then April. The frequency and mortality of pyremia bore a direct relation to low baro- metrical pressure and moisture of air, while the deaths from shock occurred in a constant ratio with the opposite condition, dryness of weather. The deductions of Dr. Richardson tend strongly in the same direction, for he finds that the most favorable time for operating is when the barometer is steadily rising or steadily high ; when the wet bulb thermometer shows a reading of five degrees lower than the dry bulb; and when, with a high baro- meter, and a difference of five degrees in the two thermometers, there is a mean temperature at or above 55° Fahr. On the other hand, the time is unfavorable for operations when the barometer is steadily falling, or steadily low; when the wet bulb thermometer approaches the dry bulb within two or three de- grees; and when, with a low barometrical pressure, and approach to unity of reading of the two thermometers, there is a mean temperature above 45°, and under 55° Fahr. Such arc the results of precise observation, and they seem to accord with the general empirical idea that large operations should not be unnecessarily performed in very warm weather — at all events in the height of an Ameri- can summer, when the thermometer frequently ranges from 90° to 100° in the shade. We all know that at such times a certain degree of lassitude is felt by every one; and it would seem reasonable that the eombined influence of intolerably warm days and breezeless sultry nights, must be to weaken the constitution temporarily, and to deprive it for the time being of those powers <>f resi stance which are so essential to speedy convalescence after operation. It is not likely, as is commonly supposed, that wounds heal less kindly in warm weather, but it is certain that debilitation from any cause docs seriously inter- fere with the general recuperative powers, and the main consideration alter CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 463 operation is the patient's strength. From what has been said, it will be seen that the season has not as much to do with operation as the weather, and in this relation the tendency to intercurrent diseases must be borne in mind. During the winter, these are most apt to involve the pulmonary organs, in the forms of acute bronchitis and pneumonia, while in the summer, the abdo- minal viscera suffer from the acute internal inflammations, accompanied by diarrhoea. Locality has something to do with the result of operations. "When the patient is exposed to damp and depressing exhalations, and to malarious in- fluences, wounds do badly, and convalescence, particularly after the lar^e operations, is tardy. The reverse is the case when the atmosphere is dry and exhilarating, as on the mountain slopes. The sea breezes also act as a most powerful tonic. It would be easy, from the recent military experiences of our country, to adduce example after example in support of these asser- tions. It has often happened that, after great battles, soldiers who had under- gone amputations and other severe operations, have from military exigencies been left for a time in field hospitals, planted in unhealthy districts, and swept by marsh exhalations. Under such circumstances, wounds and stumps not unfrequently did badly, and assumed a sloughing and unhealthy appear- ance. As soon, however, as the men could be removed to hospitals in salu- brious localities, an immediate change in their condition was observed. The wounds cast off their unhealthy character, and entered upon active repara- tion. No operation should be performed, except in cases of emergency, in any locality in which an epidemic is prevailing, such as diphtheria, erysipelas, cholera, yellow fever, and possibly influenza of a bad type. Influence of Visceral Affections. — There are certain organic diseases of the great viscera which exert a direct and unfavorable bearing upon the chances of operation. Chief among these are affections of the heart, lungs, and kidney. Heart and Arteries. — In regard to the heart, it is probable that the risks of operation are not always so seriously increased by disease of this organ as is generally supposed. A great deal will depend upon the degree of cardiac trouble, the evil consequences which have attended it, or are present at the time, and its duration. It not unfrequently happens that cardiac dis- turbance dependent upon valvular changes is relieved by the hemorrhage which attends an operation. If the amount of disease observable is such as to greatly disturb the patient, and to interfere with his circulation and respira- tion, the risks of shock, either at the time of operation or subsequently, must undoubtedly be recognized. Fatty degeneration of the substance of the heart is attended by great danger, greater probably than the more simple degrees of valvular obstruction. These constitute the class of feeble hearts, which are strongly influenced by shock and blood loss; and to patients thus affected, ether should be given in preference to chloroform on account of its stimulating effects. Sir James Paget, in his lectures on the risks of operations, has drawn atten- tion to the manner of the heart's action when it is believed to be healthy, and to the phenomena of the pulse. lie tells us that a slow pulse does not forbid operation^ nor does an accelerated one necessarily do so, provided it be not accompanied by organic disease. Children and young persons of nervous temperament have often very rapid pulses, and the surgeon, in deciding upon the propriety of operation upon them, should be guided, not by the pulse alone, but rather by noting whether the respirations are proportionately rapid. In 464 OPERATIVE SURGERY IN GENERAL. some persons, a pulse may beat 120 or 140 in a minute, and yet indicate' no trouble if the respiration do not exceed 20 or 25. The same condition may be observed in some old persons, who may still be good subjects for operation. This plan of checking the pulse by the respiration is also to be followed in cases of individuals recovering from sharp hemorrhages, when the pulse is often quickened, while the respiration is proportionately slower. Habitual irregularity of the pulse, not accompattted by valvular changes or degeneration of the heart tissue, need not be seriously feared in estimating the chances of operation. In giving due weight, however, to the effect of organic cardiac disease, it must be remembered" that, in addition to its immediate influence, it is often indicative of grave changes in other portions of the system, and notably in the arteries. "Thus aneurism may be present, or degenerations in the arterial walls, which may forbid or modify the performance of an operation. Arte- rial degeneration, not in itself a matter of great importance in minor opera- tions, or in those upon the face or trunk, becomes a serious affair in amputa- tions, and in the ligations of large vessels. Not only does this condition favor secondary hemorrhage, but it also predisposes to defective reparation and extensive sloughing. Indeed, it is one of the causes which produce the high rate of mortality after amputation of the lower extremities in old persons. Lungs. — The question of operating when there is coincident disease of the lungs, is one of the gravest questions which can be presented to the considera- tion of the surgeon, and, unfortunately, it is one of everyday occurrence. I)u- ■ ring acute inflammation of these organs, of course there can be no hesitation as to the proper course. No operation should be then performed unless for the most exceptional and urgent causes. Interference with the pulmonary circulation is too serious a matter to be lightly encountered after operation, and the inconveniences incident to a forced position, difficulty of breathing, and the rack of coughing and expectoration, must necessarily exert a harmful influence, locally as well as constitutionally, upon the issue of any surgical operation demanding quiet and rest. The matter, how T ever, assumes a different aspect if tuberculosis is present; when the patient is suffering from phthisis, and at the same time from some other ailment or casualty necessitating sur- gical interference. If he has received an injury or compound fracture, de- manding amputation, there can be no hesitation. His only salvation may lie in the amputation of the limb, and the condition of his lungs has, for the time, nothing to do with the decision as to the propriety of operation. It may affect his after chances, but the necessity of the case demands that he shall run this risk, and there is no alternative. The case is far different, however, when the operation to be decided upon is one of expediency, rather than of absolute pressing necessity, as, for example, the removal of a tumor or hemorrhoid, the amputation of a limb for a scrofulous bone or joint, or the division of a fistula. The operation in these instances is one which in ordi- nary states of the system is highly proper, and which ought to be done. Is it right to attempt it upon a phthisical patient? The answer to this question is not in reality as difficult as it seems at first siudit , and is based upon a careful balancing of the patient's chances of comfort and life. In the first place, the surgeon ought to make a thorough examina- tion, physical and otherwise, of the condition of his patient, in order to deter- mine whether the phthisis is, in Paget's words, "active, acute, and progres- sive," or "passive, chronic, and. suspended." If it be the former, no operation of magnitude should be attempted, since the course of the disease would be probably hastened, and the patient's life shortened by the shock of operation, the subsequent febrile disturbance, and the possible establishment of a second CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 465 source of discharge and constitutional drain. If, on the other hand, the dis- ease of the lung has been of long continuance, but is now quiet, and is not making active progress, there is really no reason why an operation, if necessary, should not be resorted to. Yet it must be quite clear to the surgeon, that the proposed operation will make less demand upon the strength of the patient, than the cause for which it is performed is already doing. Thus it would unquestionably be proper to remove a limb for a suppurating joint or diseased bone, whatever the cause of the lesion might be, if it were quite evident that the patient's vital powers were giving way under the exhausting drain. It not unfrequently happens that both loeal and constitutional evidences of scrofu- losis or tuberculosis exist in the same person, the deposit in the lung being accompanied by a disorganized joint. The propriety of amputation here de- pends upon the precise pulmonary condition. If the phthisis be far advanced, and the lung already breaking down, operation is usually inadmissible; but if the lung be as yet but slightly affected, there is always the possibility that its condition may be improved by the removal of the source of local irritation. It is well known that JisUda-in-ano frequently occurs in phthisical patients. By most of the surgeons of a past generation, and indeed by many of the present day, the existence of anal fistula was and is regarded as rather favor- able to the patient than otherwise, it being held that it acts as a derivative, diminishing the progressive development of pulmonary tuberculosis. Of late years, this opinion has been challenged, and there are not a few, including many of the most learned and practical pathologists of the present day, who believe that the reverse is the case ; and the belief is gaining ground that the fistula acts as a supplementary weakening discharge, rather than as a revulsive. The propriety of operation in sueh cases follows as a matter of course, with the proviso that the attempt to cure fistula? occurring in phthisical patients must be restricted absolutely to those in whom the disease is incipient, or at all events not progressive. Here, as in other instances of tuberculous and strumous affections, it would then seem proper to attempt the cure of the affec- tion by operation, remembering, however, that in all sueh cases there is an indisposition to healthy granulation, and that the wished-for cure may not always be accomplished. Dr. Van Buren, in his excellent treatise on diseases of the rectum, expresses himself strongly on this matter. He says that while no judicious surgeon would operate for fistula upon a patient with advanced cardiac disease, or with cirrhosis of the liver, Bright's disease, or cancer, yet in pulmonary disease the tendency of opinion is becoming more favorable to well-considered operative interference. He adds : — "On the following points I do not hesitate to speak positively: there is no reliable evidence that the suppression of an habitual discharge can do any harm in these cases; on the contrary, it is pretty certainly a positive advantage to arrest it; and I would advise the attempt to cure a fistula in a patient with physical signs of phthisis, pro- vided there were no positively advancing softening, or severe cough, because, in addition to stopping a waste, it would remove an impediment to exercise in the open air, possi- bly on horseback. The objections to operating where there is softening or hectic an*, that the concussion from coughing, and the lack of power, might prevent the wound from healing,- and that the use of the knife would necessitate confinement to bed, and thus injure the patient." In all operations which the surgeon may attempt on phthisical or scrofu- lous patients, he must, as Paget has advised, carefully avoid keeping them too long in one atmosphere, lest he may bring about that gradual impairment of health which is so favorable to the progress of tubercular disease. Urinary Organs. — The results of operations and of injuries are more powerfully influenced by organic disease of the kidney than by that of any vol. :.— 30 466 OPERATIVE SURGERY IN GENERAL. other organ. In health, the kidney would seem to exercise less influence upon life than the heart or liver ; yet after traumatism, the recovery of the patient often depends upon the manner in which the kidneys are acting. The function of these organs is essentially one of elimination and blood purifica- tion, and upon their perfect working, the excretion from the blood of noxious elements to a large extent depends. An impaired kidney, which has under- gone certain pathological changes, and which may be secreting urine contain- ing albumen or sugar, or failing to excrete the usual amount of normal uri- nary products, may suffice for a while for the support of life, provided that no extra strain be put upon it. It is, however, an organ of a delicate and sympathizing nature, and is peculiarly susceptible to the shock of operation — indeed marvellously so, when the genito-urinary organs are concerned. The slightest disturbance often serves to modify and arrest its secretion, to such an extent as to give rise to fatal consequences. A careful examination of the urine should therefore invariably be made before any operation of magnitude is attempted, and, if necessary, this examination should be repeated at inter- vals. The steady presence of albumen, not dependent on febrile causes or mechanical impediment, especially if accompanied by renal casts, reveals the story of a kidney organically changed. Here all operation must be refrained from if possible, or, if imperatively demanded, the increased attendant dan- gers must be looked steadily in the face. The clinical import of albuminuria is familiar to every one, as indicating a tendency to the development of in- flammations of the serous membranes, and of some of the viscera. Two difficulties are met with in forming a diagnosis of renal affections. The first of these is the existence of disease in the bladder, attended by the formation of pus and albumen, and their collateral products. The second is the occurrence of chronic disease in the ureter, leading to its closure by thickening of its walls, or by the choking of its canal dependent upon the inspissation or hardening of inflammatory products. In each of these condi- tions the functions of the kidney are deranged, its secretion is interfered with, and a corresponding extra amount of work is imposed upon its fellow. When cystitis is present, it is absolutely impossible to form any idea of the man- ner in which the duties of the kidneys are being discharged. When ordinary desquamative nephritis — Bright's disease — is developed, it is always attended by oedema, dropsies, and other familiar symptoms. The contracting kidney is marked by intermittent albuminuria, and by the presence of renal casts. It is, however, an affection which progresses slowly, and its symptoms are at times obscure. Clinically speaking, the dangers of operations in this form of kidney are greater than in the ordinary form of Bright's disease. Renal congestion, accompanied by alteration or suppression of secretion, not unfrequently follows the simplest surgical procedures, such as catheterism, or the dilatation of a stricture. Its occurrence portends new and alarming danger for the patient, and it is therefore not improbable, as has been suggested by Mr. Reginald Harrison, that this is just the state so often productive of surgical calamities, the causes of which are puzzling, and apparently difficult of explanation. Pyelitis, or suppurating kidney, often spoken of as the "surgical kidney," is frequently observed by the surgeon. In this disease the renal pelvis and calyces are inflamed and suppurating. The inflammatory action may extend into the secreting portion of the kidney, and, when pus is formed in quantity, we not unfrequently find after death that the ureter has been largely involved, sometimes presenting sacculi of considerable size, filled with purulent fluid. Viewing the very decided post-mortem appearances, it might be supposed that this condition could always be detected during life. Unfortunately its existence is often, perhaps most often, coincident with chronic vesical or pro- static disease, and the symptoms of its occurrence are therefore to some CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 467 decree masked, and at times difficult of recognition. It need scarcely be said that such a state of affairs bears terribly on the chances of operation. A kid- ney thus damaged, and forming pus, is unable to discharge its duties under ordinary circumstances ; and certainly not when subjected to the shock and increased irritation produced by urethral and vesical operations. Disease of the bladder also, like disease of the kidney, with which it is usually associated, exerts a most unhappy effect upon the issue of operations, especially when it is chronic, or occurs in old persons. The occurrence of sugar in the urine is not a whit less serious than albumi- nuria, and, if the sugar be present in marked quantity, must be regarded as almost a positive bar to operation. In the condition of glycosuria, wounds have a tendency to remain open; they will not heal, and, still more, they are apt to run into spreading gangrene. This is notably the case if the lower extremity be the seat of the wound or operation. Here all attempts to arrest the diabetic gangrene commonly prove futile, and the disease spreads obsti- nately, slowly, and continuously, until the patient sinks from exhaustion. Liver. — The liver is so intimately associated, both physiologically and pathologically, with neighboring organs, that it is somewhat difficult to define the precise limits, in surgical cases, over which its power is exercised. This much, however, may be said, that a diseased liver always increases the risks of operation, and favors the development of hemorrhage, inflammation, and constitutional septic poisoning. And this is so whether the case be one merely of torpid or inactive liver, or whether decided organic changes have already occurred. If the liver has undergone either fatty or amyloid enlarge- ment, its evil influences are greatly augmented, and, before operation, careful examination should be instituted to ascertain the fact. The existence of a fatty liver may, indeed, be looked upon as an evidence of further internal mischief. It may be that the patient is suffering under some exhausting affection, or that he is, possibly secretly, intemperate. In amyloid or waxy degeneration of the liver, so often associated with splenic enlargement, renal albuminuria, and the syphilitic or tubercular cachexia, the prognosis of operations is unfavorable in the highest degree. In long-continued suppura- tion of bones, amyloid degeneration often occurs in the spleen, kidney, and liver, in the order mentioned, although either may be selected as its point of primary development, and sometimes nearly all the organs in the body are similarly affected. Cirrhosis of the liver, whether the result of alcoholism or other causes, exercises also a most deleterious effect on operative results. In fact, whenever the liver is diseased, no matter from what cause, it is a fair inference that the other organs adjunct to the portal circulation are more or less involved; and this must necessarily be so from the intimate and abundant vascular connection which exists between the liver and other abdominal viscera. The result will be portal disturbance, poor digestion, and imperfect assimilation — conditions which separately or in the aggregate promise badly for the success of the operator. Bowel Affections. — The contra-indications to operation offered by the exist- ence of diarrhoea and dysentery' are so evident as to require but a passing mention. No surgeon would deliberately operate at such time, yet it occa- sionally happens that a patient, seemingly healthy, may die shortly after operation from the development of a fresh attack of obstinate chronic dysen- tery contracted years previously. This has always been the experience of military practice, and has been fully corroborated in the annals of our own military service. The writer has on several occasions known officers and soldiers, who had long since recovered, as they supposed, from the dreaded 468 OPERATIVE SURGERY IN GENERAL. Mexican or malarial dysentery, succumb to a fresli attack on the receipt of some slight injury, or the performance of some comparatively trilling opera- tion. Cachexia. — The influence of the different cachexia upon operations may be regarded from a twofold point of view. In the first place, as to the chances of immediate recovery from operations and the healing of wounds, and, secondly, as to the ultimate result. In regard to scrofulous patients, it is a matter of daily observation that they do well after operations. The removal of the source of irritation, the doing away with their chronic dis- charges, the relief from pain which they experience, all* contribute to an improvement in their general health. If they are carefully watched and well nourished, and if their general hygiene and the ventilation of their rooms be attended to, their wounds of operation will heal — possibly slowly, sometimes not altogether perfectly, but still in some sort or other they close. The cica- trices of the scrofulous, as one would naturally suppose, are poorly organized, and have a tendency to open, if the diathesis continues to exert its force ; the latter, too, may give fresh evidence of its power in other parts. The pre- vious training of suffering which scrofulous patients have undergone stands them at this time in good stead. They bear confinement well if it is not too prolonged, and seem to be exempt from the influence of septic poisons which sweep away healthier persons. The influence of tuberculosis has already been alluded to in the remarks upon pulmonary disease. The general rule there laid down, that operative interference should be confined to cases of quiet and suspended phthisis, is equally applicable, with a change of terms, to the general diathesis. In short, operation should only be attempted when with- out it the patient must die, and when the removal of the source of irritation is attended with less immediate danger to life than its retention. Constitutional syphilis undoubtedly in many cases influences unfavorably operative results, but, at the same time, it need not be considered as absolutely forbidding operation. There is probably in such cases a tendency greater or less to secondary hemorrhage, in consequence of the predisposition to disease of the walls of the larger arteries ; and this must be borne in mind in apply- ing the ligatures. The wounds made in syphilitic subjects do not always heal kindly ; primary union is sometimes difficult, or, if partially effected, the adhesions may break up suddenly and apparently without sufficient cause. Hence it happens that plastic operations, particularly on parts in the vicinity of the genital region which have been the seat of previous destructive processes, are often unsuccessful, and that attempts to close fistula? and losses of substance are commonly of no avail. Operations upon cancerous patients are constantly performed where neces- sity commands, and there is no reason why they should not be done. These wounds heal readily, and there is no evidence to show that the constitutional condition of the patient is rendered more unfavorable. The question in such cases is simply one of expediency, and the surgeon must decide from a careful consideration of the circumstances surrounding each individual at the time. The gouty and rheumatic diatheses are supposed to act in a measure as contra-indicating operations. As far as they impair the strength of the patient, this is so; and no one would willingly select the period of an attack of gout, or of the acute febrile stage of rheumatism, as the time of operation. As is well known, in gouty persons, any constitutional disturbance may give rise to a fresh attack. In rheumatic patients, the tendency to cardiac com- plications, and the possible exacerbations of existing disease by operative interference, must always be borne in mind. The lithic acid diathesis is like- wise unfavorable to operation, since it is usually accompanied by impaired CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 469 bodily strength and by deranged action of the kidneys. Operations during an attack of erysipelas, or through tissues already affected by that disease, must not be practised if they can possibly be avoided. They may only be attempted in extreme cases, and where no other means of saving life are avail- able. Under such circumstances, the most active stimulant and tonic treat- ment, and the free exhibition of iron preparations, should be carefully pressed. Cutaneous eruptions not unfrecpiently occur as the sequence of operation. Allusion has already been made to the scarlatina of children. Urticaria is often consequent upon operations on the genital organs, and erythema, some- times of a very intense type, is not unusual. Erysipelas need only be men- tioned in this connection, forming, as it does, in conjunction with disintegra- tion and gangrene of the cellular tissue, one of the common causes of death after operation. Purpura and ecchymotic extravasations are evidences of blood-poisoning, and are not rare in depraved constitutions. Conditions Connected with the Operation Itself. — There are certain con- ditions, incident to the performance of operations, accidents as it were, which greatly influence the result. One of the most potent of these is pain, which in itself is depressing and conducive to shock, especially in children, who so illy sustain it. Fortunately, the discovery of anaesthesia, perhaps the greatest blessing which has been conferred on suffering humanity, has deprived surgery of half its terrors, and the operator is seldom justified in attempting "any serious operative procedure without resorting to it. Hemorrhage, once the dread of the surgeon, has too in great part been over- come, and the importance of Esmarch's invaluable contribution of bloodless surgery cannot be overestimated. It is a mistake to suppose that bleeding is advantageous in operations, for it must be remembered that the blood is a fluid of complex formation, and that, once withdrawn from the body, its place can- not be readily supplied. The baneful effect of bleeding on children and in the old is very decided, and has much to do with the production of shock. The relative loss of blood is often the turning point, as to recovery or death after an operation. It is dangerous when it occurs as a primary accident, and even more so in its secondary forms. In the first case, it contributes directly to shock, and in the latter, indirectly to the predisposition to septic poisoning. It must therefore be carefully guarded against, as well at the time of opera- tion as in the after conduct of the case. If it is evident during an operation that too much blood is being lost, and symptoms of exhaustion become appa- rent, the head of the patient must at once be lowered, to favor the access of blood to the brain. The respiratory efforts must be stimulated by the vapor of ammonia and cold aspersions, and, if the temperature of the body continue to fall, artificial heat must be applied. Excessive hemorrhage during opera- tion is much to be dreaded when it occurs in patients who are already anaemic from any cause. In military practice secondary bleeding has oftei/been too common, particularly in men who have been ovcrmarchcd, and whose vital powers have been broken down hy privation, nervous exhaustion, defective diet, and exposure to malarial and other depressing climatic causes. Under these circumstances, prolonged transportation in wagons and rude ambu- lances has proved most injurious by inducing bleeding; and the writer has known many a life thus lost, which might have been saved if the exigencies of war had only permitted the sufferer to rest in quiet near the scene of conflict. Shock, — A powerful element in the production of shock is prolonged opera- tion. In some instances, this would seem to be chargeable to the very state of anaesthesia. When a patient is insensible to pain, the surgeon may be tempted, perhaps unconsciously, to extend his operation over a longer period than is altogether judicious. Then too there is sometimes undue exposure of 470 OPERATIVE SURGERY IN GENERAL. the patient to draughts of air, and he becomes unnecessarily chilled ; and full reaction, upon which so much depends, takes place slowly. The development of the shock of operation is thus favored. It may, however, result from the previous effects of mental depression. In one or two instances the writer has seen it brought about, or at all events greatly augmented, by fear; in fact, in one well-remembered case, from fear, carried to such a state of abject cow- ardice and demoralization as to lead to disastrous consequences on the recep- tion of an insignificant wound. Surgical shock often accompanies large ope- rations, or operations on internal viscera, and, as a rule, the more extensive the operation or mutilation, the more intense will be the resulting shock. It may, however, attend comparatively trifling wounds or injuries, and the writer has seen it present in an exaggerated form, in one instance, where the spermatic cord was merely grazed by a bullet. The time of operation has much to do with the result. Thus, as a rule, no operation ought to be attempted during the existence of shock, but the surgeon should watchfully await the period of reaction. Exceptions to this law, it is true, may arise from the absolute ne- cessities of the moment ; for example, a limb may be almost torn off by a shot, or piece of shell, or may be hopelessly crushed in a railroad accident, and its prompt removal may be demanded by uncontrollable hemorrhage, or reaction after injury may be tardy, and the state of shock be kept up by the presence of the mutilated member. Here immediate operation may be proper, and indeed necessary to release the patient from his depressed condition, and thus preserve life. The relative influence of primary and secondary operations must also be considered, particularly in military practice, and when coupled with the question of after transportation. Intermediate operations, or those practised during the existence of traumatic fever, and before the arrival of the true secondary fever, should be discountenanced; since errors of judgment in this respect have too often led to unfortunate results. Local Condition. — The local condition of a part must always be carefully considered ; and operations should not be performed through unhealthy tis- sues, or through those which are inflamed, sloughing, or gangrenous, or in which phlebitis exists. Neither should plastic operations be repeated too soon after previous failures in obtaining union, but sufficient time should be granted to the tissues involved to harden and return to their original state. Neglect of this precaution is almost sure to be followed by the cutting out of pins and sutures, and by failure to unite. Hemorrhagic Diathesis. — There is one state of the system which greatly affects the question of operation; it is the existence of haemophilia or the hemorrliityii' diathesis. Fortunately this is not common, but still many cases have been recorded in which death has resulted, often after trifling operations, and for which the surgeon 1ms been severely, and generally unjustly, blamed. It behooves him, therefore, to be on his guard, and always to make inquiry before operating, whether the peculiarity has ever been observed in the patient or his relatives, for the disease not unfrequently affects several members of a family, who are often spoken of as "bleeders." If the answer is an affirma- tive one, the utmost caution should be observed; or, better still, if the patient himself possesses this constitutional proclivity, no operation should be per- formed, unless life be at stake. Condition of Patient after Operation. — The hygienic surroundings of the patient after operation, are of vital importance. If he is to be treated in a private house, it becomes the duty of the surgeon to see to these matters himself, and not to trust to the well meant but often badly executed inten- CONDITIONS DETERMINING THE RESULTS OF OPERATIONS. 471 tions of the family or friends of the patient. Every precaution must be taken to insure cleanliness in the widest sense of the term; a proper bed and bed- ding ought to be provided, and rubber cloths to prevent soiling by the dis- charges ; all unnecessary hangings and draperies should be taken down as possible receptacles of dust, and of orgaDic poisonous matters and emanations. The bed should be so placed as to be out of the way of draughts of air from doors and windows, and of direct currents of heat from hot-air flues, while at the same time convenient arrangements must be adopted to insure satisfactory ventilation, the temperature of the room being regulated by a thermometer. All excreta ought to be removed at once, and every means adopted to keep the room tidy, and the patient in as clean and comfortable a condition as pos- sible. Disinfectants should be freely used, not only in the room, but about the patient, whose person, where no objection exists, should everyday be care- fully sponged and dried without uncovering him unduly. The hygiene of hospitals has of late years been made the subject of elabo- rate study, and is daily attracting more attention. In all well-ordered hos- pitals, the diet sheets are usually sufficient and well arranged, and the personal cares rendered by the attendants are properly watched. The great danger in all large hospitals is, however, that of overcrowding; of bringing too many patients under one roof. Xot only ought this to be guarded against, but care should be exercised to see that the wards are not too large ; from twenty-five to thirty beds is a quite sufficient capacity for any one ward. The amount of air space usually regarded as sufficient for surgical cases, is from fifteen hundred to two thousand cubic feet, with a floor area of from one hundred to one hundred and thirty or forty square feet for each patient. These figures are all very well as far as they go, but it is well to see that, even with full averages, the height of the ceiling is sufficient, not less than fifteen or six- teen feet. Different systems have been devised for bringing in fresh air, and getting rid of the foul air, by means of upward and downward currents, and by the use of steam fans. Such ingenious methods have doubtless gone far to purify hospital wards ; at the same time there is reason to believe that the best system of obtaining ventilation and insuring perfect change of air is that which may be called the natural one, namely, by doors, windows, and open fireplaces. Ventilation and change of air during the night are strongly to be insisted upon, and the persistent efforts of hospital attendants to close up their wards tightly during the hours of sleep, ought to be watchfully anticipated and restrained. The population of large wards ought also to be vigilantly scrutinized, and too many suppurating cases should not be placed in one room. Patients with bad sloughing sores and putrid emanations had best be isolated when practicable, in order to prevent ward contamination, and every ward should from time to time be emptied and thoroughly cleansed and disinfected. In other words, no effort should be spared to preserve the purity of a ward, and to permit at all times the free access of fresh air, in itself the most thorough of all disinfectants. The importance of good hospital drainage must never be forgotten, and, in effecting this, proper measures ought to be taken to prevent the_ backing of sewer gas, which not unfrequently occurs from defective trapping. Such emanations are of the most deadly character, and are fearfully potent in giving rise to various forms of blood-poisoning. Mr. Eriehsen, in his truthful and forcible remarks on the overcrowding of hospitals, has pertinently pointed out the baneful influences of deficient sani- tary regulations, and has shown how cruel such a system is to patients, and how unjust to hospital surgeons ; inflicting on the former an unnecessarily high rate of mortality, and on the latter an undue burden of anxiety and respon- sibility. The subject of civil and military hospital construction and organization is. 472 OPERATIVE SURGERY IN GENERAL. foreign to the present article. Yet it may be said that for military purposes the well-known pavilion system of hospitals, with a central building for fid- ministration, is probably the most perfect which can be designed. It has also been shown practically that the same system, with certain modifications, can be made applicable to the erection of civil hospitals when sufficient ground can be obtained. One advantage of this system is the possibility of its ex- pansion to almost any extent, an important consideration in the foundation of hospital charities designed to meet the wants of rapidly-growing popula- tions. The experience of our late war conclusively proved the advantages of the pavilion system of hospital construction, and the history of the mag- nificent and extensive pavilion hospitals, which then sprang up over our whole country, will remain forever as a memorial of the intelligence, zeal, and ready adaptability to circumstances, which characterized the services of our army medical staff'. Perhaps in this connection it may not be amiss to refer to the excellent results which at that time attended operations treated in tent hos- pitals. As is well known, after severe battles, vast numbers of wounded were thrown upon the hands of the army surgeons. These patients were accommo- dated in division, corps, and general hospitals placed near the seat of action. These hospitals were composed of hospital tents, the number used being suited to the urgency of the occasion, and varying from ten or a dozen up to several hundred. Four or live or more of these tents were often pitched end to end, arranged in conformity with the lay of the ground, so as to form wards of proper size, which could be readily cared for and overlooked by the nurses and medical attendants. In winter weather and during the heat of summer, these tents were protected by the army tent-fly. In cold weather, the warming was accomplished by small iron wood-stoves. In many instances, where it was probable that the hospital would be in use for some time, board floors were laid down. Whether this was realty an advantage or otherwise seemed at times questionable. Tents so furnished looked better, it is true, but were open to the objection of foul accumulations taking place beneath the floor. They were supposed to be more free from dampness, but this could usually be guarded against by proper trenching, and it is not impossible that the earth floor in itself was preferable from its inherent antiseptic qualities. During this period it was surprising to note how well operations did, and how rapidly convalescence took place under these simple arrangements, which, rough as they might seem to the unprofessional eye, were undoubtedly to be preferred to any form of barrack, or, indeed, permanent hospital. Causes of Death after Operations. Hemorrhage. — Death may occur during or after an operation from different causes, acting singly or in combination. It may result, in the first place, from hemorrhage; and the more rapidly this takes place, and the greater its amount, the more depressing and disastrous will be its effects. If it be very excessive, death may be almost immediate; but generally in operations, although bleeding may possibly be profuse, it is prolonged, marked by quantity rather than by rapidity, and by timely and vigorous effort it may be arrested. There are instances, too, where, although not great in extent, its effects may at the time be pronounced, and, in the end, fatal. This is apt to be the case in patients of broken-down constitution, and wdio are usually spoken of as bad subjects for operation. These fail to react, and either sink from exhaustion or fall ready victims to septic or intercurrent discuses. Fortunately, at the present day, -death upon the operating table from bleeding rarely happens, since the resources of modern surgery have CAUSES OF DEATH AFTER OPERATIONS. 473 placed in the hands of the operator so many and such ingenious means of preventing such an occurrence ; at the same time, it is just possible that the very employment of some of these means of controlling the primary flow may predispose to its secondary occurrence. Thus, if Esmarch's upper bandage be drawn too tightly, it may by its pressure prevent bleeding from vessels of medium size, which it were well to ligate, so that on the removal of the constriction and on full reaction, after the patient has been carried to his bed, troublesome bleeding may set in. This fact must be remembered, and caution should be observed in regulating the pressure at the time of operation; and very careful search must be instituted for bleeding points. Secondary arterial hemorrhage may happen at any moment, from the hour of operation until the deep portions of the wound are healed. It may result from imperfect ligation, from enlargement of the vessels, from too rapid and great development of the collateral circulation, from sloughing, from atheroma of the arteries, or from premature falling of the ligatures. Secondary venous bleeding may take place from the backward flow of blood at points destitute of valves, either where the valves are normally deficient, or where they have become imperfect from disease ; or bleeding may occur from veins where a varicose condition exists. And in this connection it may be said that there is no reason why the veins which bleed should not be tied in amputations. The risk of so doing is exaggerated ; the writer has frequently practised such ligations, and has known many instances where others have pursued the same course with good results. Venous bleeding may also be caused after ampu- tation by adhesive strips or bandages applied circularly around the stump, so as to produce too much pressure when swelling of the part has occurred. The danger of bleeding, let the cause be what it may, cannot be overesti- mated, constituting, as it so often does, the turning point in the case, and forming one of the factors in the production and maintenance of shock. Shock. — The shock of operation, familiar to every surgeon, is usually the result of no single cause, but rather of several combined. Hemorrhage, anaesthesia, prolonged manipulation, chilling of the body consequent upon exposure to the air, and the operative lesion to the tissues, are alike con- cerned in bringing about the prostration which characterizes this state. Mental causes also exert no slight predisposing influence in the production of shock. There is scarcely any better preparation for a patient about to submit to operation than a bright, hopeful disposition ; there is none worse than despondency and dread. Other things being equal, the chances of recovery in the former instance are far better than in the latter. Shock is usually attended by extreme depression of the nervous system and inter- ference with the action of the heart. The skin is of a waxy-white pallor ; there is loss of color in the face, and particularly in the lips ; a cold clammy perspiration, with sweat-drops forming on the forehead ; and a pinched and contracted expression of countenance. There is intense muscular prostra- tion, loss of bodily temperature, feeble respiration, and, in extreme cases, relaxation of the sphincter muscles. The pulse becomes feeble and irregular, and sometimes cannot be detected at the wrist. If an anaesthetic has" been used, it will be difficult to form an opinion of the condition of the special senses ; but, if not, these will be found to be somewhat dulled and interfered with. Intellection may remain in part — ordinarily, however, accompanied by some degree of hebetude or bewilderment. In milder cases of shock, there are not unfrequently nausea and vomiting, the latter of which is usually followed by reaction. Where the shock is very great and prolonged, death occurs from cessation of the heart's action; and this may at times happen 474 OPERATIVE SURGERY IN GENERAL. as a purely nervous effect, independent of hemorrhage or the other lethal causes referred to. Another cause of shock, of more common occurrence than it should be, is too prolonged or lengthy operation ; and this must be carefully guarded against, particularly in childhood and old age — periods of life more than all others susceptible to depressing influences. Pain, if great or of long dura- tion, either at the time of operation or afterwards, contributes not a little to prostration, and may weigh down the scale of life and death. Violence dur- ing operation, or roughness of manipulation, leading to bruising of delicate tissues, as the prostate gland and neck of the bladder, may produce disastrous consequences, and the more so if such efforts are persisted in for any length of time ; and the same may be said of forcible extension of the knee-joint, a procedure too often fraught with fatal shock. When, from any circumstance, a condition of sudden depression, prostration, or shock, is becoming apparent during or immediately following operation, the most active measures must be instantly resorted to. Hemorrhage must be stopped at once, even if the operation has to be temporarily discontinued ; the patient's body must be elevated, and his head made dependent, so as to invite the flow of blood to the brain. With the same intent, the large arteries of the extremities may be compressed by tourniquets, so as for the time to cut off' the vascular supply in this direction, and increase the amount avail- able for the demands of the central organs. The anesthetic should be imme- diately withdrawn, and the vapor of ammonia and that of nitrite of amyl employed for their stimulating effects. The temperature of the body should be kept up by the application of hot-water bottles and cloths to the trunk and limbs, and by the use of stimulating or hot-water enemata. If the loss of blood has been very severe, transfusion should be attempted. The success of this measure in chronic hemorrhages has been sufficiently great to warrant, and, indeed, command, its employment as an immediate resource in acute suro-ical cases, where of all others its happy influence may be expected. Any of the different processes may be resorted to, but caution should be observed as to the quantity of blood injected ; not more than three or four ounces should be thrown in at first, and the effects of the operation carefully watched. Usually, if this has not been too long delayed, these are promptly marked by the stronger heart-beats and the improved character of the pulse. If blood cannot be readily obtained, intra-venous injections of milk or other fluids can be made, in the manner described in another part of this work. (See Article on Minor Surgery.) Hypodermic injections of ether may also be used as a substitute for transfusion, with excellent results. Occasionally it happens that death after operation results from secondary shock or exhaustion. This is most frequently the case in old persons, or those of delicate constitution, or of impressionable temperament. In them the first reaction is apparently complete and satisfactory ; the respiration and circula- tion seem good ; they sleep ; and there may be sonic return of appetite. These favorable appearances arc, however, delusive and of short duration, for in a little while, it may be at the expiration of eight or ten hours, or perhaps even after two or three days, the patient becomes weaker and weaker, and slowly relapses into a condition of shock, from which he cannot be extricated, and which continues until death. Sometimes the patient's downward course is rapid, at other times very gradual. Usually, in these cases, the mind remains clear to the last, and the patient seems indifferent as to his condition. It is difficult to offer any explanation of the state of secondary shock, except on the idea of exhaustion of the heart, and the giving out of its power, dependent upon some of the causes already spoken of. Heart clot, formed during the CAUSES OF DEATH AFTER OPERATIONS. 475 operation, is the pathological condition found in many of these cases, and its ill effects may be sometimes obviated by the free administration of ammonia, either by the month or by intravenous injection. Delirium. — Death may also take place after operation, or after injury, by the setting in of delirium., which usually presents itself as an acute affection in one of three forms. In the first place, it may appear as acute traumatic de- lirium, attended by symptoms of a highly inflammatory character. The pulse is then quick and full, the face flushed, the skin hot and dry, the eyes suffused, the restlessness and jactitation extreme, and the mental condition varying from incoherent babble and disjointed talk up to the most violent busy excite- ment. In another class of cases, and by far the most common, the affection is a true delirium tremens, characterized by all its well-known symptoms, tre- mors, delusions, and fancies. This form of delirium occurs in persons of in- temperate habits, and in those who have been recently drinking. It is also met with in such as have been only moderate drinkers, and in those who have discontinued their habits in this respect for some time. The occurrence, after operation, of either of these forms of delirium is a most serious complica- tion, and although many patients do recover from them, the prognosis is always grave, and not a few perish. One peculiarity of patients suffering from these invasions of delirium is their indifference to pain, and their con- stant tendency, and often persevering attempts, to do themselves bodily injury, by tearing off dressings, leaping from the bed, and inflicting violence upon themselves of every form. The treatment in such cases readily suggests itself. In the first place, such restraint must be enforced as is necessary, with constant watching ; and for the acute inflammatory delirium, cold to the head, local depletion, and the cautious use of sedative narcotics. In the traumatic form of delirium tremens, the ordinary remedies for the treatment of this affection must be resorted to, such as bromide of potassium, capsicum, chloral, and opium, employed singly or in combination as may appear most appropriate. In many cases the hypodermic mode of medication will be the only one possible. The great indication is to procure sleep, and the therapeutic efforts in this direction must be steadily carried out until the result is obtained. There is one other form of delirium after operation which is occasionally encountered. . This is the traumatic nervous delirium observed in females of hys- terical tendencies, and in persons of both sexes of broken-down constitutions, or in anremic conditions. It is sudden of invasion, and is attended with men- tal hallucinations of almost every sort ; usually of a quiet kind, but sometimes also of a noisy nature. This. affection is one of weakness rather than of a true inflammatory nature ; the pulse although frequent is feeble; the skin is not hot, but is often covered with a cold perspiration, and at times tremors are present. The prognosis in such cases is unfavorable, and death results in the majority of cases. The treatment consists in the employment of stimulant and soothing narcotics. Thrombosis and Embolism. — Patients occasionally perish after operation from the formation of a heart clot, or from embolism ; sometimes the coagula form in the large vessels, and then by their detachment give rise in turn to heart clot and secondary embolic plugging. There is alwa3's a predisposition to undue coagulation of the blood, after excessive bleeding, and this is greatly favored by the occurrence of fainting. The patient at these times must there- fore be kept quiet, and cautiously moved, nor should he be allowed to sit up in bed, or to attempt any muscular exertion for fear of the development of fatal syncope. 476 OPERATIVE SURGERY IN GENERAL. Air in Veins. — Another accident from which death has heen recorded is the entrance of air into a vein, following upon its incision during an opera- tion. This circumstance ought to he borne in mind when large veins are involved, particularly in the deep portions of the neck, and when the tissues are infiltrated and indurated by disease. If a vein of any size be opened un- der these conditions, the lips of the wound may, on account of the tissue-con- nections of the vein, gape sufficiently to permit the entrance of air, and death may ensue, sometimes almost instantly. Whether the presence of air in the right heart paralyzes cardiac movement, or whether the air entering the branches of the pulmonary artery causes cessation of the circulation, is a mat- ter for discussion ; yet the great clinical fact remains, and enforces upon the surgeon the greatest caution in operating in these dangerous regions. Gangrene and Sloughing. — Death after operations may occur, particularly in military practice, from the formation of sloughing sores, or the develop- ment of true hospital gangrene. The latter, in this country, has, however, been more rare than it is generally believed to have been ; many of the cases described as such being in reality sloughing sores, not possessing the property of contagiousness. This was shown in a remarkable manner in our late war, where not a few eases of gangrene from the Libby and Andersonville prisons reached the northern lines. These possessed apparently all the destructive tendencies and evidences of hospital gangrene, but }-et when placed in beds in general hospitals, under favorable hygienic conditions, the disease evinced little tendency to spread from bed to bed, or at all events to attack men who had not been exposed to the same predisposing causes, imprisonment, starva- tion, and exposure. The most effectual treatment for such cases consisted in ventilation, diet, and active cauterization of the sloughing surfaces with pure bromine, as suggested by Dr. M. Goldsmith, late Surgeon IT. S. Volunteers. Tetanus is another cause of death after operations. It may occur after slight operations as well as after those of great magnitude. Yet, in propor- tion to the whole number of cases, it is, at least in our climate, so infrequent that it may practically be disregarded in deciding upon the propriety of ope- ration. Almost every imaginable circumstance has been advanced as an ex- citing cause of this terrible affection, as injuries, wounds, the presence of foreign bodies, verminous irritation, the arrest of natural or existing dis- charges, and exposure to heat or to dampness and cold. It has been the custom to lay stress upon the latter condition as a powerful causative agent in mili- tary practice. This is, however, probably incorrect. It is not the degree of cold which acts, but rather exposure to trickling or changing draughts of air, or, as Ilennen has put it, to air in motion. The writer has known of instances where large numbers of wounded have at the same time been exposed to severe cold, without the development of a single case of the disease, while on the other hand, an instance was reported to him where two, if not three, consecutive cases of tetanus occurred in the same bed, every other one in the ward being exempt. The fatal bedstood in the direct draught of air between a window and an opening door, and on its removal to a less exposed position no further instance of the disease appeared. Tetanus at times almost seems to be epidemic, <>r at all events t<> affect many who are the victims of casu- alties of a given nature. Tims in the summer of 1880, frequent deaths from this disease occurred in Philadelphia, and during 1881, in Baltimore, from the use of a toy pistol, which exploded metallic powder cartridges. This dangerous plaything was the means of injuring numerous children by its pre- mature and imperfect explosion. In almost every such case admitted to hos- pital, and in others treated in private practice, tetanus ensued and was followed CAUSES OF DEATH AFTER OPERATIONS. 477 by death, the disease often making its appearance many days after the recep- tion of the wound, and in some instances long after its closure and apparent healing. Erysipelas is a not infrequent forerunner of death after operation, and must be regarded as a constitutional rather than as a local affection. It has long been the custom to look upon it as contagious ; but it is probable that this view is too exclusive. The doctrine is last gaining ground that this dis- ease is not really contagious, but that it is the result of a true septic poison depending on many circumstances. It, too, at times seems to be epidemic, occurring as it does, particularly in this country, during periods of rapid changes In the weather, and during atmospheric vicissitudes. It is apt to be induced by dampness and cold, and to make its appearance in persons of broken-down constitution. Its treatment is essentially a supporting one, and general tonics and iron are to be relied upon, rather than depleting agents. Closely allied to erysipelas, are those forms of diffused and spreading cellulitis and inflammation of the veins and absorbents so often observed in hospital, following wounds and operations, on those of debilitated constitution, and on drunkards. In many of these cases, surgical therapeutics avail little, and death from exhaustion ensues, after delusive intervals of hectic more or less prolonged. Indeed, exhaustion from long-continued discharges, whatever may be their origin, may be assigned as a not infrequent cause of the fatal termination of operations. The disastrous influences of Pyjemia and Septicemia require but a passing mention here, since they form the special subjects of another article. These forms of blood-poisoning are met with most often in patients of depraved system, or in the aged, or in those who have been broken down by overwork, mental or bodily. "They cause a large proportion of the deaths after opera- tions, and from their fatal consequences demand the closest study from the operating surgeon. MINOR SURGERY. BY CHARLES T. HUNTER, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA J SURGEON TO THE EPISCOPAL HOSPITAL, PHILADELPHIA. Surgical Dressings. Surgical Dressings are generally considered to comprise various materials peculiarly adapted to protect wounds, absorb discharges, serve as vehicles for applying medicinal substances to wounded or diseased structures, aid in retaining injured parts in position, etc. The substances usually employed for these purposes include lint, charpie, tow, oakum, cotton, paper-lint, and jute. Lint. — Two varieties of this material, domestic and patent, are used for surgical dressings. Domestic lint consists of pieces of old linen thoroughly cleansed either by being washed with soap and water, or boiled with a weak lye, and having one surface rendered downy by scraping up the threads, or cutting them at intervals, with a knife. Old linen, treated in this way, is peculiarly adapted to absorb secretions and to protect very delicate and sensi- tive surfaces. Patent lint is manufactured in large quantities by machinery : hence it is more uniform in shape and consistence than the domestic variety, but much more expensive. This lint has a soft tomentose surface that renders it un- suitable for direct contact with granulating or wounded parts ; for the fine filaments adhere to the granulations, and thus become a source of irritation. When thickly encased with some unctuous preparation, such as the oxide of zinc ointment, it forms an admirable protective covering. Charpie consists of bundles of straight threads, varying in length from two to four inches, and obtained by ravelling square pieces of linen. Expe- rience has demonstrated that charpie made from new linen is softer and pos- sesses greater absorbent properties than that made from old. Charpie ought never to be placed on an unprotected granulating surface, or directly in contact with a recent wound, as is not infrequently done ; in either case its presence will excite injurious irritation. Since the introduction of oakum and other less expensive materials as surgical dressings, charpie is not as much used as formerly, especially in hospitals and dispensaries where it is necessary to con- sult economy. Tow is occasionally made use of as a padding for splints, and as an exterior dressing, but rarely as an application for uncovered wounds. An elegant ] 're- paration of carbolized tow has recently been introduced, and has been found to be serviceable in many ways. (479) 480 MINOR SURGERY. Oakum was introduced as a cheap substitute for other more expensive sur- gical dressings, during the late American war, by Prof. L. A. Sayre, 1 of New York, and since then it has been very generally employed both in private and hospital practice throughout the civilized world. It is highly probable, however, that this substance has been often used for surgical purposes on board ship. In Pepys's diary, mention is made of a marine who had just returned from a severe naval, engagement fought off the North Foreland, June 1-4, 1666, with "his right eye stopped with oakum." Oakum is believed to have antiseptic properties by virtue of the tar with which the pieces of old rope from which it is made are impregnated. Formerly this material was applied directly to the surface of wounds, but on account of the stiffness and coarseness of its fibres it has been found too irritating for this purpose. It is admirably adapted for use as an outer and protective dressing, and as padding for surgical apparatus. Cotton, freed from its oleaginous principle by being boiled with alkalies or otherwise treated, is rapidly coining into favor as a surgical dressing. Pre- pared in this way, it quickly soaks up the secretions from a wound, and is preferred in many instances to oakum or marine lint as an outside absorbent dressing. It may be medicated with any of the popular antiseptics, such as carbolic, boracic, or salicylic acid, thymol, etc. Gynaecologists, in their prac- tice, find it a useful means of making applications to the female genital organs. Paper-Lint. — This dressing was first used for surgical purposes by Dr. Studdiford, of Lambertville, K". J. It is made from old rags that have been specially prepared and rolled in sheets of the requisite form and size. Dr. "W. W. Keen, of Philadelphia, has suggested the incorporation of cotton or linen threads with paper-pulp, before it is rolled, in order that the lint may be rendered more tenacious. As an application to the unbroken surface of the body, and as an absorbent, external dressing, this variety of lint is quite as useful as patent or domestic lint ; but, in consequence of its not possessing the softness and the pliability so characteristic of linen, it is not, as a rule, a good substitute for this material in the dressing of wounds. Its cheapness in comparison with the high cost of patent lint recommends it for hospital and dispensary use. Jute. — This substance, of which gunny bags are made, is the fibre of an Indian annual, the Corchoms capsularis. In consequence of the peculiar character of its fibres, it is well adapted for the absorption and the retention of the various antiseptics ; this property, and its cheapness in comparison with gauze and surgical cotton, have recommended its use as an antiseptic medium, to many of the advocates of Listerism. Jute may be employed with advantage as an absorbent dressing in all cases in which oakum or cotton is used ; rolled loosely in small masses, it is considered in hospital and military practice a good substitute for sponges by those surgeons who believe that the use of these may result in the infection of wounds. To meet a great variety of indications in the treatment of wounds, sur- l:<'(>iis are accustomed to make the following forms of dressing froin the sub- stances already described. COMPRESSES are usually made by folding; pieces of lint, flannel, paper-lint, or muslin, upon themselves, so as to form firm masses of varying size; these 1 Boston Medical and Surgical Journal, vol. lxvii. p. 84. SURGICAL DRESSINGS. 481 may be made square, oblong, triangular, or graduated in shape. When a compress has a hole in its centre, it is termed a perforated compress ; if there are many perforations, it is called a cribriform compress. JLjpyramidal compress is constructed by placing a series of square compresses, gradually diminishing in size, upon one another, in such a way as to form a pyramid. Oblong compresses arranged in the same serial order make a prismatic com- press. A square piece of lint or muslin, slit from its angles towards the cen- tre, forms a Maltese cross ; an oblong piece, with slits extending from the angles of one side obliquely towards the opposite side, is called a half Mal- tese cross. These two forms of compress are found of service in covering the end of a stump, or in retaining dressings in contact with it. The Pledget is a form of compress consisting of charpie, oakum, or jute, the fibres of which are arranged in a direction parallel to one another ; after the ends are folded down, the mass is flattened between the hands, and fashioned into the required shape, either square, oblong, pyramidal, or graduated. Constructed in this manner, pledgets are applied as external dressings to wounds, extremities of stumps, and ulcers, for the purpose of absorbing discharges and excluding the air, and in some instances to make compression, and to aid in giving fixity to other dressings. The Tent is a small roll of either of the substances referred to in the last paragraph, doubled upon itself, and made to" assume a conical shape by twisting its free ends between the thumb and fingers. A strip of lint or muslin is often used for the same purpose. Tents made in this way are de- signed in special cases to keep wounds patulous, and thus to afford a ready escape to discharges. A tent should be introduced into a wound by a rotary motion, having previously been smeared with some bland, unctuous substance. The Meche is made by twisting a mass of parallel threads of charpie at the middle ; if the threads are tied together with a string, the mass is called a Roll. These dressings, anointed with olive oil or simple cerate, and placed in the track of a sinus or fistula that has been laid open, will delay union of its edges till the deeper part has granulated. Hemorrhage from a deep wound may be checked by pressing a meche or roll down to the bottom ; the central part of the mass will compress the bleeding vessels, and the loose end will favor the formation of a clot. Meches and rolls are introduced into a wound by means of a poiie-meche (Fig. 40), director, or probe, placed against the compact centre of the mass. Fig. 40. 1 GEMRIG &S0N. PHIL, Porte-m&che. Pellets and Bullets are small masses of charpie, oakum, cotton, or jute, rolled loosel} T between the palms of the hands. The former differ from the latter only in being inclosed in small bags of linen or old muslin. They may be usefully employed as tampons in cases of wounds, to check bleeding, and may be introduced into suppurating cavities for the purpose of absorbing pus and preventing burrowing. Retractors are strips of muslin designed to protect soft tissues from being- injured b} r the saw in amputations. The retractor of two tails is an oblong piece of muslin, ten to fifteen centimetres (four to six inches) wide, and thirty to forty-five centimetres (twelve to eighteen inches) long, with a slit extend- vol. i. — 31 482 MINOR SURGERY. ing from one extremity to the centre, where a diamond-shaped piece is cut out. The retractor of three tails is of the same size as the preceding, but has three tails instead of two. The former is used in amputations of the arm and thigh. After the flaps have been fashioned and the soft parts divided, the retractor is applied by passing the tails one on either side of the bone, and crossing them ; then by drawing the tails up on one side and the body of the retractor on the other, the flaps are held out of the way of the saw, and pro- tected from the bone-dust. The three-tailed retractor is employed in ampu- tations of the forearm and leg ; the middle tail is passed through the inter- osseous space, and the other two are carried around the bones. To get the greatest advantage from the use of wet dressings, in cases in which heat and moisture are indicated, it is necessary that the dressings shall be covered with some material impervious to water. The following substances possess this property to a greater or less degree :— Oiled Silk and Gutta Percita or Rubber Tissue, are the substances most commonly used in private practice; the former in this country and the latter in England. Although these two substances make the best water-proof covers for moist dressings, yet their great cost, and the supposed risk of their be- coming media of contagion if used more than once, have led to the substitu- tion of other less expensive articles, viz., waxed paper and water-proof paper. Waxed Paper was first suggested and used in the Pennsylvania Hospital, by Dr. A. Hewson. 1 It is prepared by placing a sheet of tissue paper on the surface of melted wax in a broad, shallow pan, and, before the paper sinks in the wax, slowly drawing it over the edge of the pan, in order that the super- fluous wax may be removed from its under surface. The sheets of paper thus treated are suspended on cords for a few hours in a cool place ; after which they are ready for use. A sand-bath is employed to keep the wax in a liquid state. Water-proof Paper. — Dr. W. W. Keen, of Philadelphia, 2 has devised a method of preparing paper by which it is rendered impervious to water and air. The paper is treated with a combination of rubber and paraffine which makes it impermeable to water for a period of seventy-two hours, and it may be used with the hottest dressing that can be borne. Unlike waxed paper, its water-proof property is not in the least affected b} T being creased or crumpled, nor will it absorb either water or the discharges from a wound. It is asserted by some surgeons that in hospitals where large quantities of water-proof material are concerned, it has been found more economical to use water-proof paper than oiled silk or rubber tissue, even when the former is not used a second time. In order that wounds maybe treated strictly antiseptically, two substances, made impervious both to the discharges from the wounds and to the surround- ing media, are essential: one to protect the wound itself from contact with the dressing ; the other to prevent putrefactive germs from gaining access to the dressing as it becomes saturated with the discharges. The Protective. 3 — This material is to be placed in direct contact with the wound. It consists of oiled silk coated on both sides with a thin layer of ■ Pennsylvania Hospital Reports, 1868, p. 389. 2 Medical and Surgical Reporter, vol. xl., 1879, p. 331. 3 MaeCormac, Antiseptic Surgery, p. 135. THE USE OF BANDAGES. 483 copal varnish, and, when dry, brushed over "with a solution containing one part of dextrine and two of starch, dissolved in fifteen parts of five per cent, carbolic solution." Immediately before using the protective, it is to be dipped in a 1-40 carbolic acid solution, in order that no germs may be left adhering to it. The same piece of protective may be used several times if it be properly disinfected. Mackintosh. — This substance consists of cotton or silk, made impermeable to water and air by being coated on one or both sides with India-rubber. Other substances, among which are rubber-tissue and oiled paper, have been employed as substitutes for mackintosh, but they have proved less efficient. It is placed external to the gauze-dressing, and may be secured by a gauze- bandage, or by an elastic bandage, which Mr. Lister occasionally uses now. A piece of mackintosh may be repeatedly used, if care be taken to clean and disinfect it thoroughly each time that it is applied. The Use of Bandages. "Roller Bandages. — The Roller consists of a band or strip of woven mate- rial, prepared for application to some portion of the body by being rolled into cylindrical form. The materials commonly used are unbleached muslin and flannel ; for special purposes, however, linen, calico, silk, India-rubber, or crinoline, may be selected. It is desirable that a bandage should consist of a single piece, free from seams and selvage ; yet bandages are sometimes made of several pieces sewed together. The latter should be avoided if possible whenever it is necessary to apply a bandage next to the integuments, for Flg " the seams (and the same is true of sel- """"X^,^'-^ -- vage) will leave creases in the skin. / / M m!i&Ds §StL Bandages vary greatly in length and /■; width according to the purposes for >\ which they are employed, ranging from 2 to 10 centimetres (f of an inch to 4 inches) in width, and from 18^- to 91 decimetres (2 to 10 yards) in length. Bandages may be rolled by hand, or with a machine called a winder (Fig. 41), which is commonly used in hospitals where large quantities of bandages are consumed. In private practice a medical attendant may be x -,1 -, . . . u ., Bandage winder. called upon, at any moment, to roll a bandage ; hence the art of rolling one by hand, which may be readily ac- quired with slight practice, should be familiar to every physician. In Fig. 42 is illustrated the way in which a roller is to be held in winding it by hand. A bandage rolled into the form of a cylinder is called a single,or single-headed roller (Fig. 43); if rolled from each extremity towards the centre, into two round masses, it forms a double, or double-headed roller. (Fig. 44.) The latter form of roller is hardly ever used. Parts of a Roller. — The free end of a roller is termed the initial extremity ; the end inclosed in the centre of a roller is its terminal extremity; the portion intervening between the extremities, the body ; a roller has two surfaces, ex- ternal and internal. Bandages derive their names from one of two circum- stances, either from the direction that they are made to take when applied, 484 MINOR SURGERY. Fig. 42. Mode of rolling a bandage by hand. or from the purposes subserved by them. Thus there are circular, oblique, spiral, spica, figure-of-eight, and recurrent bandages of the first kind ; and re- taining, compressing, uniting, dividing, etc. of the second. Fie. 43. Fnr. 44. Single-headed roller. Double-headed roller. General Rules for Bandaging. — The operator, as a rule, should stand with his face towards his patient, and before he begins to bandage any part — a limb, for instance — he should see that it is in the position, as regards flexion and extension, which it is to occupy after the bandage is applied. In the application of a bandage, the external surface of the initial extremity should be placed next to the pari to be covered; for then, as the bandage is unwound, it tends to roll into the operator's hand, thereby giving him more control of it. To Secure a Bandage. — The initial extremity of a bandage is secured by two or three circular turns ; the terminal end may be fastened by one or two pins, or by tearing it into two tails and tying them around the part. (See Pig. 49.) When pins are u yards) long. The initial extremity is first secured by two circular turns around the wrist, after which the roller is carried from one side of the wrist to the opposite side of the hand obliquely across either the dorsum or the palm, the direction being determined by that surface of the hand which is to be covered ; from this point the bandage is wound around SPIRAL BANDAGES. 487 the base of the finger and taken back to the wrist, making a figure-of-eight of the finger and wrist. A figure-of-eight turn is made in like manner around the base of each finger and the wrist in succession, and the roller is finally fastened at the wrist. (Fig. 49.) This bandage is admirably adapted to con- fine dressings to either surface of the hand, as occasion may require ; it is less cumbersome, and retains a dressing with more security, than any other means used for the same purpose. Fig. 48. Spiral bandage of a finger. Spiral bandage of the hand, or demi-gauntlet. The Spiral Reversed Bandage of the Lower Extremity. — Two rollers, each 6J-7 T 7 -g- centimetres (2|-3 inches) wide and 6 h metres (7 yards) long. The initial end being secured just above the malleoli by two circular turns, the roller is carried obliquely across the dorsum of the foot, and, on reaching the metatarso-phalangeal articulation, is conducted directly around the foot; the body of the foot is now covered by two spiral reversed turns and the same Fig. 50. Spiral reversed bandage of the lower extremity. number of figure-of-eight turns, the latter being around the ankle and instep, and the roller is then continued up to the knee by spiral reversed turns, each turn covering one-third of the preceding ; the reverses should be in a line on the outer side of the spine of the tibia. As in the case of the elbow, the knee may be covered by spiral, spiral reversed, or figure-of-eight turns. If it be de- signed to keep the knee flexed, the figure-of-eight turns should be employed. From the knee the roller is conducted up the thigh by spiral reversed turns, and is secured by pins. The second roller is used for the knee and the thigh. (Fig. 50.), A modification of this bandage is occasionally employed to cover the heel, and is known as the American Spiral in contradistinction to that just de- scribed, which is sometimes called the French Spiral. The turns by which the heel is included are made in the following manner: After the foot is cov- ered by two or three spiral turns, the bandage is carried directly over the point of the heel, across the tarsal portion of the foot, thence beneath the in- step, around one side of the heel and up over the instep again ; from this point it is conducted beneath the instep, around the other side of the heel and up 488 MINOR SURGERY. in front of the ankle, from which it may be made to ascend the leg, as in the preceding bandage. (Figs. 51, 52.) The Spiral Bandage of the Chest. — A roller 7f— 9 centimetres (3-3J inches) wide, and 9^- meties (10 yards) long. Make two circular turns around the Fig. 51. Fig. 52. Fig. 53. American spiral of the lower extremity. waist, to secure the initial extremity of the roller, and then ascend the chest by spiral or spiral reversed turns, each turn overlapping one-third of the pre- ceding ; when the borders of the axillae are reached, conduct the roller around the base of the neck, or through one axilla and over the corresponding shoul- der, obliquely down the anterior aspect of the thorax. If this longitudinal strip be pinned or stitched to the spiral turns at their intersections, the bandage will not be easily disarranged. The Spiral Bandage of the Penis. — A roller 2 centimetres (f of an inch) wide and | of a metre (30 inches) long. Secure the initial end of the roller by two circular turns around the penis, close to the pubes, and conduct the bandage by oblique turns to the corona glandia ; from this point ascend the body of the penis by spiral or spiral reversed turns; then make two or three figure-of-eight turns around the neck of the scrotum and the root ol the penis, and secure the terminal extremity by dividing it in two strips and tying them around the root of the penis. (Fig. 53.) The terminal figure-of-eight turns of this bandage keep it securely in position, and thus render it a very useful means of compressing the urethra over a catheter or bougie, in cases of obstinate hemor- rhage from the penile portion of this canal. Spica Bandages. — These bandages are exceed- ingly serviceable as a means of retaining surgical dressings on particular parts of the surface of the body, for which the spiral rollers are not well adapted. They derive their name from their fancied resemblance to a spike of barley. SPICA BANDAGES. 489 The Spica Bandage of the Thumb. — A roller 2 centimetres (f of an inch) wide and 2f metres (3 yards) long. Fasten the initial extremity by one or two circular turns at the wrist, then carry the roller obliquely over the dor- sum of the thumb to its distal extremity, and there make a circular turn ; from this point conduct the roller obliquely over the back of the thumb to the wrist, around which make another circular turn; then carry the bandage Fig. 54. in a figure-of-eight form around the thumb and back again to the wrist. These turns overlapping one another by half or two-thirds of their width, are repeated till the whole length of the thumb is enveloped. (Fig. 54.) Spica bandage of the thumb. The Spica Bandage of the Shoulder* — A roller 6 J centimetres (2| inches) wide and 6f metres (7 yards) long. Fix the initial extremity by two circular turns around the arm just below the mar- gin of the axilla ; carry the roller from the outer surface of the arm, if on the right side, obliquely across the front of the chest ; if on the left side, obliquely over the back ; through the opposite axilla and back to the shoulder from which the bandage was started, there- by completing the first spica ; then Fi g- 55. conduct the roller around the arm of this side, up over the shoulder, across the thorax, through the axilla the second time, and back to the shoulder again. Repeat the turns in like man- ner, over the shoulder and through the opposite axilla, till the former is cov- ered ; after which conduct the terminal end around the neck and down the front of the chest where it may be se- cured by a pin. Where the turns of the bandage intersect on the shoulder, they should overlap one another to the extent of one-third of their width ; in the opposite axilla, however, they should completely cover one another. (Fig. 55.) When the intersections or spicas advance successively from the point of the shoulder to the base of the neck, the bandage is called the ascending spica. If the succession of the spica be in the reverse direction, that is, from the neck towards the arm, the roller is termed the descend- ing spica. Small masses of cotton, oakum, or jute, should be interposed be- tween the borders of the axilla and the turns of the bandage to prevent excoriation. Spica bandage of the shoulder. The Spica Bandage of the Groin. — A roller 74 centimetres (3 inches) wide and 9|- metres (10 yards) long. Secure the initial end by two circular turns around the body, just above the pelvis ; then carry the roller obliquely down- wards across the lower part of the abdomen, either to the outer side of the 490 MINOR SURGERY. left thigh, or to the inner side of the right, as the case may be; thence around the thigh, obliquely upwards, crossing the preceding turn, and around the body. Continue these turns around the thigh and abdomen, either in an as- cending or a descending order as regards the thigh, till the roller is exhausted. Each turn around the thigh should overlap that immediately preceding by one-third of its width. If the intersection of the turns on the anterior surface of the thigh and the groin be from above downwards, a descending spicu will be formed ; if they be in the reverse direction, that is, from below upwards, an ascending spica will be made. (Fig. 56.) Fig. 56. Fig. 57. Spica bandage of the groin. Spica bandage of both groins. The Spica Bandage of both Groins. — Two rollers, each 74 centimetres (3 inches) wide and 6f metres (7 yards) long. Fig. 58. Spica bandage of the foot. This bandage is begun like the preceding, by two circular turns above the ilia, after which a spica turn is made, as above de- scribed, first on one thigh and then on the other, either in an ascending or a descending series. (Fig. 57.) The Spica Bandage of the Foot, sometimes called Ribbail's Bandage. A roller 5 centime- tres (2 inches) wide and Of me- tres (7 yards) long. Make fast the initial end of the roller, laid obliquely upwards on the dor- sum of the foot, by a circular turn around the metatarst (-pha- langeal articulation, and one or two spiral reversed turns around FIGURE-OF-EIGHT BANDAGES. 491 the metatarsus ; then carry the bandage parallel with the inner or outer margin of the sole of the foot, according to whether it be the right or left foot, directly across the posterior surface of the heel, thence along the oppo- site border of the foot and over the dorsum ; this completes one spica turn. From the dorsum the bandage is made to encircle the foot and pass around the heel and over the foot the second time, thereby forming another spica on the foot. By continuing these successive turns around the foot and the heel, each complete turn overlapping one-half or two-thirds of the preceding, in an ascending order, the entire foot and ankle are covered. (Fig. 58). In all cases in which firm compression of the foot is indicated, as in bruises, chronic sprains, wounds of the tibial vessels, etc., this neat bandage will be found of great advantage. Figure-of-Eight Bandages. — The Figure-of-Eight Bandage of the Elboic. — A roller 6 \ centimetres (2 h inches) wide and If metres (lh yards) long. Fix the end of the roller by two circular turns around the upper part of the fore- arm, then carry it obliquely across the bend of the elbow to the arm, above the inner or outer condyle according to the direction taken, thence over the posterior surface of the arm to the opposite side, and across the front of the elbow again, to the point from which the roller started. These turns are re- peated, making those above the joint overlap the lower thirds of the preceding turns, and those below, the upper thirds, till the point of the elbow is reached; then complete the envelopment of the joint by a circular turn carried over the olecranon process. This bandage, when it does not form a constituent part of the spiral reversed of the upper extremity, is principally used to retain a compress or other dressing on the wound made in venesection at the bend of the elbow. The Anterior Figure-of-Eight Bandage of the Chest. — A roller metres (2| inches) wide and 6f- metres (7 yards) long. Make fast the initial extre- mity by two circular turns around the upper part of the right arm, after which cany the roller over the shoulder, obliquely across the front of the thorax, through the left axilla, over the shoulder of the same side, thence back across the front of the chest (intersecting the pre- ceding turn over the ster- num) through the right axilla, and up to the top of the shoulder. Repeat the figure-of-eight turns on the anterior face of the chest, till the bandage runs out, and pin the ter- minal end. The borders of both axilke should be protected from excoriation by compresses of cotton or jute, inserted between them and the tur bandage. (Fig. 59.) 6 J centi- Anterior figure-of-eight bandage of the chest. ns of the 492 MINOR SURGERY. The Posterior Figure-of-eight Bandage of the Chest. — A roller 6J centimetres (2| inches) wide and 6f metres (7 yards) long. Secure the initial end of the roller on the upper part of the left arm by two circular turns, then conduct the bandage over the shoulder, obliquely across the back, through the oppo- site axilla, over the shoulder of the same side, obliquely across the posterior surface of the thorax (crossing the previous turn between the scapulae), through the left axilla, and up to the summit of the shoulder, from which similar turns across the back and through the axilla are to be repeated till the band- age is exhausted. (Fig. 60.) The same precautions against excoriation of the borders of the axilla? are to be adopted as in the case of the pre- ceding bandage. The Suspensory and Compressor Bondage of the Breast. — A roller 6^-7f centimetres (2J-3 inches) wide and 7 t 3 q--9/ ¥ metres (8-10 yards) long. Make fast the initial end of a roller, placed over the sca- pula of the aflected side, by two oblique turns carried over the oppo- site shoulder, under the affected mamma, and through the axilla of the same side ; from this point con- duct the roller transversely around the chest, covering the lowest por- tion of the gland in its course. Con- tinue making oblique turns of the shoulder and axilla, alternating with circular turns of the chest, each of the respective turns overlapping the upper part of the preceding by about one-third, till the aflected breast is completely covered by oblique and circular turns. (Fig. 61.) Posterior figure-of-eight bandage of the chest. Fig. 61. Fig. 62. Suspensory and compressor bandage of tho breast. Suspensory and compressor bandage of both breasts. BANDAGES TOR THE HEAD. 493 Fig. 63. The Suspensory and Compressor of both Breasts. — Two rollers, each 6|-7f centimetres (2J-3 inches) wide and 6| metres (7 yards) long. Secure the initial end by two oblique turns of the shoulder and the axilla, as in the pre- ceding bandage ; then carry the roller transversely across the back, up under the breast and over the shoulder, thence obliquely downwards over the back and towards the other side, and transversely around the front of the chest (covering the lower part of both breasts) to the point of beginning on the back. Continue the application of the roller first by an oblique turn of one shoulder and the opposite axilla, then of the other axilla and the opposite shoul- der, followed by a circular turn of the front of the thorax. Each turn, both of the oblique and of the circular series, should overlap one-third of the pre- ceding in an ascending order, till both breasts are covered by oblique and circular turns. (Fig. 62.) VelpeaiCs Bandage. — Two rollers, each 6 J centimetres (2| inches) wide and 65- metres (7 yards) long. Let the patient place the hand of the affected side on the opposite shoulder, then apply the initial end of a roller on the body of the scapula of the sound side, and secure it by two turns made by conducting the roller over the shoulder of the affected side, down the outer and posterior surface of the arm of the same side, behind the point of the elbow, thence ob- liquely across the front of the chest and through the axilla of the sound side to the point of be- ginning. . From this point, cany the roller in a transverse direction around the thorax, pass- ing over the flexed elbow of the affected side, thence through the axilla to the back. Carry the roller again over the shoulder, down the outer and posterior surface of the arm, behind the elbow, obliquely across the front of the chest, through the axilla of the sound side, and thence around the chest and arm. The application of the oblique and circular turns is continued in like manner till the flexed arm is firmly bound to the anterior surface of the chest. The turns running over the shoul- der and winding round the outer and posterior surface of the arm, should advance towards the point of the elbow by each overlapping tiro-thirds of the preceding turn; the, circular turns should ascend the arm and chest from the point of the elbow by each covering one-third of the preceding turn. (Fig. 63.) Velpeau's bandage. Bandages for the Head. — Tlie Figure-of-eight Bandage of the Head and Jaw. — This bandage is commonly called Barton's bandage. A roller 5 centime! res (2 inches) wide and 4| metres (5 yards) long. When this bandage is used for fracture of the lower jaw, its initial extremity is placed on the "head just be- hind the mastoid process of the sound side, and is carried under the occipital protuberance, obliquely upwards, under and in front of the parietal eminence, across the vertex, down the side of the face on the sound side, beneath the jaw, thence up along the side of the face, over the top of the head (passing over the other turn in the median line), under the parietal eminence to the point of commencement. It is then conducted under the occipital protuber- 494 MINOR SURGERY. ance, forward under the ear and in front of the chin, and thence back to the point from which the roller started. Continue to make the figure-of-eight turns over the head and the circular turns around the base of the skull till the bandage is exhausted. Each turn should completely cover the preceding, so that the bandage when applied should look as if it were formed of single turns. In order that the bandage may not be easily displaced, the different intersections should be pinned. (Fig. 64.) Fig. 64. Crossed or oblique bandage of the angle of the jaw. The Crossed or Oblique Bandage of the Angle of the Jaw. — A roller 5 centimetres (2 inches) wide and 4| metres (5 yards) long. Barton's bandage. Make fast the initial end of the bandage by two circular turns around the vault of the cranium, going from left to right, if it is designed to cover the left angle of the lower jaw, and vice versa if the right angle. On reaching the back of the head, conduct the bandage obliquely across the nape of the neck, under the ear and the jaw on the sound side to the angle on the affected side, thence up over the face in a line half way between the eye and the ear, obliquely across the top of the head, and down behind the ear of the sound side ; from this point carry the bandage again under the jaw and up over the side of the face, making it overlap the posterior two-thirds of the preceding turn, thence obliquely across the top of the head, down behind the ear of the sound side, and again under the jaw and up over the face, coveritig the posterior two- thirds of the second upward turn. When the intersection of the circular and the descending turns is reached on the sound side, reverse the bandage and terminate it by two circular turns around the head. (Fig. 65.) This bandage will be found useful for retaining dressings on the side of the face in cases of wounds of the parotid region. "When employed in the treat- ment of fracture of the ramus and neck of the lower jaw, an oblong compress should be placed between the seat of fracture and the ascending turns of the bandage. / The Recurrent Bandage of the I had. — A roller 5 centimetres (2 inches) wide and 4.1 metres (5 yards) long. Secure the initial extremity of the roller by two circular turns around the forehead and occiput; on reaching the middle of the forehead or the occipital protuberance, reverse the roller and carry it over the top of the head to a poinl directly opposite, where it is again reversed or turned back, and conducted back over the vertex to the point of commence- BANDAGES FOR THE HEAD. 495 ment, overlapping one-third or one-half of the preceding turn. These recur- rent turns over the summit of the skull are repeated till the top of the head is entirely covered, after which the bandage is reversed and two circular turns are made around the vault of the cranium, to secure the ends of the recurrent turns just above the root of the nose and below the occipital protu- berance. (Fig. 66.) While this bandage is being applied, one extremity of the recurrent turn must be kept in position either by an assistant or by the patient ; the other extremity may be retained by the surgeon himself, till they are made fast by the terminal circular turns. Fis- 66. Fig. 67. Recurrent bandage of the head. V-bandage of the head. Tlie V-bandage of the Head. — A roller 5 centimetres (2 inches) wide and 3f metres (4 yards) long. Secure the initial extremity of the roller by two circular turns around the vault of the cranium, and, on arriving at the back of the head, conduct the roller forward under the ear, over the upper or lower lip, as the case may be, and backward on the opposite side of the head to the occipital protuberance. Then make alternate turns around the base of the cranium and the front of the face, and terminate the bandage by pinning it at the intersection of the turns on the occiput. (Fig. 67.) This bandage was suggested by the writer for the purpose of retaining dressings on the lip or the front of the chin, in cases Fig. 68. of wound of those parts. In consequence of the direction of its turns, this bandage offers no obstruc- tion to the patient opening his mouth, which is not the case with Barton's bandage when it is used to meet the same indications. Other Roller Bandages. — Tlie Recurrent Band- age for Stumps after Amputation. — A roller 5-6| centimetres (2-2 J inches) wide and 4J-6J metres (5-7 yards) long. After securing the initial end of the roller by two circular turns around the stump, a few inches above its extremity, reverse the band- age on the under or posterior surface of the stump, and conduct it over the extremity to a point oppo- site, on the upper aspect, thence back over the end of the stump to the point of beginning. Repeat these recurrent turns, each turn overlapping the preceding by one-third or Recurrent bandage for stumps. 496 MINOR SURGERY. one-half of its width, covering first one half of the end of the stump and then the other, after which make two circular turns, to fix the extremities of the recurrent turns. If considered necessary, the stump may now be envel- oped by spiral or spiral reversed turns made in the usual way. (Fig. 68.) In addition to the foregoing roller bandages, another variety, denominated the T-bandage, is occasionally used to retain dressings. The simplest form of the T-bandage consists of two strips of muslin, one a transverse piece, suffi- ciently long to pass once or twice around the part to which it is to be applied ; the other, a longitudinal piece, which is sewed at right angles to, and at the middle of, the transverse piece. The longitudinal piece should be, as a rule, about half the length of the other. When two longitudinal strips are attached to the transverse piece, the double T-bandage is formed. The Single T-bandage is sometimes applied to the head, to keep dressings on the scalp. In applying it to this portion of the body, the transverse piece is carried around the vault of the cranium, and the longitudinal strip taken over the summit of the head and beneath the transverse strip on the opposite side; it is then turned back on itself and pinned. When it is necessary to cover a considerable surface of the scalp, the longitudinal piece may be made of sufficient width to meet the particular indication. If the free end of the longitudinal piece be slit into two tails for about two-thirds of its length, the single T-bandage becomes a useful means of keeping dressings on the perineum after operation, as in eases of fistula and abscess in this region. When this form of T-bandage is applied to the perineum, the transverse piece is secured around the body, just above the pelvis, while the longitudinal piece is brought down between the nates, and its tails, separated so as to pass on either side of the genitals, are carried obliquely upwards and outwards and fastened to the transverse piece. Another modification of the single T-bandage is employed for the ear. The modification consists in attaching one end of an ear-shaped piece of muslin to the centre of a transverse strip ; to the other extremity of the ear-shaped piece is sewed a longitudinal strip. If it is designed to retain a dressing on the surface of the head immediately around the ear, a slit is made in the ear-shaped piece, through which the auricle passes. The Double T-bandage is a convenient means of retaining a dressing on the nose. In its application, the portion of the transverse strip intervening between the attachments of the longitudinal pieces, is placed on the upper lip below the nose ; the longitudinal pieces are then brought up along the sides of the nose to its root, where they cross each other ; thence they pass over the top of the head, and are secured by the extremities of the transverse strips which are carried around the head. The double T-bandage consisting of a broad transverse piece of muslin with two narrow longitudinal strips sewed to its upper border, is the best bandage in use for retaining dressings on the chest, especially after operations on the mamma. The transverse piece should be about 20| centimetres (8 inches) wide, and long enough to pass one and a quarter times around the thorax. The two longitudinal strips, each about 5 centimetres (2 inches) wide and 51 centimetres (20 inches) long, should be attached to the transverse piece, a short distance apart, one on either side of its middle. The transverse piece is carried around the chest and pinned in tit nit ; the longitudinal strips arc brought directly over the shoulders, and se- cured by pins to the upper margin of the broad piece. Another form of bandage, termed the Sling, is occasionally found serviceable in cases of fracture of the lower jaw, and in keeping dressings on the nape of HANDKERCHIEF BANDAGES. 497 the neck, the chin, or other parts of the body. To make a sling, or four- tailed bandage, take a piece of broad bandage, long enough to encircle the part to which it is to be applied and to overlap a little, and split both ends to- wards the centre. The central portion of the piece thus treated is called the body ; the extremities the tails. To apply the four-tailed bandage to the nape of the neck, place the body directly over the dressing which it is designed to retain, and carry the upper tails around the forehead and the lower tails around the neck, where they may be secured by pins. A similar bandage may be used as a temporary support in cases of fracture of the lower jaw. The body of the bandage is placed beneath the chin, and the upper tails are directed backward below the ears, towards the occiput ; before securing these, the lower tails are carried up the sides of the face, crossed on the vertex and se- cured by pins where they terminate. The lower tails are then crossed below the occipital protuberance, and brought above the ears towards the forehead, where they are pinned together. The Many-tailed Bandage, or the Bandage of Seultetus, is a convenient dress- ing in some cases of compound fracture or severe wounds ; for, after it has been once applied, it can be renewed without disturbing the affected part. It is made by cutting a roller bandage into the requisite Fi s- 69 - number of pieces, each long enough to go around the part and overlap 5-7| centi- metres (2-3 inches). These pieces are disposed in such a way, under the part, that the first piece shall be over- lapped by the second, the second by the third, and so on, from below upwards ; the extremities of the last piece are secured by pins. (Fig. 69.) Whenever it is necessary to change strips that have become soiled, it can be readily done, without raising the limb, by pinning fresh pieces of bandage to those which are soiled, when, as the latter are pulled out, the former are drawn beneath the limb. This bandage is sometimes made by sewing a longitudinal piece to the middle of the several strips ; this arrange- ment, however, is objectionable, as it prevents single strips from being removed when they have become soiled. Handkerchief Bandages. — Handkerchiefs or square pieces of muslin may be resorted to with advantage, in many cases, as provisional, or even as perma- nent dressings. M. Mayor, a Swiss surgeon, reduced the application of hand- kerchief dressings to a system, nearly fifty years ago, whence these bandages are generally called " Mayor's handkerchiefs." The various handkerchief bandages are all modifications of the simple handkerchief, or square piece of muslin. The different forms that the handkerchief is made to assume are (1) The Oblong, made by simply folding the square once on itself; (2) the Triangle, made by bringing together the diagonal angles of a square, the parts of the triangle being the base, the apex or summit, and the angles ; (3) the Cravat, formed by folding a triangle from its summit towards its base; and (4) the Cord, a cravat twisted, the parts of the cravat and the cord being the body and the extremities. This system of provisional dressings has an elaborate nomenclature founded vol. i.— 32 Bandage of Scultetus. 498 MINOR SURGERY. upon the shape of the bandages and the anatomical designation of the parts to which they are to be applied. The essential point to be borne in mind in the application of these dressings, is that the base of the triangle, or the body of the cravat, is to be placed on the part, the designation of which forms the first portion of the name of the bandage. The angles or extremities are, as a rule, carried around the part, and either knotted or fastened with pins. The advantage of this arrangement of the names may be illustrated in the case of the Occipito-Frontal Triangle, or the Fronto-Occipito-Labial Cravat. The name of the former indicates that a handkerchief, in the shape of a tri- angle, is to be used, and that its base is to be applied to the occiput, and its angles carried around the head to the frontal region ; that of the latter denotes that a handkerchief folded in cravat form is to be employed, its body being placed on the forehead, and its extremities crossed on the occipital region and terminated on the upper or loAver lip, as the case may be. Fixed Dressings, or Hardening Bandages. — A great variety of substances are used, at the present time, to give greater fixity and solidity to bandages, in the treatment of fractures and other surgical affections. The substances most commonly employed in the preparation of fixed dressings are plaster of Paris, or gypsum, starch, and silicate of potassium ; other materials are sometimes used, among which may be mentioned a mixture of chalk and gum, a combi- nation of oxide of zinc and glue, glue alone, and paraffine. Plaster of Paris Bandage. — The plaster for this purpose should be the extra- calcined variety used by dentists for taking casts for teeth, and by modellers. If it is not fresh and free from moisture, it will fail to serve the purpose for which it is used. This band- age may be applied in two ways : — First Method. Add dry plaster to some cold water in a basin, and stir the mixture till it becomes of the consistence of cream. Thus prepared, the plas- ter may be smeared over the surface of a bandage on a limb; or a bandage previously wetted may be loosely rolled in the plaster-cream, and then applied. Strips of bandage dipped in plaster-cream are some- times applied after the manner of the many-tailed bandage of Scultetus. To render the surface of the dressing smooth after it has been applied in either of the above ways, a little dry plaster may be rubbed over it. Secovd Method. The bandages used in this method are made of some loosely-woven material, such as cross-barred muslin, mosquito-netting, or (what is far belter than either) crinoline, a substance recom- mended by Prof. Say re. This material is cut into strips <^.-7f centimetres (2|-3 inches) wide and 4!-(!| metres (5-7 yards) long. As these strips are loosely rolled into cylinders, dry plaster is rubbed into their meshes, either by hand or by means of a machine called a x plaster bandage winder (Fig. 70). Bandages thus prepared may be kept ready for use in some air-tight receptacle. Before applying one of these bandages, il is placed on end in a basin of tepid water, sufficiently deep to cover it entirely, Apparatus l^r u iinlitig plaster ', . <■<■ -, , • i-n j_i i i 1 i j? • bandages. and is allowed to remain till the bubbles of air cease FIXED BANDAGES. 499 to escape through the water from the upper end of the roller ; it is then taken out of the water and firmly squeezed between the hands, to remove the ex< vss •of liquid, when it is ready for application. When two or more bandages are to be used, a dry bandage should always be put in the water before the satu- rated one is taken out; if this be done, there will be no unnecessary delay in the application of the dressing. As a roller is applied, the surface of the turns should be gently smoothed by the operator or by an assistant, in order that the plaster may be uniformly spread over the surface of the dressing. Three or four thicknesses of bandage are usually sufficient. Plaster bandages should never be applied directly upon the skin. The best protective for an extremity is a flannel roller, or a light woollen stocking; for the trunk, a closelj' fitting knitted shirt or vest. If bandages with dry plaster well rubbed into their meshes are evenly applied to a part after being thoroughly saturated with water, there will be no need of smearing the successive layers, or the outer surface of the dressing, with plaster cream. Under favorable circumstances, a plaster bandage becomes perfectly firm in from fifteen to thirty minutes, and, unlike the other fixed dressings, it expands a little as it hardens. A small quantity of size, or stale beer, put in the water, will retard the setting of plaster; on the other hand, the addition of a little salt will hasten it. The removal of a plaster bandage, as well as other fixed dressings, may be accomplished by slitting it up with a stout-bladed knife, or with Seutin's or Von Bruns's pliers. (Figs. 71, 72.) The writer has recently had made Seutin's pliers. Fig. 72. Von Bruns's pliers. a plaster-bandage saw, of the shape represented in Fig. 73, which greatly facilitates the division of these bandages. It is necessary that the teeth Fig. 73. Saw for removing' plaster-of-Paris bandages. should be widely set, so that a wide groove may be cut in the bandage for the free passage of the saw. 500 MINOR SURGERY. Starched Bandage. — The starch is first mixed with enough cold water to make it of the consistence of cream ; then, as the mixture is stirred, boiling water is gradually added to it till it becomes a clear, thickish mucilage, which is known as " clear-starch." The starch mucilage is painted with a brush, or smeared with the hand, over the outer surface of the bandages as they are applied to a limb. To give additional support, pieces of paste- board cut or torn of the requisite size and shape, and thoroughly soaked in starch, are sometimes placed between the layers of bandage. In order that there may be no liability to dangerous constriction of a part, only those bandages that have been washed and well shrunk should be used with starch. The starched bandage dries very slowly, requiring from twenty-four to forty-eight hours before it becomes firm. Gum and Chalk Bandage. — For this bandage, a mixture of the two sub- stances is made by adding to equal parts of powdered gum arabic and pre- cipitated chalk, enough boiling water to bring the mass to the consistence of cream. This dressing is applied in the same manner as the preceding; it requires only five or six hours to harden, and hence is to be preferred to the starched bandage. Silicate of Potassium Bandage. — "When silicate of potassium (liquid glass) is employed to stiffen bandages, it is painted over the several layers of bandage with a broad brush. It takes about the same length of time to become firm as the starched bandage, and, unless washed bandages are employed, its use is attended with the same dangerous liability to strangu- lation of the limb. In consequence of the ready solubility of silicate of potassium, the bandage may be easily cut up with scissors after it has been softened by the use of warm water. Paraffine Bandage. — One disadvantage attributed to the foregoing fixed dressings is their liability to become offensive from the absorption of dis- charges, especially in cases of compound fracture. Mr. Lawson Tait claims that paraffine, in consequence of its non-absorbent property, is not open to this objection. Paraffine, which melts at from 105° to 120° F., is kept in a liquid state by being placed in a bowl floating in hot water ; it may be most conveniently applied by passing through it flannel bandages of loose texture, as they are being placed upon a limb. In the course of five or ten minutes, the bandage will become firm, and, if it be deemed necessary, the dressing may be strengthened by brushing over it melted paraffine. Should the coating of paraffine crack, the damage may be easily repaired with a hot wire. Glue alone, as used by the late Mr. C. De Morgan, or in combination with oxide of zinc, as suggested by Dr. Levis, may be employed to make fixed dressings. It does not possess any decided advantages over the materials already noted, to compensate in any way for the increased trouble which attends its application. Revulsion and Counter-Irritation. It has been demonstrated by experience of the most positive character, that artificial irritations, under favorable circumstances, have a decided effect in modifying a great variety of morbid processes. The substances employed to excite external irritation are termed counter-irritants ; and the REVULSION AND COUNTER-IRRITATION. 501 extent of their action varies from the production of superficial redness to the complete destruction of the vitality of the part to which they are applied. Rubefacients. — These agents, in consequence of their irritating properties, excite, when applied to the surface of the body, intense redness and con- gestion of the skin, which are of temporary duration only. "When it is desirable to make a quick impression on the skin, flannel cloths wrung out of hot water and laid upon the part, will answer the purpose if they are frequently renewed. Oil of turpentine is not unfrequently used as a counter-irritant, in the form of stupes. These are made either by sprinkling the oil of turpentine over flannel cloths that have been wrung out of hot water, or by dipping these hot cloths into warm turpentine ; in either case the excess of turpentine should be squeezed out of the stupes before they are applied. A turpentine stupe ought not to be left on longer than twenty minutes. A few drops of chloroform, on a piece of flannel or folded napkin, confined to the skin by oiled silk, will quickly excite a rubefacient effect. Mustard-flour is probably more often employed as a rubefacient than any other substance. Of the two varieties of mustard, Sinapis alba and Sinapia nigra, the latter is the more powerful — a fact that ought not to be lost sight of in the use of these substances as revulsives. The advantage attending the use of this material is the ease with which its specific action may be regu- lated. The usual method of preparing a sinapism is to mix the mustard-flour with warm water, and spread the paste on muslin or paper. The surface of the sinapism should be covered with some thin material, such as gauze, to prevent any of the mustard from sticking to the skin when the application is removed. The intensity of the irritating effect of mustard may be dimin- ished by diluting the mustard-flour with wheat-flour, Indian-meal, or linseed- meal ; the usual proportions are, for the black variety about one-half, for the white one-third. A sinapism of this strength may be allowed to remain for a period varying from fifteen to thirty minutes, according to the texture of the skin and the sensations of the patient ; its action should never be allowed to extend to vesication, for a blister produced by mustard is excessively painful, and slow in healing. After the removal of a mustard poultice, the irritated surface of the skin should be protected by a piece of lint smeared with oxide of zinc ointment or Goulard's cerate. A mustai^d foot-bath, made by putting a tablespoonful or two of mustard-flour into a bucket or foot-tub of water at a temperature of 105° F., is an efficient method of quickly exciting revul- sive action. In the employment of counter-irritants with patients who are in a comatose state, or deeply under the influence of a narcotic, care must be observed that the applications are not too long continued, lest troublesome consequences should arise as a result of the impaired vitality of the tissues, or of a temporary loss of the sensation of the patient. Vesicants. — These substances are employed when it is desirable to make a more decided and permanent counter-irritant effect than that produced by the use of rubefacients. By their specific action on the skin, they cause an effusion of serum, or of serum and lymph, beneath the cuticle, giving rise to vesicles or blisters. When there are indications for rapid vesication, it may be produced by the application of the aqua ammonice fortior, or of chloroform confined to the surface of the body by an inverted watch-glass; or by the employment of iron heated in boiling water. The substance most commonly resorted to for producing vesication, is cantharis, or Spanish fly, which may be used in the form of a cerate, or in combination with collodion. There is still another form, the cantharides paper (charta carttharidis), which is considered 502 MINOR SURGERY. by some more elegant than either of the above preparations, and nearly as efficient. The most convenient way of using the ceratum cantharidis is to spread it on a piece of adhesive or diachylon plaster, leaving a margin of about 1 J-2 centimetres (J to f of an inch) wide, uncovered, which will adhere to the skin and thus hold the blister in position. The average length of time that a fly-blister may be allowed to remain in contact with the skin, is from six to eight hours ; then it should be removed, and the part covered with a flaxseed-meal poultice. A blister raised in this way is not very painful, nor is it apt to be followed by strangury. In cases in which the skin is delicate, or in which urinary irritation is apprehended, camphor, alone or in combina- tion with opium, may be incorporated with the cerate before it is applied. Cantharidal collodion, painted on the skin in three or four layers, with a camel's- hair brush, is the best means of blistering in cases of maniacs or other patients whose movements are not easily controlled ; it is, likewise, a very convenient application for uneven or irregular surfaces. Blisters must be cautiously used with children, even with those who are robust, and they are positively contra-indicated in the case of children suffering from any low form of disease. When a blistered surface is to be healed as quickly as possible, the vesicle should be carefully punctured at the most dependent point, to let the serum escape, and, without detaching the cuticle, the part should be covered with oxide of zinc ointment or simple cerate. If, on the other hand, there is need for keeping up the derivative effect of a blister, the cuticle should be stripped off and the denuded surface dressed with savine cerate or mezereon ointment, or the compound resin cerate. Nitrate of silver is sometimes applied to the skin for the purpose of exciting counter-irritation. A strong solution of this salt may be used where the ob- ject is simply to produce rubefaction ; but, for the purpose of exciting vesica- tion, preference should be given to the solid stick. Freely applied to the scrotum in this form, nitrate of silver is thought by some surgeons to be effi- cacious in abating an acute epididymitis. Acupuncture. — This method of exciting counter-irritation is effected by thrusting needles deeply into the subcutaneous tissues, where they are allowed to remain for a variable length of time. The needles should be of steel, polished, strong, sharp pointed, and from 5 to 10 centimetres (2 to 4 inches) long, and should have round metallic heads, or be fixed in cylindrical handles. In introducing the needles, the skin should be made tense between the thumb and fingers of the left hand, while each needle is forced through the integument into the deep-seated structures by a rotatory motion. As it is withdrawn, the skin around each needleought to be supported. In performing the ope- ra lion of acupuncture, certain localities containing important organs, such as large bloodvessels, the viscera, joints, etc., must be avoided. Acupunctura- tion has been found of service in cases of deep-seated neuralgia, especially of the sciatic nerve, cases of muscular rigidity, obstinate rheumatic affections, etc. Issues are ulcers made artificially by the application of caustics, or the moxa, or by the use of the knife, for the purpose of relieving either local or general disease by establishing a permanent, derivative action. When they are established with a view <>{' producing a drain on the system, certain situa- tions, such as the nape of the neck, the insertion of the deltoid muscle on the outer side of the arm, and the outer aspect of the thigh, should be selected; for in these localities the subcutaneous areolar tissue is abundant, and there arc no important bloodvessels or nerves. In the case of local affections, cir- cumstances will determine the points at which issues are to be made. Salient points of the skeleton and the immediate vicinity of large bloodvessels and REVULSION AND COUNTER-IRRITATION. 503 nerves should, however, always be avoided. The plan usually practised in making an issue, is to protect the surrounding skin by covering it with a piece of adhesive or diachylon plaster, in which a bole is cut a little smaller than the proposed eschar. A ring of wax may be used instead of plaster. A small piece of caustic potassa, or Vienna caustic made into a paste by mixing it with a little alcohol, is placed in the hole, and kept in position by another strip of plaster. In an hour or two, the strips of plaster should be removed, and the part washed with vinegar and water, to check the further action of the caustic ; a poultice of llaxseed-meal should then be applied, to hasten the separation of the slough. The ulcer remaining after the removal of the eschar may be kept from healing by placing in it an issue-pea or a glass bead, which may be maintained in position by means of a small compress of lint and a strip of plaster ; or, if the issue be on the arm, by a wire-gauze armlet. Tlie moxa is occasionally used to make an issue, but its application is so painful that a local anaesthetic should then always be employed. Thenioxa is composed of some combustible material, such as cotton, lint, agaric, the pith of the sunflower, etc., rolled into cylindrical or pyramidal shape, and is designed to be burnt in contact with the skin, for the purpose of producing an eschar. That the combustion of the moxa may be more rapid, and the pain attending its application less prolonged, it is customary to make it of cotton or lint impregnated with nitrate or chlorate of potassium. To facilitate the application of the moxa, a convenient instrument called the porte-moxa, or " moxa-bearer," may be employed. (Fig. 74.) The eschar left in the skin Fig. 74. Porte-moxa. after the burning of the moxa, is somewhat greater in extent than the base of the latter. The treatment of the slough and of the ulcer is the same as that described in the preceding paragraph. Tlie knife may be resorted to for establishing an issue, either by raising the integuments and cutting them from within outwards, or by making a crucial incision, well down into the subcutaneous areolar tissue. Issues made in this way are always troublesome to keep open, and hence this method is not often practised. The Seton, which is simply a subcutaneous issue, or a sinus with two openings, is established by introducing a narrow strip of muslin, a small roll of thread, a piece of lamp-wick, or a strip of India-rubber cloth, through the base of a fold of the integument. This may be accomplished either by using a seton-needle (Fig. 75), or by means of a sharp-pointed bistoury and an eyed Seton-needle. probe. A seton should pass deeply into the superficial fascia, for if it bo carried between the skin and fascia, the former will slough and leave an open wound ; in order to get free drainage, one opening should be a little lower than the other. When the seton-thread is in position, its ends arc to be loosely knotted, and it should not be disturbed till suppuration is fully established in the wound. After this, the wound is to be dressed every day, 504 MINOR SURGERY. and the seton-thread, either oiled or smeared with some stimulating ointment, if it he desirable to increase the quantity of the discharge, should be moved a little at each change of dressing. Setons are occasionally used to empty chronic abscesses or cysts ; in cases of the latter, and in those of hydrocele, the presence of a seton in the sac will sometimes effect a cure by exciting sufficient inflammatory action to cause adhesion of the walls. The Actual Cautery, consisting of some form of metallic substance brought to a high degree of temperature, constitutes the most powerful counter-irritant in use. It is likewise employed for the purposes of checking hemorrhage and destroying diseased growths. The cauteries most commonly employed are made of Iron, and are fixed in handles of wood or other non-conducting material, and have their heads or extremities fashioned in a variety of shapes, as the olive, the button, the hatchet, etc. (Fig. 76.) This variety in shape is designed to meet the special in- Fl &- 76 - dications for which cauting-irons are used, and to suit different localities. In an emergency, an ordinary knitting-needle, or a poker, or other piece of iron, may be made to serve the purpose. The irons may be heated in a brazier which usually accompa- nies a set of the instruments, or in an ordinary tire, or by the flame of a spirit-lamp. When the actual cautery is resorted to for its revulsive effect, the hatchet-shaped iron is the one usually selected. This, heated to a dull red heat, should be quickly drawn over the skin in Canting-irons of various shapes. Fig. 77. A B Paquelin's tliormo-cautery. A, spirit lamp; B, cover for lamp ; C, bottle containing benzole ; D, cover for bottle; E, India-rubber bulbs and tubing; F, handle for knives ; 0, II, platinum knives ; I, platinum button. BLOODLETTING. 505 lines about 2| centimetres (one inch) apart, either parallel to or crossing one another. The intense burning that follows the application of the hot iron may be allayed by placing on the cauterized part compresses wrung out of cold water, or saturated with equal parts of olive oil and lime-water. It is not deemed prudent to apply the actual cautery to the skin covering salient points of the skeleton, or immediately overlying important organs. Brace's gas cautery, which consists of a point, disk, or wedge of platinum heated by a name of gas, has the advantage over the ordinary cauting-iron, that it can be easily maintained at a high temperature while it is in contact with moist tissue. A very convenient and efficient form of thermo-cautery has been recently introduced by Paquclin, which comprises two hollow knives (Fig. 77, G, H) and a hollow button of platinum (I) ; a metallic handle (F), likewise hollow and covered with wood ; a reservoir for benzole (C) ; and rubber bulbs and tubing (E), similar to those used with the hand spray-apparatus. In pre- paring the cautery for use, the platinum extremity, in which there is platinum sponge, is first heated by the flame of an alcohol lamp (A) ; it is then quickly made incandescent by passing through it a continuous stream of air saturated with the vapor of benzole. By compressing the rubber bulb, air is forced into the rubber bag surrounded with netting, and the elasticity of this causes a steady flow of air through the reservoir or bottle containing benzole ; the air thus charged is conveyed by the rubber tubing to the platinum point. The use of the galvanic cautery will be referred to on a subsequent page. Bloodletting. The operation of bloodletting is occasionally resorted to, both as a local and as a general remedial measure. The methods by which local depletion (that is, from the capillaries) is effected, are scarification, puncturation, cupping, and leeching. General bloodletting comprises venesection and arteriotomy. Scarification consists in making small incisions with a lancet or a sharp- pointed bistoury in the surface of a congested or inflamed part. By means of these incisions, the overloaded capillaries are promptly relieved, and a vent is afforded for the escape of transudation. The cases in which this operation is most efficacious are, inflammation of the integuments, engorgements of the tongue and tonsils, chemosis of the conjunctiva, and urinary infiltration. The incisions should be in parallel rows, and, as a rule, should correspond in direction to the long axis of the part. Their length and depth, as well as their number, must be determined by the circumstances of each individual case. Care must be taken that the large subcutaneous veins are not wounded. Warm fomentations will increase and prolong the flow of blood from the small wounds. Puncturation is an operation somewhat similar in character to that just described, and may be done with a sharp-pointed, narrow-bladed bistoury. It is of marked service in cases of acute epididymitis, phlegmonous erysipelas, etc., both by relieving tension and by effecting depletion. Cupping. — Under this head are included two minor operations, viz., dry- cupping and wet or bloody-cupping. The use of cups relieves deep-seated inflammation by inviting the blood to the surface. Dry-cupping is indicated in cases of inflammation in which the action of a derivative is desired without the abstraction of blood. In an emergency, this 506 MINOR SURGERY. may be accomplished by means of wineglasses or small tumblers instead of cupping-glasses. When the former are used, the air in them may be quickly rarefied by burning in them small rolls of paper, or little masses of cotton wet with alcohol, or by the introduction of the flame of a spirit lamp for a moment or two. In using cupping-glasses, either for dry or wet-cupping, the glasses are first placed on the part, and then the air in them is exhausted by means of a portable air-pump (Fig. 78) ; the immediate effect of the removal of the air is marked congestion of the integument covered by the glasses. Cupping- glasses are easily removed by opening the stopcock with which they are pro- vided ; or they may be tilted to one side, and the skin gently pressed away from the edge of the glass on the opposite side. They should never be pulled off. Wet or bloody-cupping. — By this means local depletion is easily effected, and the quantity of blood abstracted may be accurately determined. The instruments required for this operation are a scarificator (Fig. 79), cupping- glasses, and a portable air-pump, or a vulcanized India-rubber bulb (Fig. 80) ; Fig. 78. Fig. 79. Fig. 80. Cupping-glass and porta- ble air-pump. Scarificator for wet-cupping. Cupping-glass with India-rubber bulb. in place of the scarificator, any sharp-pointed knife may be used. As a pre- liminary to the performance of this operation, the skin should be sponged with warm water, and if necessary shaved. The cups are placed on the surface, to produce superficial congestion, and in the course of a minute or two should be removed, and the scarificator immediately applied. As soon as the inci- sions are made by springing the set of lancets concealed in the scarificator, the cups should be promptly replaced. When the cups become filled with blood, as their suction power is exhausted, they should be taken oft* and emptied; and, if more blood is to be abstracted, they may be reapplied to the same spots, or fresh cups maybe substituted. After they arc removed, the part should be carefully washed, and dressed with compresses and strips of plaster or a bandage. In using the scarificator, the blades should be set so as to cut through the true skin only. If a knife housed to make the scarifications, the same cart; must be exercised not to encroach upon the subcutaneous areolar tissue; the incisions should be parallel, and about one centimetre (one-third of an inch) apart. Cupping glasses should not be applied in the immediate vicinity of inflamed tissues, nor over the mammary region. Wet-cupping is BLOODLETTING. 507 always followed by scarring, hence wet-cups should never be put on the upper part of the chest or shoulders of women. Leeching is not often done by the surgeon himself; still its importance as a remedial measure renders a knowledge of its practical application of service to every practitioner. It is a convenient method of taking blood from cer- tain localities where it is impossible to employ cups. In this country, two varieties of leech are used, known respectively as the American, and as the European or Swedish leech ; the former variety is estimated to draw about four grammes (one fluidrachm) of blood ; the latter nearly four times as much. The quantity of blood abstracted maybe increased by applying warm fomen- tations to the leech-bites. In selecting leeches, preference should be given to those which are active and healthy ; they should be taken from water an hour before they are applied, and should be dried in a soft, dry cloth. The part to be leeched must be clean and free from hair. If the leeches are slow in taking hold, their action may be hastened by smearing a little milk or blood on the skin ; immersion of the leeches in lukewarm water or small beer is said to stimulate them to bite more actively. When two or three leeches only are to be applied, they may be taken between the thumb and fingers and held with their buccal extremity to the part. If a larger number be used, they may be conveniently confined to the surface by covering them with an inverted tumbler, or a loose mass of cotton. By means of a leech-glass or a small cone of stift paper, a leech may be kept in contact with a particular part, as the inner canthus of the eye, the gum, the verge of the anus, etc., till it adheres ; for the cervix uteri a speculum should be used. In cases of in- flammation, leeches should be applied to the parts surrounding the seat of disease, and not directly over it ; nor should they be put on the eyelids or the scrotum, for here, in consequence of the large amount of loose cellular tissue and the delicate nature of the skin, un- sightly ecchymoses are almost sure to follow. Leeches should not be forcibly removed ; when they show no dispo- sition to relax their hold, a little salt or snuff sprinkled on their bodies will cause them to let go and drop off. In- jections of tobacco smoke or solutions of common salt will facilitate the detach- ment and removal of leeches from the inside of the mucous outlets. Usually there is no difficulty in checking he- morrhage from a leech-bite ; exposure to the air, or the application of dry lint, is generally sufficient. Should the bleeding continue obstinately, it may be stopped by the application of dos- sils of lint wet with Monsel's solution (liquor ferri subsulphatis), or a warm, saturated solution of alum ; or by touching the wound with a pencil of nitrate of silver, or the actual cautery improvised by heating the end of a darning needle to a dull-red heat. If all these means fail, the bleeding surface must be constricted by passing a threaded needle below it and winding the thread around beneath the ends of the needle. Mechanical loech. 508 MINOR SURGERY. Tlie artificial or mechanical leech is a cupping apparatus which combines in a single instrument a scarificator, a cup, and an exhausting syringe ; or con- sists of two parts, viz., a small steel cylinder containing a lancet that is pro- pelled by a cord, or, better, projected by a spring, and a hollow glass cylinder with a piston that is moved by a screw (Fig. 81). In using this apparatus, the piston of the exhausting instrument should be drawn out slowly, or at the same rate as the blood flows from the wound. If a vacuum be made over the wound before sufficient blood has escaped to till the cylinder, its edge will be apt to compress the integuments to such a degree as entirely to check the flow of blood. Venesection. — For this operation, any superficial vein which is acces- sible, and which can be readily made prominent, may be selected ; hence the veins at the bend of the elbow, those in the vicinity of the inner ankle, and the external jugular vein, are generally chosen. In this country, the operation is usually performed either upon the median basilie or the median cej)hcdic vein. The median basilic vein is generally larger in size, more superficial in situation, and less movable than the median cephalic, and therefore preference is usually given to the former ; although an operation upon the latter, in consequence of its remoter position from the course of the bra- chial artery, is attended with less risk. At the bend of the elbow, the median basilic vein crosses the brachial artery to the inner side of the tendon of the biceps muscle, and is separated from the artery by the dense bicipital fascia. With a little care on the part of the operator, the danger of puncturing the artery may be avoided by opening the vein either above or below the point at which it crosses the other vessel. There are required for the operation of venesection, a lancet or sharp-pointed bistoury; a piece of bandage or tape, from two to four centimetres (an inch or an inch and a half) wide; a small compress; a bowl; a staff; a basin of water, sponge, and towel. The patient should be in the sitting posture, grasping a staff or other firm body in his hand, with his arm bared and extended, and his forearm supinated. The bandage or tape should be applied to the arm a few centimetres (an inch or two) above the elbow, sufficiently tight to arrest the superficial venous circulation without checking the radial pulse. Now, as an assistant holds the bowl in a convenient position for catching the blood, the operator grasps the upper part of the forearm with his left hand in such a way as to enable him to support the limb, and, at the same time, to control the vein with his thumb just below where the puncture is to be made ; then, with a lancet held firmly between the thumb and forefinger of his right lini id, he quickly incises the distended vessel at a point not directly over the artery. The incision should be about 5 millimetres (a fifth of an inch) long, and in a direction oblique to the long axis of the vein. On removing the thumb from the vein below the incision, the blood will flow in a continuous stream if the vein be fairly opened, and if there be no obstruction in the wound. Should the escape of blood be slow, the patient should be directed to grasp firmly the staff or other body that he holds in his hand ; or the operator may stroke the forearm from the wrist towards the el how. If the position of the forearm be changed from supination to prona- tion, after the vein has been incised, the wound of the skin will not corre- spond with that of the vein, when there may either be an arrest of the flow of blood, or the blood may escape into the cellular tissue and give rise to a thrombus. As soon as the required quantity of blood has been drawn, the operator places the index finger or thumb of his left hand on the wound, and quickly loosens the fillet or bandage above the elbow. The compress is now placed on the wound and secured by a figure-of-eight bandage, the intersec- TRANSFUSION OF BLOOD. 509 tions of which should be made directly over the compress ; a few circular turns may be carried around the elbow to give additional security. It is ad- visable, also, to apply a firm roller to the hand and forearm, to support the venous circulation of these parts till the wound is healed. The arm should be carried in a sling for a few days. Venesection may be practised on the external jugular vein, whenever, either from excess of fat, or in cases of children, the veins at the bend of the elbow are not easily found. To distend this vessel, and, at the same time, to prevent the admission of air when the incision is made, the thumb of the operator, or a pad, should be placed over the vein at the outer edge of the sterno-cleido-mastoid muscle, just above the clavicle. If the pad be used, it may be secured by a bandage carried over the pad and through the opposite axilla. The best place to incise the vein is over the sterno-cleido-mastoid muscle ; the opening should be parallel with the fibres of the muscle. By making the incision in this direction, the fibres of the platysma myoides muscle (which is superficial to the vein) will be divided transversely, and, by their retraction, the oblique opening in the vein will be kept patulous. In order that all risks of air gaining access to the vein may be avoided, the wound must be securely closed before the pad is removed from the vein in the supra-clavicular fossa. When this operation is performed in the veins of the ankle the internal saphena is selected. That this vessel and its tributaries may be fully dis- tended, the foot and ankle should be immersed in warm water for a few min- utes before the constricting band is placed around the lower third of the leg. The internal saphena vein, where it passes up in front of the internal malle- olus, should be opened by an oblique incision, made from behind, forwards and upwards. The accompanying nerve lies immediately behind the vein. Arteriotomy. — The vessel usually selected for this operation is the tempo- ral artery, above the zygoma, or one of its two principal branches, either of which may be easily found. "Whichever trunk be chosen, it must be firmly held in position by the finger or thumb of the operator, placed on it below the point at which the incision is to be made. A transverse opening should be made in the vessel with a sharp-pointed bistoury or lancet, and, if the blood does not flow with sufficient freedom, the vessel may be cut entirely across. The hemorrhage may be checked b} 7 a firm compress laid on the wound and secured by a circular bandage of the vault of the cranium ; if this fail to arrest the bleeding, both ends of the vessel may be ligatured in the wound, and the same dressing applied. Transfusion of Blood. This operation has never found much favor with the profession in this country, partly owing to the fact that a very large proportion of the patients operated upon die (though not in consequence of the operation, but rather in spite of it), and partly as a result of the many difficulties attending the per- formance of the operation itself. There are two methods by which transfu- sion may be effected : the immediate or direct, and the mediate or indirect. By the former, blood is conveyed directly and without exposure to the air, from the vessels of one person to those of another ; by the latter, it is first drawn and then injected either as a whole or after being deprived of its fibrine. It would seem, theoretically at least, that the immediate method possessed the greater advantages, by virtue of the fact that by it blood is transferred from one individual to another in its natural state, and is not contaminated by 510 MINOR SURGERY. being exposed to the surrounding media. Panum, of Copenhagen, and other observers, have, however, demonstrated by experiment that blood exposed to the air for a brief period, and deprived of fibrine, is not thereby rendered unfit for introduction into the bloodvessels. Direct Transfusion. — The means most commonly employed in direct transfusion are the Aveling syringe and Roussel's apparatus. The Aveling syringe is simply an India-rubber tube, about 50 centimetres (19| inches) long, with a small bulb in the centre, and having metallic extremities provided with stopcocks ; for connecting the tube with the bloodvessels, there are two bevel-pointed metallic canula?. A small, sharp-pointed bistoury and a deli- cate pair of forceps are used for exposing and opening the vein. In using the Aveling syringe, it is filled with tepid water, or a weak saline solution, for the purpose of displacing the air ; this is done by placing the rubber tube, the stopcocks being open, in a shallow basin containing the liquid. The person supplying the blood, sometimes called the blood-donor, is brought to the bedside of the patient and directed to place the arm from which the blood is to be drawn, nearly parallel with the patient's arm. The operator now proceeds to open the most prominent vein in the bend of the patient's elbow, and to insert into it one of the canulse filled with water, with the point directed towards the body, while an expert assistant, at the same time, introduces the other canula, also filled with water, into the donor's vein; in the latter the point of the canula should be directed towards the Fig. 82. Aveling's transfusion apparatus. A B, assistant's hands holding the canula! in position ; C D; operator's hands, compressing the bulb and, alternately, the afferent and efferent tubes. hand. As the canulse are held steadily in position by assistants, they are quickly connected by the tube, the stopcocks of which are closed before it is taken out of the basin, to prevent the escape of the water which displaced the air. Now on opening the stopcocks, a direct vascular communication is established between the patient and the donor. (Fig. 82.) The introduction of the contents of the bulb into the patient's vein is effected by the operator slowly compressing the bulb with one hand, while he keeps the tube closed on the donor's side with the finger and the thumb of the other hand. Then by releasing the tube on the donor's side of the bulb, and closing it on the patient's side, blood will flow from the donor's vein into the bulb as it is slowly permitted to expand. Communication on the donor's side is again closed, and opened on the patient's side, when, as the bulb is compressed a second time, its contents are driven into the patient's vein. By this alternate TRANSFUSION OF BLOOD. 511 emptying: and filling of the bulb, direct transfusion is effected. By bearing in mind the fact that 8 grammes (2 drachms) of blood are emptied by eacn compression of the bulb, the quantity transferred may be readily determined. After the operation is completed, the wounds of the veins are treated as in a case of venesection. The apparatus devised by Rousscl, for effecting direct transfusion, is much more complicated than the Aveling instrument, and hence its successful em- ployment necessitates considerable familiarity with its use on the part of the operator. The apparatus (Fig. 83) consists of a glass receiver containing a % Fig. 83. Roussel's apparatus for transfusion of blood. lancet, and a Higginson's pump, which connects the receiver with a canula that is to be inserted into the patient's vein. The receiver is placed on the blood-donor's arm, directly over the vein from which the blood is to be ob- tained, and is retained there by atmospheric exhaustion. In order to get rid of air, the apparatus is first filled with a solution of bicarbonate of sodium in the proportion of 2 grammes (| drachm) of the salt to 1 litre (a quart) of water; then the donor's vein is punctured by means of the lancet in the re- ceiver, and, as soon as the sodium-solution is displaced by the blood, the latter is slowly pumped into the recipient's vein. Indirect Transfusion. — The mediate or indirect method of transfusing blood has been very often resorted to in this country. In an emergency, this opera- tion may be done with few instruments. The first time that the writer had occasion to perform transfusion, the instruments used were a hard rubber syringe, to which was fitted a tubular needle (sometimes used by gynaecologists in operations on the female perineum), two porcelain bowls, a linen strainer, a brush made of fresh broom-corn, and a sharp-pointed bistoury. By means of these instruments, five ounces of defibrinated blood were successfully in- jected into the veins of a woman who was moribund from excessive hemor- rhage consequent upon an abortion. The patient made a quick recovery. Various plans and many ingenious apparatuses have been devised with a view to facilitating the safe performance of this operation ; but with care it may be done as safely and as expeditiously with the simple instruments just named as with the most elaborate apparatus. Hewitt's Apparatus. — Dr. Graily Hewitt has devised an apparatus by which blood, before it has had time to coagulate, may be introduced into an indi- vidual's vein. It comprises a glass syringe holding 64 grammes (2 ounces), with a piston, easily removed and inserted, and a curved nozzle provided with a stopper. There is also a curved stylet and canula (the latter fitting the nozzle of the syringe), for insertion into the recipient's vein. In using this instrument, the blood is allowed to flow into the syringe, the piston having been previously removed, and the nozzle closed with the stopper. During this part of the operation, the surgeon or a dextrous assistant should open the recipient's vein, and insert the canula closed with the stylet. As 512 MINOR SURGERY. Fig. 84. soon as the syringe is full, the piston is attached, and the nozzle is in- serted into the canula, the stopper and the stylet having been taken out. The blood, now, is slowly injected by forcing home the piston. In order that more blood may be easily abstracted for another injection, the supplier should be directed to keep the opening in his vein closed with his thumb or finger till the syringe is cleansed and prepared for receiving another supply. The suc- cess of this operation depends upon the expedition with which it is per- formed. JSTot more than two minutes should be permitted to intervene be- tween the reception of the blood in the syringe and its introduction into the recipient's vein ; otherwise, coagulation of the blood is liable to take place, which would seriously embarrass the future steps of the operation. Allen's Apparatus. — Mediate transfusion is commonly effected in this city (Philadelphia) by means of an apparatus that was first suggested by Dr. J. G-. Allen, and subsequently modified by Dr. T. G. Morton and the writer. The apparatus consists of a blood-can ; a strainer, either metallic or linen ; a graduated glass sy ringe holding five or six ounces ; a curved canula with its point bevelled on the convex side ; a brush, either made of fine wire or of fresh broom-corn, and a lancet or sharp-pointed bistoury. The blood-can has two compartments, an outer for hot water, and an inner, conical in shape, and extending down into the former, for the reception of the blood as it flows from the supplier's vein. To the side of the can is affixed a clinical thermo- meter, the curved bulb of which projects into the hot-water chamber ; there is likewise a short tube communicating with this chamber for the introduc- tion of hot water. The conical wire strainer is made to fit ac- curately the conical blood-cham- llfl ^er. A short piece of flexible tubing is used to connect the nozzle of the syringe with the canula, (Fig. 84.) In the employment of this apparatus, the first step is to fill the outer chamber of the blood- can with water at a temperature of 110° F. ; should the temper- ature fall below 100° F. during the performance of the opera- tion, more hot water at the former temperature should be added. The syringe should be kept in hot water till it is required. The supplier's vein should now be opened, as in venesection, and, as the blood escapes, the blood-can with the conical strainer should be held in a convenient position for receiving it, Before the blood in the can begins to coagulate, it should be slowly stirred with the wire brush to separate the fibrine ; and from time to time the brush should be cleansed in warm water to keep it free from coagula. If desirable, the abstraction of the blood and its preparation for injection may be attended to by an assistant in an adjoining room, while the surgeon himself lays bare the recipient's vein and inserts the point of the canula. It* a sharp-pointed canula be used, its point may be thrust through the thin wall of the vein into its cavity; but if the canula be blunt, it is a safer plan to place a ligature around the vessel on the distal side, and make an opening in it for the introduction of the canula. As soon as the fibrine of the blood in the can is separated, the strainer is removed, and with it all fragments of clot and foreign matter, leaving nothing but defibrinated blood in the can, surrounded with hot water. The syringe Allen's transfusion apparatus, modified. TRANSFUSION OF BLOOD. 513 with the flexible tube attached is then filled with defibrinated blood, and quickly connected with the canula which has previously been introduced into the recipient's vein. The blood should be slowly and .steadily injected. If air be drawn into the syringe with the blood, it may be expelled before the syringe is attached to the canula by holding the syringe in a vertical position with the nozzle upwards, and pushing in the piston sufficiently far to displace the air. Should it be deemed necessary to introduce more than one syringc- ful, the syringe may be charged again with defibrinated blood, and the injec- tion repeated. The wounds of the veins of the supplier and the recipient should be treated as in a case of ordinary venesection. Many other ingenious instruments have been devised for effecting mediate transfusion, among which may be mentioned Collin's apparatus, which is used in the French army, and llasse's syringe. In Ilasse's syringe, the piston is moved by a female screw, which enables the operator to regulate the flow of blood with the utmost nicety. Transfusion by hydrostatic pressure is urgently recommended by Dr. Friedrich Esmarch, who considers it free from many of the objections which have been urged against the use of the syringe. Arterial Transfusion, as recommended by Hitter, is occasionally prac- tised. In this operation, defibrinated venous blood is injected into an artery (usually the radial above the wrist, or the posterior tibial behind the inner malleolus), towards the distal extremity of the limb. The artery is exposed and secured by a ligature ; it is then opened on the distal side of the ligature by a valvular wound, into which the point of a canula or the nozzle of a syringe is introduced. When the operation is completed, the artery is cut across and the peripheral end ligatured. Auto-transfusion is a term applied to an expedient that may be resorted to in eases of excessive hemorrhage to support a moribund patient till trans- fusion can be performed, or other means of resuscitation adopted. It consists in the application of elastic bandages, or, if these be not at hand, muslin bandages, to the extremities, for the purpose of forcing the blood towards the vascular and nervous centres. Intra-venous Injections of sometimes employed, as a sub- stitute for transfusion, after ex- cessive hemorrhage, and in dis- eases which greatly deteriorate the quality of the blood, as per- nicious anaemia, epidemic cho- lera, carbonic acid poisoning, etc. In 1850, Dr. E. M. Hod- der, of Toronto, first made use of milk injections in the treat- ment of cholera collapse. Since then, this operation has been repeated by Dr. J. W. Howe, Dr. T. Gaillard Thomas, Dr. Bullard, and others, in the treatment of various disorders, with more or less benefit to the patients. The writer has him- self resorted to infusion of milk vol. i. — 33 Milk, or of various Saline Solutions, are Fig. 85. Funnel and tube for intra-venous injection of milk. 514 MINOR SURGERY. eleven times, with sufficient success to encourage him in the belief that, under certain circumstances, the procedure is perfectly justifiable, and that milk introduced into the system in this way may become a valuable therapeutic resource. Intra-venous injection is an easier operation than transfusion, and is most conveniently effected by hydrostatic pressure. The apparatus used by the writer consists of a glass funnel holding about 160 grammes (5 ounces), connected with an India-rubber tube to which is attached a small curved canula provided with a stopcock. (Fig. 85.) A cup-shaped strainer of fine wire, made to fit the expanded extremity of the funnel, is an important part of the apparatus. (Fig. 86.) Fig. 86. Strainer for intra-venous injection of milk. Either cow's or goat's milk may be used, and, as it is absolutely essential that the milk be perfectly fresh, and alkaline or neutral in reaction, it should be taken from the animal immediately before it is injected. The surgeon exposes a prominent vein in the bend of the patient's elbow, and raises it up by passing a probe or director beneath it, while an assistant fills the apparatus by pouring the milk into the funnel through the wire strainer. In order that no air may be left in the apparatus, the canula with the stopcock open is held vertically along- side of the funnel, and, as the milk begins to flow from the canula, the stopcock is closed ; by this plan the milk is retained in the canula by atmospheric pressure. The sharp point of the canula is now thrust into the lumen of the vein (or, if the vein be small or collapsed, a V-shaped incision may be made in it for the canula), when, on opening the stopcock and raising the funnel above the level of the patient's arm, the milk will flow into the vessel. The rate at which the milk enters the vein may be regulated by the stopcock, or by varying the height at which the funnel is held above the arm. Artificial Respiration. Artificial respiration is resorted to in cases of threatened death from apncea consequent upon drowning, inhalation of irrespirable gases, profound ansesthetization, or other causes that act by temporarily checking or inter- fering with the function of breathing. Two conditions are essentially neces- sary to the successful application of this procedure: these arc (1) an unob- structed passage for the entrance of air to the lungs, and (2) the absence of all obstacles to free expansion of the chest-walls, itence mucus, free liquids, or foreign bodies in the air-] lassages must be removed — if necessar} T , by trache- otomy ; and all bands or tight clothing around the chest and neck must be loosened. Mouth to Moutii Inflation is a method of practising artificial respiration sometimes adopted in cases of great urgency, as a temporary expedient till other more efficient measures may be instituted. It is especially applicable to cases of children under six months of age, in consequence of the weak and inelastic condition of their chest-walls. Instead of the operator applying his ARTIFICIAL RESPIRATION. 515 mouth to that of the patient, air may be introduced into the lungs through a flexible catheter passed into the trachea. The Bellows may be employed as a means of forcing air into the lungs. Dr. Richardson, of London, has devised a "pocket-bellows" (Fig. 87) which Fig. 87. A Richardson's bellows for artificial respiration. A, bulb for filling the lungs ; B, bulb for exhausting them. consists of two elastic bulbs terminating in a single tube. This tube is inserted into the nostril, and, the other nostril and the mouth being closed, air may be driven into the lungs by compressing one of the bulbs (A), and withdrawn by compressing the other (B). This is an ingenious imitation of natural respiration. The entrance of air into the oesophagus, when either of the two methods just described is practised, may be prevented by pressing the larynx upwards and backwards. Howard's Direct Method of Artificial Respiration. — The three methods by which artificial respiration may be most effectively practised are Dr. Benjamin Howard's "Direct Method," Sylvester's Method, and Marshall Hall's "Ready Method." In this country, the "direct method" is generally acknowledged to be the best. It has been adopted by the United States Government Life Saving Service, the Life Saving Society of New York, etc. Dr. Howard gives the following rules for the direct method : — Rule I — "To drain off Water from Chest and Stomach. Instantly strip the patient to the waist. Place him face downwards, the pit of the stomach being raised above the level of the mouth by a large, hard roll of clothing placed beneath it. Throw your weight forcibly two or three times, for a moment or two, upon the patient's back, over roll of clothing, so as to press all fluids in the stomach out of the mouth." The above ride is to be followed only in case of drowning ; in apnoea from other causes it is to be omitted. Rule II — " To perform Artificial Breathing. Quickly turn the patient upon his back, the roll of clothing being so placed beneath as to make the breast-bone the highest point of the body. Kneel beside or astride patient's hips. Grasp front part of the chest on either side of the pit of the stomach, resting your fingers along the spaces be- tween the short ribs. Brace your elbows against your sides, and, steadily grasping and pressing forwards and upwards, throw your whole weight upon chest, gradually increas- ing the pressure while you can count one — two — three. Then suddenly let go with a final push, which springs you back to your first position. Rest erect upon your knee while you can count one — two ; then make pressure again as before, repeating the entire motions at first about four or five times a minute, gradually increasing to about ten or twelve times. Use the same regularity as in blowing bellows, and as is seen in natural breathing, which you are imitating. If another person be present, let him with one hand, by means of a dry piece of linen, hold the tip of the tongue out of one corner of the mouth, and with the other hand grasp both wrists and pin them to the ground above the patient's head." Sylvester's Method. — The patient, with all tight clothing and bands re- moved or loosened, is placed on his back on a flat surface, his head and shoul- 516 MINOR SURGERY. ders being supported by his coat or some other garment folded into a broad cushion. The mouth being cleared from all foreign substances, the tongue is drawn forwards, and secured to the chin by a piece of tape or string tied around it and the lower jaw; or the tongue, with a piece of linen, or a pocket handkerchief, around it, may be pulled forwards and held by an assistant. Now, the operator, kneeling at the patient's head, grasps the arms at the el- bows, and carries them first outwards, and then upwards, till the hands are brought into contact with each other above the head ; they are kept in this position for two seconds, after which they are brought slowly back to the sides of the thorax, and pressed gently against it for two seconds. These movements are gently and deliberately repeated fifteen times in a minute, until a spontaneous effort to breathe is made, or until it is evident that further exertion is useless. Marshall Hall's "Ready Method." — To clear the mouth and secure free entrance to the larynx, the patient is turned on his face, with one wrist under his forehead and a folded coat or other article of dress beneath his chest. Respiration is now to be imitated by " turning the body gently on the side and a little beyond, and then briskly on the face, alternately." Each time the body is brought into the prone position, firm compression is to be made on the posterior aspect of the thorax. As in the methods already described, the manipulations designed to imitate respiration are repeated fifteen times in a minute, for two or three hours, unless resuscitation is sooner accomplished. The efforts of the operator should not immediately cease when the first natural respiratory movement is detected, but they should be continued in such a way as to coincide with the spontaneous inspiratory and expiratory motions, until the breathing becomes regular. Other agencies, such as aqua ammonise passed back and forth beneath the nostrils, cold water dashed on the surface of the body, etc., may aid in exciting respiration. The tempera- ture of the body may be restored by friction applied by the hands of assistants to all parts of the surface, by the hot-water or hot-air bath, warm coverings, etc. As soon as the patient becomes capable of swallowing, he should be given hot coffee or tea, or brandy or whiskey properly diluted. After respiration has become normal, the patient must be closely watched, in order that the first signs of secondary apncea may be instantly detected, and that suitable measures to avert it may be promptly adopted. Vaccination. Vaccination is a minor surgical operation which every practising physician is expected to be able to perform when occasion demands. Although in itself exceedingly simple, yet, unless the operation be carefully done, failure to afford that protection against smallpox which is reasonably expected, is liable to result. Vaccination may be safely employed in the case of any healthy individual, at almost any period of life. Children should be vaccinated before they arc three months old, unless there be special contra-indication to the pro- cedure ; in id, in the event of exposure to smallpox, even at an earlier age — immediately after birth if necessary. Vaccination may be effected by the use of two 'kinds of lymph, humanized and bovine. Humanized lymph may be used in one of two' forms, either as a viscid fluid taken from a well-formed vaccine vesicle on the eighth or ninth day, or as a scab or crust which has separated spontaneously about the twentieth day. The former is generally considered more effective than the latter, yet the dried scab is more commonly employed in this country. Bovine or animal virus is obtained directly from VACCINATION. 517 the udder and teats of the cow, and is made available by being allowed to dry on slips of ivory, quill, or whalebone. Humanized lymph in either form must be free from blood and pus, and, when kept for use, must be preserved from the action of heat and moisture ; otherwise its employment may be pro- ductive of serious results. In this country, the suppliers of animal virus en- velop the charged ivory and quill points in antiseptic cotton, which is sur- rounded with water-proof material. The only instrument needed for effecting vaccination is a common lancet, one which is somewhat dull being usually preferred, as drawing less blood. By means of this simple instrument, the operation may be done quite as satis- factorily as with any of the many ingenious devices which have been sug- gested for the purpose. That the lancet may not be the means of carrying contagion, it should be kept perfectly clean. The place usually selected for the insertion of vaccine virus, is on the outer side of the left arm, near the attachment of the deltoid muscle, although the operation may be performed on almost any part of the body. Whenever practicable, arm-to-arm vaccina- tion is to be preferred to all other methods. In this mode of proceeding, fluid lymph is taken directly from a well-formed vesicle on the eighth day, when its contents are probably the most effective, and inserted into the skin. If ivory or quill slips be used, the dried lymph must be softened by holding the points in the steam of hot water, or by dipping them in warm water ; or, if the crust be employed, it must be reduced to a semi-liquid condition with a little water or glycerine. There are several ways in which vaccine virus may be inserted into the skin, any one of which, if carefully practised, will undoubtedly prove suc- cessful. Probably, the one most commonly employed in this country is that of abrasion or " cross-scratch ;" it certainly seems to be the method most usu- ally successful when dry lymph is used. In making the abrasion, the ope- rator grasps the left arm of the patient in such a manner as to put the skin overlying the insertion of the deltoid muscle on the stretch. He then with the lancet scratches off the epithelium and exposes the absorbing surface of the cutis vera ; the appearance of bloody oozing is an indication that the cutis has been sufficiently denuded. On this surface, after the blood has been wiped off, the lymph is smeared, either with the flat surface of the lancet- blade, or with an ivory or quill point. The part is to be left uncovered till the lymph dries. There is no need of making any topical application subse- quently ; the only precaution necessary is to keep the part from being chafed or scratched till the scab falls off Another plan, peculiarly suited to arm-to-arm vaccination, is to insert the lymph into small punctures made in the skin with the point of a lancet. These punctures should be made obliquely from above downwards, and should extend well into the cutis. The virus is introduced on the point of a lancet, or on an ivory or quill point. The valvular character of the wound favors the retention of the lymph. Instead of making four or five punctures as above described, multiple punctures may be made, and the lymph rubbed over the wounded surface ; or the lymph may be first smeared on the surface and then pricked in, as in tattooing. Revaccination is imperatively called for in cases in which primary vacci- nation has entirely failed, or lias been modified by causes not apparent. It is also advisable to revaccinate at or shortly after puberty, even when there are unmistakable evidences of a successful and thorough primary vaccination. Some authorities go further, and advise a repetition of the operation once in seven years, and likewise whenever an epidemic of smallpox is prevailing. The methods by which revaccination is effected differ in no way from those adopted for the primary operation. 518 MINOR SURGERY. Hypodermic Injections. Hypodermic injection is a simple method of introducing certain drugs, especially anodynes, into the system, and is frequently resorted to by surgeons in cases in which a more prompt and decided impression is desired than could be obtained were the same remedies administered either by the mouth or by the rectum. Although this operation, in the hands of an experienced person, is one of extreme simplicity, and free from danger, yet unpleasant and even fatal consequences have followed its employment when incautiously per- formed ; hence, as a rule, the surgeon should either do the operation himself, or intrust it to an intelligent assistant. The instrument employed consists of a small syringe, holding about 30 minims, with an adjustable nozzle, which is a hollow needle. (Fig. 88.) The Syringe for hypodermic injections. barrel is made of either glass, hard-rubber, metal, or a combination of glass and metal. In order that the syringe may be air-tight, the piston must accu- rately fit the cylinder ; hence the calibre of the latter must be the same through- out. A glass syringe may be graduated to minims, either on the barrel or on the piston-rod ; other forms of the instrument have the piston-rod graduated. The perforated needle may be attached to the barrel by either a screw or a socket-joint. The metallic syringe is the one to which the writer gives pre- ference. This has two delicate needles with lancet-shaped points, which are attached to the barrel by a screw-joint. It is provided with a screw-cap that is to be kept on the end of the barrel when the instrument is not in use, in order that the piston may always be moist, and the cylinder free from dirt. A delicate piece of annealed wire, sharp pointed and attached to a small handle, will be found useful to remove dirt or moisture from the needles whenever they become clogged; this may be dispensed with, however, if the f this apparatus arc an air-pump; blunt canulae of various calibres, with blunt and sharp-pointed stylets; an India-rubber stopper perforated with two curved tubes, each having a stopcock; a bottle; and rubber tubing. (Fig. 91.) The stopper is conical in shape, and of a size rendering it adaptable to the necks of ordinary bottles varying in capacity from a pint to half a gallon or more. The bottle is first exhausted of air by the air- pump; then the canula, inclosing the sharp-pointed stylet, being attached to one of the tubes in the stopper by a piece of flexible tubing, is pushed SURGICAL USES OF ELECTRICITY. 521 through the integuments into the cavity containing the fluid to be evacuated. On withdrawing the stylet and opening the stopcock, the fluid passes quickly into the bottle. If there be more fluid than one bottle will hold, the step- cock of the tube connected with the canula may be closed, the stopper Potain's aspirator. removed, and the bottle emptied ; it is then to be re-exhausted by the air- pump. Occasionally, as in the case of cold abscesses, the flow of pus is suddenly stopped by a small mass of lymph or cheesy matter becoming lodged in the canula. Such an obstruction may be easily removed by pass- ing a blunt stylet or plunger through the canula. With Potain's aspirator all unpleasant odors are conveyed with the pus into the bottle-reservoir, and therefore do not escape into the patient's room. This is an advantage not possessed by any other variety of the instrument. As the canulse of this apparatus are blunt-pointed, they will not wound the delicate inner surface of the sac of an abscess as its walls collapse ; hence hemorrhage into the cavity of an abscess is less liable to follow the use of this aspirator than of those that are provided with sharp-pointed cannlre. In aspirating an abscess, it is advisable to use a large canula, in order that the pus, even if it be somewhat consistent, may escape freely. When urine or serous accumulations are to be drawn off, a smaller canula should be selected. The slight wound made by the stylet or canula should be carefully closed by a strip of adhesive plaster. Although the operation of aspiration is made very simple by the improved instruments now in use, yet certain precautions must be observed to render its performance free from danger. The operator should make himself perfectly familiar with the relation that the bloodvessels and nerves, or other important organs, bear to the cavity containing the fluid, before he proceeds to introduce the canula or needle. Without this special knowledge, he is liable, of course, to do his patient an irreparable injury. Surgical Uses of Electricity. 1 The surgical uses of electricity consist chiefly in the various applications of the operations known as electrolysis and electro- or galvano-cautcry. Electro- 1 The writer takes pleasure in acknowledging his indebtedness to Dr. Charles K. Mills. Lecturer on Electro-Therapeutics in the University of Pennsylvania, for valuable assistance iu preparing this section. 522 MINOR SURGERY. lysis means chemical decomposition by electricity, and the term is applied in surgery chiefly to the decomposition by means of this agent of tumors, exu- dations, or other morbid products. Electro- or galvano-cautery is the process of cauterizing or burning tissues by means of a wire, or other metallic instru- ment, which has been heated hy electricity. Strictly speaking, galvano- cautery is not an electrical operation; electricity is simply used to heat the instrument with which the cauterization is performed. The terms electro- puncture and galvano-puncture refer to electrolysis, to the plunging of needles into a part through which an electric current is made to pass. Electrolysis. — For electrolysis, a suitable battery, and needle electrodes of special shapes, are required. The apparatus generally preferred is a galvanic or continuous-current battery of a considerable number of cells of medium size; some form of zinc-carbon battery of thirty or more cells. The fluid that will probably be found most serviceable is the well-known solution of potas- sium bichromate. Almost any of the constant batteries, however, which are employed in the treatment of diseases of the nervous and muscular systems, can be made use of in this operation. Fig. 92 represents an improved, portable, Fig. 92. Constant galvanic l>attery. constant galvanic battery, manufactured by Messrs. Flemming and Talbot, of Philadelphia. This battery contains thirty cells ; others ranging as high as sixty cells are made. Electrolysis lias been resorted to with more or less suc- cess in the treatment of aneurism, tumors, and conditions dependent upon old inflammatory deposits The forms of tumor that have been treated electri- cally are naevi, goitres, polypi, cysts, hydatids, fibroids, cpitheliomata, scir- rhous cancers, etc. SURGICAL USES OF ELECTRICITY. 523 In the treatment of aneurism, two methods are employed. One method is to insert the needle, connected with only one of the poles of the battery, into the sac, the other rheophore being applied to the surface of the body. In the second and better method, two tine, sharp needles, carefully insulated nearly to their extremities, and connected with the conducting cords from both poles of the battery, are introduced into the aneurisnial sac. At first a weak cur- rent is allowed to pass, its strength being gradually and cautiously increased as the operation 'advances. The operation should be performed slowly, as clots that are rapidly produced are liable to be washed away by the blood current. At the expiration of a period varying from half an hour to an hour, the needles are to be removed, and the punctures closed by small compresses of lint secured by plaster or collodion. In some cases it will be found neces- sary, in consequence of the timidity of the patient, or of pain, to resort to anaesthesia either local or general. In treating tumors of any kind by electrolysis, the methods are practieally the same. As in the case of aneurism, needles either from one or from both poles of the battery are introduced directly into the tumor, in the same way that a hypodermic needle would be inserted. The cells of carcinomata are said to yield sooner to electrolysis than other cells, just as one body may decompi >se more readily than another. Some electro-therapeutists, the two Brans, for example, consider that the destructive action of the current is strictly and wholly due to the action of the alkali developed at the negative, and the acid at the positive pole. In addition to its uses in cases of aneurism and tumors, it is claimed by electro-therapeutists that electrolysis is serviceable in the treatment of hydrocele, stricture of the urethra, opacities of the cornea, cata- ract, inflammatory thickenings in and about the ear, etc. Galvano-Cautery. — Galvano-cautery batteries are made with plates or ele- ments of a large size, but comparatively few in number, and placed close to one another. In this way, " internal resistance" as the electrician would say, is reduced, and a current is obtained which will keep a metallic electrode at a white heat. There are many varieties of the galvano-cautery battery, but perhaps the most compact and generally useful apparatus is the Byrne Cautery Battery, an invention of Dr. John Byrne, of Brooklyn, X. Y. Figs. 93 and 94 represent the battery and the necessary appliances, such as handles, ecraseurs, knives, moxa, scoops, etc. The galvano-cautery may be employed in nearly all operations in which the actual or potential cautery, or the ecraseur, are employed. By its aid morbid growths and diseased parts can be removed with greater expedition, and with less risk of con- secutive hemorrhage, than with the ordinary, ecra- seur. When resorted to as a means of applying the cautery in cavities, its. action can be more accu- rately localized than that of the ordinary methods of cauterization; for which reason, many gynae- cologists prefer this apparatus to all others in their operations on the cervix uteri and in the cavity of the womb. The success attending the use of the galvano- cautery is mainly dependent on the degree of tem- perature employed. Experience has demonstrated that a dull red heat pro- duces the best results, and hence this temperature should be continuously Fig. 93. Byrne's cautery battery. 524 MINOR SURGERY. maintained during the period of actual cauterization. The main advantage of a galvano-cautery, is that the wire or other electrode can be accurately ad- L iCOSOQ a gjySflfS Q' Electrodes for galvano-cautery. 1, £craReur -with -wire loop ; 2, Handle without ecraseur attachment ; 3, Cautery knife ; 4, Universal hard-rubber handle , 5, Platinum moxas and scoops , 6, Porcelain moxas. justed in the required position while cold, and then quickly heated. The galvanic ecraseur of Middeldorpf consists of a coil of platinum wire which, by its attachments to a rod and a screw, can be shortened as it burns its way through the tissues around which it is placed. Before applying the coil around a diseased mass, as a cancerous nodule of the tongue, it is highly im- portant that the morbid structure should be isolated from the healthy tissues. This is best accomplished by long pins, ivory pegs, or curved needles in han- dles, passed through the healthy part in different directions. The coil is then placed around the part, behind the pins, and, as it burns its way through, the direction of the section will be determined by that of the pins. [Faure's in- genious "secondary battery," by which the galvanic current can be, as it were, stored away for future use, will probably add very much to the practical advantages of this mode of applying electricity. 1 ] [i See British Medical Journal, June 11, 1881, pago 914.] MASSAGE. 525 Galvanization and Faradization often prove of service in the various neuralgic and paralytic conditions which accompany or follow surgical affec- tions. In some forms of spinal curvature, and of club-foot, the muscles can be advantageously faradized. Sprains, muscle-strains, and some forms of synovitis, can also with advantage be treated by local faradization or galvanization. Fig. 95 represents one of the best forms of faradic battery. Massage. Under the general term of massage, Dr. "W. Wagner, of Friedburg, 1 includes four different manipulations, viz., (1) stroking {effleurage)\ (2) kneading {■petrissage)', (3) tapping or per- cussion (tapotement) ; and (4) passive and active motion. To these varieties may be added an- other form of massage, quite extensively used Faradic battery. in this country, which consists in pinching up the integuments and muscles, the latter singly or in groups, and rolling them gently between the thumb and fingers. In the larger cities this treatment is generally intrusted to assistants called rubbers, manipulators, or masseurs, who, being specially trained to the art, soon gain great dexterity in its appli- cation. Preliminary to the application of massage, the part to be operated upon should be anointed with cocoa-oil or vaseline. If there be a heavy growth of hair on the part, this should be carefully shaved, as otherwise irri- tation of the follicles and the development of boils may be the consequences of the rubbing. Stroking {Effleurage) consists in gently smoothing or rubbing the surface of a part with the palm of the hand from the periphery ; distended veins and lymphatics are thus emptied, and liquid transudation removed from the tis- sues. In the early stages of inflammation, this manipulation is first applied above the seat of disease, in order to afford more space for the returning cur- rents. By degrees the inflamed part is approached, and, when reached^ firm but gentle pressure is made on it, thus forcing the fluids inwards, and pro- moting the absorption of exudations if they have already occurred. With a diminution in the contents of the vessels, there is a proportionate subsidence of all the local phenomena of inflammation. Kneading {Petrissage) is a form of massage, applied by rubbing a part cir- cularly with the extremities of the fingers or thumb, or the palm of the hand, and is indicated in cases of inflammatory transudations, and in those of ecchymosis into the subcutaneous cellular tissue. Kneading may with ad- vantage be combined with stroking, whenever it is desirable not only to break up exudation, but likewise to hasten the removal of the resulting detritus from the tissues. The amount of pressure to be used in applying this variety of massage must be determined by the nature and the seat of the material to be gotten rid of, and by the sensitiveness of the patient. A vigorous appli- cation of this manipulation is more apt to be tolerated in cases of partially • Berliner klinische Wochenschrift, Nov. 6 und 13, 1876. nal, May 17. 1877. Boston Medical and Surgical Jour- 526 MINOR SURGERY. organized inflammatory products, especially when they are deep seated, than in those of extravasation or serous exudation. Percussion (Tapotement) is another form of massage, which consists in tap- ping the surface of an aifected part either with the tips of the fingers held in a row, a small hammer, or the ulnar border of the hand. Sometimes the palm of the hand is brought into requisition, when a considerable surface of the trunk, as the loins, is the subject of treatment. It is claimed by some authors that percussion will cure, or ameliorate, some forms of neuralgia and of peripheral paralysis, by promoting the absorption of exudation from around the affected nerves. The beneficial effects of percussion in these cases will be greatly increased if the nerves be stretched and the overlying integuments kneaded. Passive and Active Motion, in conjunction with the manipulations already considered, are found of special service in getting rid of those trouble- some conditions so often following sprains, dislocations, fractures, and other affections that require immobilization of the affected limb as an essential feature of the early treatment. While the limb is subjected to stroking, kneading, etc., passive motion of the joints should at first be made by the manipulator, and, as soon as practicable, the patient himself should be encour- aged to employ active motion. The persistent employment of passive and active motion will often restore the functions of a stiff joint sooner, and Avith less suffering to the patient, than the forcible breaking up of adhesions under anaesthesia. In the treatment of old sprains, and of the later stages of fracture of the extremities, where the muscles have lost tone and become flabby in conse- quence of disease, Dr. Douglas Graham 1 suggests the employment of what he calls ado-passive motion, as a means of restoring the strength of those mus- cles, and of giving the patient confidence to use them. This manipulation consists in "alternately resisting flexion and extension, while keeping the resistance less than the strength of the limb, so that the patient may not re- cognize his weakness there." Muscle-beating. — C. Klemm, Manager of the Gymnastic Institution in Riga, 2 has suggested a form of massage which he terms musde-beatiwg. The instrument that he uses in practising this treatment is called a muscle-beater, and consists of three elastic tubes fastened together near a handle to which they are attached. The circumference of each tube is about that of a finger; the length and the thickness of the material of which the tubes are made vary according to the different purposes for which the instrument is em- ployed — hence muscle-beaters of different sizes are needed. Muscle-beating is not to be made on a naked surface, except in case of the head or the hand; the part should be protected by a thin covering of some kind. The duration of a "seance" should be determined by the impressionability of the part; it is always well to suspend the operation as soon as a sensation of moderate burning, or an increase of the surface temperature, is felt by the patient. The application of this manipulation should be interrupted by slight pauses of a minute or two, in order that excessive irritation of the skin maybe avoided. Among the many diseased or abnormal conditions for which muscle-beating is recommended by ('. Klemm, are coldness of the extremities, muscular ataxy, stiffness of the joints consequent upon sprains, dislocations, rheumatism, 1 Boston Medical and Surgical Journal, vol. xix. p. 578, 1877. * Muscle-beating, or Active and Passive Home Gymnastics. New York, 1S79. USE OF THE THERMOMETER IX SURGERY. 527 lateral curvatures of the spine, etc. With a little experience in the use of the muscle-beater, an individual may apply the treatment to his own person, and thus dispense with the services of a professional masseur. Many of the benefits arising from active exercise will be experienced by an individual who can practise muscle-beating in his own case ; hence it is a good plan, when practicable, for the physician to instruct his patient in the method of employing this manipulation. Massage should not be applied just before or immediately after eating ; an hour midway between breakfast and dinner, or lunch, seems the most suita- ble. If two sittings a day are deemed necessary, the second should be at a corresponding period between the midday and evening meals. The treatment should be applied at least once a day ; some cases are undoubtedly benefited by two applications in the twenty-four hours. The duration of a sitting will depend on the circumstances of each case ; an hour may be considered the maximum. Use of the Thermometer in Surgery. For clinical observations, two thermometer scales are in common use, the Centigrade and Fahrenheit; the former is used in almost all countries except England and America, where the latter is preferred. As these thermometers are specially designed for detecting abnormal variations of bodily temperature, their scale has a limited range, usually a few degrees Fig. 96. above and below the normal temperature, which amounts to 98|° /T\ F. = 36° C. The degrees, and their subdivisions into fifths or tenths, are either etched on the stem of the instrument or marked on a plate of ivory that is attached to the stem. There are many varieties of thermometers in use, but the straight, self-registering, clinical thermometer (Fig. 96) has been proved by experience to be the best. In this variety, the upper part of the column of mercury is separated by a small bubble of air. This detached piece of mercury is called the index, from the fact that when it is pushed up by the main column, it remains in position, and indi- cates the degree of temperature. Thermometers are now made with a " convex face" between the etched lines and the figures of the scale, this serving to magnify the column of mercury, and thus enabling the observer to note quickly the position of the index. Before using this instrument, the index must be shaken down to a point two or three degrees below the normal tempera- ture. This is done by holding the thermometer in the hand with the bulb downwards, and either striking the ulnar border of the hand which grasps the instrument forcibly against the radial border of the other hand, or raising the hand from the body and bringing it down with a quick motion or jerk. There should be a slight constriction between the stem and the bulb of the instru- ment, to prevent the index from passing into the bulb when it is shaken down. As accuracy of registration is of prime importance in the use of a thermometer, every instrument ought to be compared with some recognized standard. English thermometers are compared with the standard at Kew Observatory, and' if any variation be detected, no matter how small, it is noted in a certificate which cnnicTi ther- accompanies the instrument. A like arrangement is provided for mometer. 528 MINOR SURGERY. testing American thermometers, at the observatory at Cambridge, Mass. Should it not be convenient to make the comparison with some standard, the variation may be approximately determined by taking the temperature of a healthy person. One thermometer should not be substituted for another in making a series of observations in the same case. The temperature may be taken in the axilla, the mouth, the vagina, or the rectum. For obvious reasons, the axilla is usually selected, although the mouth is equally convenient for taking the temperature. The rectum or the vagina should never be chosen for taking a therniometric observation when the other regions are accessible. Before taking the temperature in the axilla, all clothing encroaching upon this space should be removed, and any moisture that there may be on the surface wiped off. To raise the tempera- ture of the axillary space to that of the body, the arm should be kept close to the side of the chest for two or three minutes ; if this be done beforehand, the instrument will not have to be left in place as long as it would otherwise. The bulb of the thermometer is then put in the centre of the axilla, well under its anterior margin, and the arm brought to the side of the thorax with the forearm across the body. The patient should keep his arm and forearm in this position for at least five minutes. In the case of an infant or a very feeble patient, the arm should be held pressed against the body. If the thermometer be self-registering, it may be removed and the position of the index noted, at the expiration of the time mentioned ; otherwise the instrument must be examined before it is taken out of the axilla. If the thermometer be introduced into the mouth, the patient should be directed to keep his lips tightly closed around the stem of the instrument, and to breathe through his nose. "Whenever a series of thermometrie observations is made in a case of disease, it will be found convenient to use, for noting the daily variation, some form of register or chart which may be kept for reference. The fact that there is a normal, diurnal fluctuation in the tem- perature of a healthy person, which is not influenced by external circumstances, must not be lost sight of whenever an attempt is made to determine the effects of disease in causing variations of the bodily heat. In a state of health, the temperature steadily rises from morning till towards evening, after which it gradually sinks again till morning. There is a difference of from 1° to 2° F. between the morning minimum and the evening maximum. Exercise and the ingestion of food have the effect of raising the temperature slightly, but rarely more than one degree. The tem- perature in middle age is a little lower than in childhood, or in the later periods of life. ."Whenever it is essential to ascertain the amount of daily exacerbations of temperature, two observa- tions should be made : one in the morning between 6 and 8 A. M. ; the other in the evening between 4 and 6 F. M. In practising surface-thermometry, instruments having bulbs of discoid shape, or drawn out in the form of a spiral or coil, are generally employed. In Fig. 97 is represented a convenient form of surface-thermometer ; this instrument has a stem and graduated scale like the ordinary axillary thermometer, but its bull) is a glass coil, surrounded by a band of hard rubber which protects it from injury and prevents loss of heat. In some local- ities, as in the intercostal spaces and the vicinity of many joints, the ordinary axillary thermometer, owing to the shape of its bulb, can be used to better advantage than any of the surface-thermo- meters. To determine accurately the amount of variation in the Fig. 97. Surface ther- momoter. USE OF THE SPHYGMOGRAPH. 529 surface temperature of a part, it is essential that the temperature of the cor- responding part of the opposite side, and the general temperature of the body, should be taken at the same time. Use of the Sphygmograph. By means of the sphygmograph, the pulsations of an artery may be auto- matically registered. Although the idea of making an artery record its own pulsations is not a recent one, yet the practical realization of this conception of Galileo dates from the invention of the sphygmograph by Vierordt and Marey. Two forms of this instrument are in use at the present time : M. Marey's, modified by Dr. Mahomed, and Dr. E. A. Pond's ; the former in England and on the continent of Europe ; the latter principally in America. Marey's sphygmograph consists of a brass framework to which are attached an arrangement of levers designed to be acted upon by the pulsating artery, and a clockwork which propels a slide carrying a piece of paper or mica on which the pulsations are registered. To regulate and measure the amount of pres- sure made on the artery by the mainspring, Dr. Mahomed has had attached to the side of the framework an eccentric wheel, which acts upon the main- spring, and is worked by a thumb-screw. The degree of pressure exerted upon the mainspring by the eccentric is indicated on a dial-plate. The pressure is measured in troy ounces, from one to eighteen; the amount of pressure employed in taking a tracing should always be recorded on the slip with the latter. Preparatory to taking a tracing, the forearm of the patient is laid, with the palmar surface upwards, on a splint or some other convenient support, as on a double-inclined pad with an angle of about 135°, with the hand bent slightly backwards. The sphygmograph is placed on the forearm with the ivory pad at the free extremity of the mainspring, directly on that portion of the radial artery which lies to the inner side of the styloid process of the radius. When the instrument is properly adjusted, it is secured by straps buckled around the limb. In order that a satisfactory tracing may be obtained, the hand must not be too much extended, nor, on the other hand, should it be tightly closed. In the former position, the pulsations of the artery are liable to be interfered with by the vessel being stretched over the surface of the bone ; in the latter, the tendons adjacent to the artery are made tense, and rise above its level, thus preventing the pad from coming in contact with the vessel. With the instrument properly adjusted, it is neces- sary to determine the amount of compression that must be made by the pad on the artery, in order to give the greatest range of movement of the record- ing lever ; this may be done by means of the graduated thumb-screw. The paper on which the tracing is to be made should be enamelled on both sides, and smoked on one. It may be smoked by holding it over the flame of a small piece of burning camphor, or over a little mass of ignited cotton saturated with olive oil, or over a smoking paraffine lamp. Slips of mica may be smoked in the same way. A slip thus prepared is placed on the travelling slide, with the point of the recording lever in contact with the blackened surface. By touching a button connected with the clockwork, the latter is set in motion, and the slide carrying the slip is steadily moved along. The sphygmograph invented by Dr. E. A. Pond, of Vermont, has many advantages which recommend it as superior to all other forms of the instru- ment. It is compact in size and very easily adjusted to the principal arterial vol. i. — 34 530 MINOR SURGERY. Fig. 98. trunks of the extremities, and furnishes tracings of a delicate and reliable character in a very short time. The improved form of Dr. Pond's sphygmo- graph does not require a splint or other support for the part to which the instrument may be applied. The pulsations of an artery are communicated to the expanded extremity of a vertical lever, inclosed in a tube that is closed below by a diaphragm of thin rubber. This lever is connected with a system of levers which serve to move a pendulum-jointed needle which records the arterial pulsations on a slip. A watch-movement attached to the vertical tube by an upright moves the tracing-slip on a fixed horizontal slide. A pressure-gauge, graduated from one to sixteen ounces, is attached to the tube containing the vertical lever, and indicates the amount of pressure made on an artery when a tracing is being taken. (Fig. 98.) A slip of enamelled paper or mica, prepared as has already been de- scribed for receiving a tracing, is secured on the slide by setting free the watch- movement ; when the slip has been carried along about a quarter of an inch, the watch-movement is stopped till the sphyg- mograph is adjusted. The operator then places the instrument over the artery (usually the radial, just within the styloid process of the radius), with the button- like extremity of the vertical lever im- pinging upon the vessel, and holds it steadily in this position while the tracing is being taken. The amount of com- pression that will give the maximum movement to the needle on the slip may be ascertained by observing the pressure- gauge as the pressure on the artery is varied ; this degree of compression should be maintained during the operation. With the instrument properly adjusted, and the tracing-slip in position, the watch- movement is to be liberated — to be again stopped when the slip has been propelled over the platform. Should it be desirable, sphygmographic tracings can be readily preserved by varnishing them. To make them of service for future reference, the name of the patient, the date of the observation, and the amount of pressure made on the artery, should be inscribed on the blackened surface of each slip by means of some sharp-pointed instrument, as a needle or pin. The varnish recommended by Dr. A. E. Sansom is composed of gum benzoin, one ounce, and methylated' spirit, six ounces. Dr. Pond prefers one consisting of alcohol, one pint ; gum sandarac, three ounces; and castor oil, half an ounce. The slips, utter having been inscribed, are carefully dipped in the varnish, and allowed to dry. Pond's sphygmograph. PLASTIC SURGERY. BY CHRISTOPHER JOHNSTON, M.D., EMERITUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, BALTIMORE. The Surgical Art Formative (ttxdaanv to form) boasts of a high antiquity, and was resorted to in remote times, as at present, to repair, remedy, or conceal the ravages and disfigurements of disease, as well as to lessen the deformities produced by the execution of judicial decrees, by natural defects, or by the accidents of personal or general conflict. That branch of this department of surgery which has for its object the restoration of noses, very probably antedated the other branches, as the records of Indian and Egyptian surgical art seem to indicate; but while the subdivisions of the art multiply, as various organs or parts are concerned, the principles governing all plastic proceedings remain the same. The synonyms of this department of surgery are numerous; thus, Chirurgica Plastica; Morioplastice, from fioptov "a part,'"' and nxdanxoi "forming;" Transplantatio; Chirurgia Anaplastica and Chirurgia Autoplastica — names preferred by Velpeau and Blandin, and derived from the Greek, the one from dvd "again," and nxdaanv "to form," that is, to fashion anew; the other from airoj "one's self," and mdaotw "to form," to form of, or out of, one's self, or "self creation" (Gross)— whence the words Anaplasty, Autoplasty; and finally Plastic Surgery, or that province of surgery which is distinctively formative. Among the foregoing appellations I revert to Transplantatio, which signifies absolute removal from one part and implantation into another, to point out that such transplantation of larger portions of the body has been designedly accomplished, or an accidentally ablated part successfully reapplied, or blood transfused — all instances of total separation before adjustment, or, in the case of the blood, of perfect abstraction and introduction into the circu- latory system of another individual ; and that the same end has been medi- ately effected as in Roux's operation, that of "Autoplasty by successive migrations of the flap." And I would associate with these instances of union of larger surfaces, or multitudes of germs, the modern operation of Reverdin, known as skin grafting, by which extremely small portions of in- tegument, and even epithelial elements scooped from the rete, after being totally separated, are implanted or " grafted" upon the surface of tardily heal- ing ulcers, as of burns. Adhesion soon occurs, and is followed by prolifera- tion around the transplanted germs, whether these have been derived from the subject himself, or from another person; whether they are pigmented or otherwise. The transplantation of the spur of the cock, from the leg to the comb, is a familiar example of this mode of procedure, as is also the trans- lated flap of Roux; but in these instances, vitalized adherence terminates the process; whereas, in the case of skin grafting, as practised by Reverdin and (531) 532 PLASTIC SURGERY. others, the stranger germs are extremely few in each grafted particle, but they form the centres or foci of a cell-formation which gradually but surely spreads and closes over the reluctant surface. History of Plastic Surgery. Though we cannot fix the exact period at which plastic surgery was first practised, yet we may be sure that it must have followed with a kindly hand the barbaric use of power and the cruel resentment which were displayed at an early period of the world's history, especially in India, in the mutilation of offenders by the lopping off of ears and noses. And in ancient Egypt, also, Rhinoplasty was known and practised, as Galen declares, and as may readily be believed if we accept as indirectly confirmatory, the Ebers Papyrus, "the Hermetic Book of Medicines of the Ancient Egyptians, in Hieratic Writ- ing," of unknown authorship. And it is also interesting to observe that in the " Secret Book of the Physicians" the science of " the beating of the heart and the knowledge of the heart" are referred to, as taught by the priestly physician, Nebsect. Ebers believes the Papyrus to have been a com- pilation made by the College of Priests, at Thebes ; and assigns the writing to the middle of the sixteenth century, or more precisely to the year 1552 B. C. This date, as is commonly supposed, was prior to the departure of the Israelites, and, according to generally accepted chronology, Moses, in 1552 B. C, was just 21 years of age. 1 The same author, Professor Ebers, of Jena, in an original work "Ouarda," in which he assures the reader that all his statements are based upon authority, besides furnishing evidence of the high position reached by Medicine in the reign of Rameses II., alludes to its divi- sion into twenty-one specialties, such as are accepted and practised at the present day, and gives prominence to the thoroughness with which the science and art were studied and practised by the priest-physicians of a great era in Egypt's history. The Roman Hippocrates, Celsus, who livid about one hun- dred and fifty years before Galen, in the reigns of Augustus, Tiberius, and Caligula, speaks of the restoration of the ears, the nose, and the lips, by the aid of the neighboring skin, and also of reparation of the prepuce. Galen says but little of the treatment of mutilations, and this is copied by Paulus ^gineta and others of his followers. Antyllus mentions coloboma and its repair. And Malgaigne, in his introduction to Fare's Surgery, refers to an Italian family, named Branca, as conservators of the art of restoring noses during the middle ages, and as having invented new methods. In the year 1597, at a time when learning received a new impetus, ap- peared the very remarkable and erudite work of Gaspar Taliacotius, entitled "He curtorum chirurgia per insitionem," in two volumes, published in Venice. In this treatise, Tagliacozzi, besides describing minutely the opera- tions for restoring or repairing multilated lips and ears, gives special promi- nence to his original method of reproducing noses, in which the flap is taken from the arm, and which has ever since borne the title of the Taliacotian or Italian operation to distinguish it from the Indian or Oriental operation, in which the flap is obtained either from the forehead, the cheek, or even the nor itself. The Indian operation was first put in practice in London, in 1814, by Carpue, and afterwards in Germany by J. F. Dieffenbach, who, at the end of the first third of the century, gave great development to the sub- ject, t<> which lie drew attention by the publication of his experiences and of his improved methods. Subsequently, in France, Blandin, Jobert (de Lam- 1 Charles Rice, in N. Y. Daily Tribune, Nov. 9, 1875. LESIONS REMEDIABLE BY PLASTIC SURGERY. 533 balle), Serres, Roux, Denuce and Verneuil ; in Belgium, Burggraeve and Ver- haege; in Germany, Zeiss, Von Amnion, Hoffacher, Banmgarten, Langenbeek and Schuh ; in England, Liston, Pollock and Spencer Wells; and in the United States, J. M. Warren, Pancoast, Mutter, Gurdon Buck and others, both by their writings and practice have made themselves deservedly emi- nent, and, occupying a high position, have placed both the profession and the public under obligation. In reviewing, however, the copious bibliography of plastic surgery, I deem it not unfair to give a well-earned prominence to American Surgeons, whose ingenious and felicitous operations and practical treatises and contributions to science have established the reputation of their authors upon an enviable and enduring basis. Lesions Reimediable by Plastic Surgery. The term Plastic Surges, says Verneuil, "signifies, then, 1 in surgical lan- guage, the repair or restoration of an organ changed in form, by the aid of a loan effected in the patient himself, and made at the expense of neighboring or distant healthful parts." "It remedies deformities of deficiency or excess by operations of anaplasty by autoplasty, which, term ought to be restricted to cases characterized by a deficiency of substance as a lesion, and by an organic borrowing from the same subject as an operation. And this double character serves (1) to establish differences between the method in question and the other anaplastic methods, and (2) to distinguish autoplasty, properly so called, from heteroplasty, which borrows substance from a stranger organism, and from prothesis, which replaces lost parts with artificial ones made out of inorganic materials." It is evident that the occasion for the operations of plastic surgery must arise from congenital defects or deficiencies, from atrophy or wasting after birth, or from actual losses of substance, whether by disease or traumatism. And it is equally obvious that different causes may bring about the same result — deformity — as in the cases of excision of a bone and its congenital absence; the loss by mutilation of part of an organ, as a muscle, and its atrophy from lesion of its tutelary nerve ; and the total loss of substance pro- duced as in the cutaneous structures, by traumatism upon the one hand, and by disease upon the other. It is unfortunate that in man}' deformities, such as arrests of development and total deficiencies of parts, the condition is irre- mediable ; in some, however, plastic surgery alone may make amends; whereas in others this reparative art needs the aid of artificial appliances or substitutes which enlightened surgery must perforce employ. And here, before going further, I would call attention to the absolute necessity for accurate diagnosis; for the positive recognition and determination of the nature of the cause or lesion, and of the actual condition of the part or organ. Whatever be, in general, the need for precision in matters surgical, anticipat- ing operative procedure, there is no department of the art in which a correct appreciation of the causes and consequences of deformity, or lesion, leads to better courses and results in practice. Plastic surgery deals, then, with deformities congenital or acquired. Among the former are to be ranged atrophies, arrests of development, and infra-uterine mutilations, which latter sometimes involve a part or the totality of a mem- ber; and, further, to quote Verneuil, who himself cites Geoftroy Saint Ililaire, 2 as saying that congenital deformities are more frequently met with at the 1 Verneuil, Art. Autoplastic. Diet. Encyc. des Sciences Medicales. Paris. 2 Teratologic Paris, 1836. 534 PLASTIC SURGERY. periphery of the body. "Surgeons may make the same remark." "Arrest of development, atrophy, or mutilation of central parts, compromise life much more certainly than the same lesions affecting the members, the tegumentary folds, the nose, lips, penis, ear, etc." The further remarks of Verncuil upon deformities, considered with a view to their relief by plastic surgery, deserve notice in this place, as also his classification of the lesions to which this branch of the art of surgery "has been most happily applied." " Deformities by deficiency, compatible with life, may be arranged in three categories, reference being had to their radical cure. "(1) The absolutely incurable. For example, the total or partial absence of a member, bone, or muscle; marked atrophy in an extreme degree; loss of substance, too deep or too superficial, but very extensive, are cases in which autoplasty can do nothing. " (2) Cases in which autoplasty can only mask, palliate, or mitigate the deformity without being able to restore both form and function ; in which, whatever loss is sus- tained, absence of the part cannot be compensated for by borrowed tissue. " (3) The last category comprises those cases in which the loss of substance is of small extent, and affects membranous organs only. Nevertheless, even in these cases, the deformity may be repaired without recourse being had to autoplasty ; for example, a vesico-vaginal fistula of the bas-fond of the bladder, in which the margins may be simply united But things are very different if the loss of sub- stance be great, if the skin be naturally adherent to the subjacent parts, if it have lost its flexibility, its mobility, its extensibility in consequence of disease. Here autoplasty becomes a necessity." And in this place a general view should be presented of the lesions in which plastic surgery has been more or less happily called upon ; but finding the enumeration of Verneuil so apposite, we do not hesitate again to draw mate- rial from his admirable article quoted above. " (1) Perforations and fistula, which establish a communication between a cavity, a reservoir, or a mucous canal, either with a neighboring mucous organ or with the exterior of the body. " (2) Mutilations, total or partial, of projecting appendices, cutaneous folds, or mem- branous curtains, which circumscribe the natural apertures. " (3) Superficial losses of substance, not penetrating into cavities, having destroyed a more or less considerable extent of skin or mucous membrane, in a single region, or at the commissures." And again, the state or condition of the deformities under consideration demands their division into the following categories : — " (1) Those without tendency to natural repair. " (2) Those met with or created before natural repair (wounds, the extirpation of tumors). " (3) Such as present themselves after nature's efforts at repair." It is evident that in the wide field of action vaguely defined in the pre- ceding pages, surgery lias offered to it a great variety of disablements and disfigurements, produced under many conditions, but which may be referred f<> congenital vices, arrests or absence of development, traumatism in atero, or the' result of infelicitous use of instruments; to injuries of all kinds; to burns; or to the external manifestations of diseases, and their vicious ^sponta- neous healing with loss of substance, or repair by distorting cicatrices; to gangrene, and to losses produced or provoked by wounds, however inflicted. It is equally apparent that, in dealing with these departures from the nor- mal, the resources of plastic surgery must be taxed, and the aid of artificial substitutes or supports invoked. And not only are these arts exercised upon parts in which disease has (tone its work, but, as in the rebellious ulcers left GENERAL PRINCIPLES OF PLASTIC OPERATIONS. 535 by burns, heteroplasty, manipulating minute flaps or particular masses of germs, attacks by the process of skin grafting, and forces repair in the midst of a tardily granulating surface. Heteroplasty, formation by borrowing from another organism, is also practised in the transfusion of blood, by which por- tions of the blood of man or other animals are introduced into the veins of those who have suffered great losses of the "mother of all the tissues," and who are revived by the refreshing stream. !N T ot only so, but intravenous injections of milk have been employed successfully by Prof. T. Gaillard Thomas and others, in cases of very considerable post-partum hemorrhage. General Principles of Plastic Operations. When all conditions agree in determining a resort to plastic surgery, no principles which govern this branch of the art should be lost sight of. They are not numerous, but their application under many circumstances of difri- culty requires the nicest exercise of judgment, more especially in certain cases in which a plastic operation cannot be repeated. For example, in a case of double harelip which fell under the writer's care, the lateral fissures, on either side of the maxillary bone, extended deeply towards the orbits, and the clefts through the soft parts involved the lip, the cheeks, and the eyelids, and were traced in each eye into a coloboma iridis. In this and similar instances, an error in judgment, compromising much marginal substance, might defeat the present, as it would most probably the final, success of an operation otherwise well devised. The risks, however, of failure in difficult cases, those in which arrest of development has left considerable and intri- cate spaces, or in which disease or traumatism lias produced deformities demanding for their relief an appeal to all the resources of art, are diminished by dividing the proposed operation into a number of lesser operations, or seances, so that, like an Alpine mountaineer, the surgeon shall undertake no step forward until abundant security has been obtained for the advance. Thus an original operation, limited in its scope, may be made the foundation of a series of secondary procedures, the success of each of which will render that of its follower less doubtful, and w r ill multiply the chances of a favorable issue for the case. A comparison of deformities and lesions will serve to arrange them all into two groups, as far as plastic surgery is concerned; the first requiring for its extinguishment or repair simple approximation of parts — widely sundered, it is true, but separated by the unopposed and not vigorous" traction exerted by the physical properties of some of its elements, and the vital property of others ; the second necessitating a borrowing from the immediate or remote neigh- borhood, and the localization and interpolation of new flaps or pieces. It may be claimed as self-evident, as it is also shown in practice, that the frequency of fortunate results in the former group is in accordance with the lack or low degree of tension, and with the analogy, or rather identity in nature, of the tissues restored to their original relation, or even, urged a little farther, made to bridge over a gap left by a minor loss of substance. In the latter group, the same absence of stretching or tension must mark the adjust- ment of flaps, and the same analogy of tissues must be preserved in the selec- tion of pieces to be permanently transposed. Besides all this, it is requisite and necessary that the flaps should be well provided with nutrient vessels, whether they be destined to retain their continuity with the mother tissues. or to lose their original basal attachment by severance as soon as they shall have acquired sufficient adhesion in their new position. It must also suggest, itself to the surgeon that hairy parts should not, if possible, be repaired with 536 PLASTIC SURGERY. bare flaps, and that hairy flaps should not, upon pain of ridiculous disfigure- ment of the patient, be translated to regions normally devoid of hair. The end of a re-made nose would be an undesirable termination of that organ, if it were made to bear a tuft derived from a well-covered scalp. Another circumstance tending towards the successful ending of a plastic operation, is recognition of a due proportion between the size of the gap to be filled or bridged over, and that of the flap. And it must be well borne in mind that, as by cicatrization a " natural autoplasty" (Verneuil) is accom- plished by the simple traction of the cicatricial tissue, it may be necessary, under different circumstances, to employ a flap smaller, the size of, or much larger than the space to be covered. A flap borrowed from situations in which the tissues are lax, ought to be many times larger than the opening or chasm ; for, by the natural elasticity of its elements, the flap is greatly reduced in size, and, inasmuch as it will not bear tension, scantiness of material may lay the foundation of failure in the operation by rendering firm union between the freshened surface and the borrowed piece impossible, and by inviting and producing inflammation and gangrene. Of course, such a condition of things would be a misfortune, since positive and extensive loss of substance in the flap, or destruction of its totality, is usually repaired with difficulty, if even the damage thus occasioned should not preclude the possibility of a repetition of the operation. Wherefore the surgeon must assure himself of the just pro- portions, as well as of the form, of the proposed flap, making due allowance for shrinkage as well as for ulterior atrophy, which sometimes follows a per- fect union. But even here, it may be added that flaps of sufficient thickness, as well as size, and abundantly provided with bloodvessels, are much less liable to ulterior atrophic contraction. Classification of Plastic Operations. From what has been said, it will readily be admitted that all plastic operations may be arranged in five categories. The first comprises all those in which the borrowed piece is obtained from, a distance and transferred directly to the seat of its future residence, retaining, however, for a time not determinable with precision, its connection by means of a pedicle with the tissues of its original site ; to the second belong those cases in which the auto- plasty is accomplished, after the method of Roux, by " successive migrations''' of the flap, from a point more or less remote ; the third includes all operations in which the flap or flaps are derived from the neighborhood, and are moved into place by gliding, or made to assume proper relations by stretching or by lapping over, as when a periosteal flap is made to cover the end of a severed bone after amputation ; the fourth embraces all those operations of simple approximation, as after the V-shaped piece is removed for the relief of ectropion, or for the attempted cure of epithelioma of the lip, or, more primitively, when the freshened " vivified" edges of a vesico-vaginal fistula are brought into contact, and maintained in apposition with more or less tension. Under the same caption may be inscribed several of the methods for bringing about adhesion in ununited fractures of the bones, the broken ends being, under some circumstances, vivified, and made adherent to one another by means of silver wire, or of a screw or screws of the same metal. Lastly, the fifth category comprehends all readjustments of totally severed parts, as a nose or a tooth, autnentic instances of which species of repair are not sufficiently infrequent to be wonderful. In this category are also to be enumerated the famous skin grafting by greffes ipidermiques, or dernio- epidermiques of llevcrdin ; the grafting by larger bits, or anaplasty, of See, GENEKAL RULES FOR PLASTIC OPERATIONS. 537 Oilier, and Poncet ; the transplantation of particular or greater morsels derived from a stranger organism, heteroplastt/, whether that be human or animal ; and, finally, transfusion of blood. General Rules for Plastic Operations. In the majority of the operations and methods enumerated, 'immediate union, or union by the first intention, of the newly juxtaposited parts, is the aim and hope of the surgeon, although sloughing or gangrene to a small extent may not wholly defeat the intention of the operator. But a scrupulous attention to the general condition and surroundings of the patient, the adop- tion of a carefully studied plan of operation and observance of its minutest details, and a sagacious and watchful after-management of the case, are cir- cumstances which lead to if they do not insure success, and which must be had in view and closely followed out if success is to be the issue. Among the evil consequences of an unwise disregard of detail, may be mentioned gangrene, as depending upon a poverty of the nutrient supply of the flaps, whether by reason of its attenuate pedicle, its thinness, the scantiness of bloodvessels in the pedicle, or their choking by excessive tension or twisting, or upon want of protection. The manner of making the sutures, the choice of proper material for them, and the distance from each other at which they are placed, will and must influence the mode and time of union of the wedded parts, and bring about, or not allow or favor, union by first intention. And thus portions along the line may fail to heal, and suppuration may perma- nently interfere with a union which, in other situations, is firm enough. And a disregard for the quality of the air in which the subject of the opera- tion lives, as loaded with the miasmata of fever or erysipelas, or the preva- lence of the latter disease as an epidemic, may not only set the operative skill of the surgeon at naught, but may open a door in the patient's body for the entrance of a fatal complication. In this connection, a very important circumstance ought to be made con- spicuous, and this is that the hiatus left by the forced loan imposed upon an innocent feature, must itself be the subject of the same interest which attaches to the locality benefited. It may sometimes be left to cicatrization and ulti- mate shrinking of the scar, but not unfrequently adhesive straps invite or force approximation of separated margins, with or without preliminary loosen- ing of the integument and connective tissue done with a view of facilitating approach, or linear or crescentic incisions may be employed to transfer de- formity to unimportant situations, by promoting instant adhesion of tissue margins separated by loss of substance. It was with this intention that the writer, after removing, by a long elliptical incision, a considerable melanotic tumor from the front of the thigh of an itinerant Methodist preacher, who made his circuits on horseback, practised on either side of the longitudinal gap a deep incision parallel with the neighboring margin, dissected up the bands lying between the incisions and elliptical space, and brought the margins together in a line on the convexity of the thigh. Immediate union occurred along the whole extent of the line, while the lateral cicatrices were so placed as to escape friction from clothing or other matters which the front of the thigh was called upon to bear. But loss of substance, if it be of limited extent, may not always require the translation of a flap, or may not call for any further abstraction of tissue. Thus for freshening the margins of some buccal fistula?, experience has shown the advantage to be derived from the employment of the actual cautery, or the thermo-cautery of Paquelin, applied at a dull-red heat and at 538 PLASTIC SURGERY. several sittings, the operator relying upon the cicatricial contraction produced by the healing of the successive burns, for the extinguishment of the distress- ing and unsightly aperture. Among the interesting documents which bear upon this subject, I would refer the reader to one by J. R. Marinus, 1 entitled "Considerations upon Heteroplasty or Autoplasty by Heterogeneous Transplantation," a compendium of remarkable cases of parts restored and replaced. This author quotes Reissiger, 2 as being the first who proposed to replace an opaque human cornea with a healthy one derived from an animal [an operation which has been, of late years, successfully resorted to in several instances] ; and after- wards Msesner, and subsequently Dietfenbach, who both attempted "kerat- oplasty " upon animals, but whose experiments led them to the conclusion that, since the cornea when nearly separated did not reunite, transplantation to another eye offered still fewer chances of success. And, on the other hand, Marinus assures us that Rudiman reports that in India belief is so strong as to the possibility of reunion of a cut-off nose, that the executioner is com- manded to throw the piece into a brazier, to prevent readjustment. In this country, as is well known, plastic surgery has been much cultivated, and practised with remarkable suceess. The operations and most valuable contributions of Prof. Joseph Pancoast are guides and texts for surgeons, and the work and practice of Mutter are monuments in this department of the art of surgery, but we would regard this notice as incomplete without refer- ence being made to Prof. Gilbert, 3 among whose successful cases may be men- tioned the construction of two noses by the Indian method ; to Dr. Gurdon Buck, 4 whose triumphs are familiar in the department of restorations ; and to Dr. Detmold, 5 to whom both the profession and the public owe so much. Skin Grafting. Under theffth caption we have grouped, and therefore associated together, a number of facts which acquire relationship by reason of the complete sepa- ration of the parts re-applied and fixed by restitutive autoplasty, as of the nose, of which Hoftlieher, officially present at duels with rapiers fought at Heidelberg, reports several successful cases, and notably one in which the organ lopped oft' was seized by a dog, but being rescued, although cold and moist, was, after careful cleaning, re-attached. Bits of fingers, lopped off, have been known to adhere vitally after replacement, and teeth also have taken hold when transplanted; indeed transplantation of these ornaments of the mouth was, within a century, a fashion in some countries, in which, it is said, sound front teeth of fresh country girls were purchased by fading belles to replace their own carious incisors or canines. It is remarkable that with such experiences, which, perhaps, were not confined to the later centuries, surgeons so slowly recognized the facts, first, that portions of the living body might be sundered from it without immediately losing life; and, secondly, that these portions, so removed, could contract vital adhesion with another part of the same individual, or will) some part of another person or creature. But, like the discovery of the, circulation of the blood, the separate anatomical and physiological truths of which were known even from the time of Galen, the 1 Annates de La Sooi6t6 de M6decine d'Anvers, 1842. 2 Baier'aohe Annalen, L824, Bd. i., Stuck 1, S. 209-215. 3 Med. Examiner, new series, vol. vii. Philadelphia, 1851. 4 Bulletin <>f the New York Academy <>f Medicine, vol. iii., and elsewhere. 5 Bulletin of the New Yurk Academy of Medicine, vol. iii. Paper upon Plastic Surgery. SKIN GRAFTING. 539 discovery of the phenomena of germination of anatomical particles when transplanted, was reserved for very modern times, although glimpses of the real significance of the process of healing of wounds and ulcers had been enjoyed in early ages. Perhaps Prof. Frank II. Hamilton, of New York, may be regarded as the first who attempted to generalize upon the experience of the past, when, in his clinique at the Dispensary of the Geneva Medical College, in January, 1847, he proposed to a boy of fifteen years a plastic operation, with the view of planting upon the centre of an ulcer a piece of new and perfectly healthy skin, taken from the calf of the other leg, and not intending to cover over the whole sore, but, perhaps, two or three square inches, which he believed would be enough to secure the closure of the wound in a short time. 1 And the reporter affirms that this proposition had been made to the lad two years before. Dr. Hamilton's earliest operation of the kind was not done, however, until January 21, 1854, upon Horace Driscoll, in the Buffalo Hospital of the Sisters of Charity. An account of this operation, contained in a paper enti- tled "Old Ulcers treated by Anaplasty," read before the Buftalo Medical Association, June 27, 1854, was published in the New York Journal of Medicine in September of that year. In the summary, the following remarkable sen- tence forms the fourth of six propositions: "If [the graft be] smaller than the chasm which it is intended to fill, the graft will grow, or project from itself new skin to supply the deficiency." The fifth proposition refers to a probable expansion of the graft, and the sixth asserts* that "in consequence of one or both of these two latter circumstances, it will not be necessary to make the graft so large as the deficiency it is intended to supply." In this we observe the declaration of a principle, not new in fact, but original in its direct suggest- iveness, implying a knowledge of the strength of border growth of new skin in an ulcer, of the weakness of the middle part, and also of the means likely to repair, or capable of remedying, the deficiency. The fact was known long before, and is still familiar in the text-books of surgery, as we find Erichsen saying, "Indeed, if the ulcer be large, there may not be enough [new skin] for the cicatrization of the centre." What Hamilton accomplished, and no doubt intended, if his words mean anything, was the establishment of a new basis of skin-formation where it was most needed, and his credit does not rest upon the performance of a simple anaplasty. The generalization of the idea which guided Hamilton was made by Dr. J. L. Reverdin, interne laureat of the Hospitals of Paris, in 1869, for on the 8th of December of that year he presented 2 before the Society of Surgery a patient who belonged to the service of his "excellent master," Dr. Guyon, and on whom he had practised a new experiment, for which he proposed the name of epidermic grafting. It consisted, to use his own words, " in transporting to a granulating wound little bits formed out of the superficial parts of the in- tegument." " This experiment had been suggested to me," he says, in an admirable article pub- lished a few years later, 3 " by having observed little epidermic islands which formed spontaneously in certain wounds ; I asked myself if, by a graft, we might not obtain the formation of similar little islands of cicatrization, and thus hasten the cure; therein was a double interest, physiological and practical. The result was such as I dared hardly hope ; not only did the little morsels continue adherent to the granulations, hut presently they began to extend* and form an island of cicatrization." And then the author, surveying the field likely to be covered by skin grafting, reproduces a part ' Buffalo Med. and Surg. Journal, Feb. 1847, p. 508. 2 Bulletin de la Societe" de Chirurgie, 1869 ; Gazette des Hopitaux, Janvier, 1870 ; British Med. Journal, Dec. 10, 1870. 3 Archives Generates de Mfidecine, 1872, t. i. pp. 276, 555, 703. 540 PLASTIC SURGERY. of his communication to the Societe de Chirurgie, and concludes with these words : " Finally, I shall have to study, as much as possible, the histological process. Is there here the simple effect of contact, or vicinity ? Is there proliferation of the transplanted elements?" During the progress of experimentation, many questions, of course, arose, which have not yet all been answered ; but after the adherence of the grafts was accom- plished, and epidermis was observed toform around them, Reverdin came to the conclusion that " the epidermis by itself, but still the living epidermis, that of the deep layer, would alone be necessary for the success of the grafting." 1 And again, "the adherence of the graft is, therefore, effected by the epidermis; the welding of the dermis is but secondary and accessory ; the part played by the dermis in the properties of the formed islets is, therefore, completely null." But the grafts remain, and are not absorbed ; yet, as Poncet 2 expresses the idea, " The cutaneous graft not only is not re-absorbed, but it possesses all the properties of the skin." The views entertained by Reverdin with regard to the epidermis seemed to him to find confirmation in " a little fact" which was that, in some cases, he found upon the strips of plaster grafts which, put in place the evening previous, had failed to unite, but which, upon being replaced, " took " per- fectly. 3 We shall see, further on, that Georges Martin, 4 in his thesis " upon the duration of the vitality of the tissues and of the conditions of adherence of cutaneous restitutions and transplantations," ascertained, through observations of his own, that some separated bits of human skin maintained their vitality, when exposed in free air, for ninety -six hours, and others in a confined space for one hundred and eight hours, at a temperature of nearly zero, C. [32° F.]. Hamilton failed to perceive that, without peduncular attachment, his little flap might adhere and grow ; but Reverdin saw this, and so earned his honors. He communicated his discovery to the Societe de Chirurgie on the 8th of December, 1869 ; the commission to which it was referred, consisting of MM. Guyon, Chassaignac, and Despres, made a report ; and Guyon, in whose service the experiments were made, presented the subject verbally, and provoked a discussion hardly favorable to skin grafting. But Verneuil declared himself in favor of the method, which he believed was calculated to render service in many departments of surgery. Gosselin, Guyon, Alphonse Guerin, and Duplay offered encouragement, and extended facilities ; 5 and Marc See dispelled the bad impressions remaining by presenting, six months afterwards, a patient who bore evidence of the success of the operation, 6 in w 1 1 ich See had been aided by Reverdin himself. Grafting now became the fashion ; M. Vulpian 7 presented before the Societe de Biologie, in the name of M. J. M. Phillipeaux, a case of transplan- tation of the spur of a young cock of forty days upon the comb of the same animal, in which the spur became incorporated with the skin, formed no adhesioD with the cranial bones, but surpassed in length its non-transplanted fellow. Some grafted the skin of the white man upon the negro; 8 or took grafts from moles or parts stained with India ink; 9 or borrowed skin from amputated members ; 10 or even supplemented, in the case of a large ulcer after a bum in a little girl, some three hundred grafts from the patient herself, ■ Loc. cit., p. 707. 2 Lyon Medical, t. xiv. pp. 293, 294, 1873. 3 Loc. cit., p. 709. * Georges Martin, These, Paris, 1873. « Archives Gen. de Med. 1872, t. i. p. 277. » G M. Sir, Gazette Bebdom. 00 ; Reverdin, loc. cit. 2 Paget, in Bolmea'B System of Surgery. 3 Loc. <-it., |>. 555. 4 Loc. cit., p. . r >(54. s Loc cit,, p. 571. 6 Loc. cit., p. 711. 7 Loc. cit., p. 707. 8 Loc. cit., p. 708. SKIN GRAFTING. 543 A. Poncet, in the previous year, 1871, had reviewed the whole matter, method and all, in a paper entitled " Des greftes dermo-epidermiques, et en particulier des larges lambeaux dermo-epidermiques," 1 taking up the same texts. In a discussion upon the subject, 8 participated in by Letievant and others, the former says, speaking of animal grafts, " I call these grafts zoo-epidermic, in opposition to human grafts which I dis- tinguish under the name auto-epidermic or hetero-epidermic, according as the grafts are gathered from the subject grafted or from his neighbors." Then the means employed to secure the grafts are referred to, the lancet of Reverdin, the scissors of Pollock, the cataract-knife of Oilier — all effecting the lifting of the epidermis and of the superficial layer of the dermis. But even with the weight of testimony in its favor, Letievant felt called upon to appose the remark " that the practice of skin grafting should be rejected as hurtful, and that it led to neglect of the important indications of the treat- ment of wounds," and at the same time undertook the defence of zoo-epidermic grafts, from the dog for example, because auto-grafts were painful, and caused new wounds in the patient. M. Christot promptly denied that he had declared grafting to be useless, but did not avow himself a partisan of the process; and with this denial further oppo- sition to skin grafting seems to have ceased. We have presented with some liberality the views of Reverdin with regard to the process of his inventing, frequently quoting his own words. It is here interesting to compare or contrast the ideas entertained by Poncet with those of the master, following upon the discovery of Reverdin, although antedating in publication the formulized expressions of the latter. At the end of the discussion just referred to, Poncet 3 took occasion to recommend the practice of Oilier in the employment of large and numerous grafts, stating at the same time that he had failed with epithelial grafts alone ; and continuing his discourse he goes on to say that "as to the proliferation of the epithelial elements, it is a simple action of the presence of the mucous layer of the epidermis, determining at times the epithelial transformation of the elements of the embryonal tissue, to which it is united. . . . In the seam of junction of the granulations with the morsel transplanted, the same phenomena are observed as in the union of the margins of a wound by first intention. The extension of the graft has not seemed to us to be owing to a prolifera- tion of the mucous layer. It must act by its presence upon the embryonal elements directly in relation with its margins, and thus determine their epidermic transformation." In the same connection we refer to the opinions already advanced by Reverdin, and we propose to adduce those of Coste, as expressed in a conference upon epidermic grafting held on the 31st of May, 1873, at the Ecole de Medecine.* " How," asks the distin- guished professor, " is the adhesion brought about ? How is proliferation accomplished ? That is very simple. The transplanted epidermis determines by its presence, by its contact, the transformation of the embryonal cells of the granulations into epidermic cells. This, according to Reverdin, Colrat, and Poncet (de Lyon), is the most probable, and even the only possible theory." On the other hand Mr. Bryant gives utterance to a directly opposite doctrine. In notes from the Wards of the Cork Hospital, 5 communicated by Mr. Martin Howard, we find the following: " The question was asked whether the skin graft was an excitor of skin action, or were the cells proliferated ? Mr. Bryant declared that the grafts grew, the skin being prolonged from the graft, and that the border also threw out a growth. This he proved in the following ingenious way. He had a white man under his care, suffering from an ulcer on his leg, and on this ulcer he grafted a portion of the skin taken from a negro in the hospital. As the ulcer decreased in size, the piece of black skin increased considerably." However satisfactory this experiment may have been, the observation is at variance with those of Reverdin and of Coste, the latter of whom expressly declares 6 that " grafts borrowed or obtained from a negro and implanted upon a white person, rapidly lose color and bleach out entirely, from the effect of the pro- gressive absorption of pigment. " I saw," says this author, " a remarkable example of ' Lyon Medical, t. viii. p. 494, 1871. * Ibid., p. 520. s Lyon Med., p. 564. 4 Marseille Medical, lOe annee, No. 7, Juillet, 1873. 6 Dublin Journ. of Med. Science, vol. lxi. p. 388. 6 Loc. cit., p. 398. 544 PLASTIC SURGERY. this, a few months ago, at the Hotel Dieu, in Paris. Besides which I note the rarity of pigment in cicatricial epidermis." M. Coste finds it necessary to preface his remarks with the observation that " in spite of the identity of terms, the animal graft bears no resemblance, either in its course or in its definitive evolution, to tlie vegetable graft ; a radical difference separates the two. What," asks the professor, " is a vegetable graft? It is an individual, or a part of an individual, transplanted upon another individual, which in some way serves as a soil for it. In this soil it lives as a parasite, the trans- ported individual develops and lives a life which is its own, meanwhile preserving its autonomy, its individuality. It is quite different, in the double point of view of theory and practice, with regard to the animal graft. This, borrowed from the individual himself or from another, has essentially for its object the filling up of a loss of substance. The borrowed part and that to which it is united, after reciprocal modifications and influences, coalesce, the one with the other ; they end by becoming confounded, by being identical, by living a common life. There is, therefore, no analogy between the animal graft and the vegetable graft ; these two grafts resemble each other in name only." We will not follow Coste further, but merely state that he reviews the experiments of Bert, especially the " greffe Siamoise" of that observer, the "rat sur rat," which tests his own views upon the same subject. Again, in 1872, M. Reverdin insisted upon the manner of adherence of the grafts, and of their effect on granulating surfaces — for he laid his grafts upon the surface — and declared 1 that he saw grafts from the negro, or black cat, lose color and become alto- gether white. And in a note upon epidermic grafting, presented by M. Claude Ber- nard to the Academy of Sciences, at the meeting of November 27, of *the same year, Reverdin says: "There results from this histological examination (1) that the adher- ence of the graft is effected, in the first place by the epidermis, and only secondarily by the dermis ; (2) that the epidermis acts by action of contact (catabiotic action, Gubler), in determining the transformation of embryonal elements into epidermis." In the same volume, page 326, may be found a note of M. Oilier, presented by M. Claude Bernard at the meeting of March 18, containing the following, bearing upon the sub- ject before us, namely, the aim and action of the transplanted or transported germs : "As for myself, in transporting large cutaneous morsels I seek to reduce, as much as possible, the natural epidermization of the granulations. My aim is to change, upon a more or less extensive surface of the wound, the process of repair. I replace the epi- thelial layer of new formation with a cutaneous, fleshy, thick layer, stable in its funda- mental elements, and destined to fill the role of a true skin. It is, therefore, an auto- plasty which I perform." AY Idle not attempting a complete history of skin grafting, I have never- theless followed the idea from mind to mind, and developed, although not at great length, the opinions entertained by the originator himself, as well as by those of his countrymen who stood, so to speak, around him, concerning the part performed by the germs transported and transplanted. The preponder- ance of testimony seems to weigh in favor of the view that the epithelial germs grow in or upon their new soil, but that a more remarkable phe- nomenon, to be observed after the transfer, is to be found in the influence which they exert in determining by their presence and contact the trans- formation of the embryonal cells of the granulations into epidermic cells. And this | lower docs not appear to be limited to the immediate neighborhood of the grafts, but seems to be communicated to the sluggish borders of the wound or ulcer. Reverdin presented his first case and announced his discovery on the 8th of December, 1869. In England, the value of " epithelial grafting" was at once appreciated, and as early as May, 1870, Mr. G. I). Pollock, of London, had put keverdin's method in practice, and had tested it in four cases, which, with a number of others, were made the subject of a paper entitled "Cases of Skin grafting and Skin Transplantation," read on November 11, 1870, and 1 Bulletin de Therapeutique, t. lxxxiii. p. 71, 1872. SKIN GRAFTING. 545 published in the Transactions of the Clinical Society of London, for the year 1871. At first he made a slight incision in the granulations, and imbedded the piece of skin; but afterwards he followed Reverdin closely, laying the graft on the granulations, or surface of the ulcer. lie found no difference in the results ; but he ascertained it to be essential that the patient should be in e;ood health — a condition which appeared to lie at the foundation of success. With regard to the process of cicatrization itself, I prefer to adduce the words of the author, for it will be observed that, while agreeing to some extent with Bryant, already quoted, in his explanation of the phenomena occurring after, or induced by, grafting, he differs altogether from Reverdin, Coste, Poncet, and other French authorities, and, in differing, presents some new features in the case. "When, as Pollock expresses himself, a graft is successful, there appears a fine, thin, delicate membrane, and in this membrane may be seen a beautiful network of red ves- sels. Shortly the membrane becomes white, and the vessels disappear. " The mem- brane is, as far as I can judge, the deeper layer of epithelial cells which possessed the greatest amount of vitality and youth." And, he adds further on, the wave of new pel- licle stimulates the margin of the original ulcer, and induces cicatrization. Mr. Pollock's first case was that of a child of eight years, who, her dress taking fire, was burned in both thighs. The left had healed at the time of her admission into St. George's Hos- pital, but the right thigh presented an ulcer extending from above the trochanter down to the outer surface of the knee. On the 5th of May, the grafting was done, and on the 26th of November, of the same year, the healing was complete. In the second case there were two ulcers ; in the third, a chronic ulcer of the right leg ; the fourth was one of ulcer over the tibia, from a kick ; the fifth one of chronic ulcer of the leg ; the sixth, a case of large sore on the chest, from a burn ; the seventh, eighth, ninth, eleventh, twelfth, and fourteenth, cases of ulcer of the leg; the tenth, one of scrofulous ulcer of the forearm ; the thirteenth, one of contraction after a burn, in which, after dividing the cicatricial bands, the gap was grafted, no success following the operation ; and the fifteenth and sixteenth, cases of syphilitic ulcer, in both of which the process proved a failure. The practice of skin grafting soon found favor in England, in spite of misgivings more or less distinctly expressed, and cases were presented to various medical societies. Among the many, we may refer to the cases of Mr. Pearse, 1 in his account of which the author advocated the employment of small pieces, and making a wide gap ; and to that of Mr. Raven, 2 who supplemented insutficient grafts from a little girl, with "zoo-epidermieal" grafts from a young pig. The method was adopted in Germany, in which country Dieffenbach had given such development to plastic surgery ; into Italy it speedily found its way ; in Spain, and other European countries, it became the accepted innovation, as, for example, in Constantinople, in which city Zebrowski published, in 18T3, 3 an essay upon skin grafting — "Sur la grefte epider- mique" — basing it on observations made upon eight successful cases. In fact, to use the language of Martin Howard, 4 in his communication already referred to, "In the journals will the work of the grafters be found;"' an evidence of the lively zeal with which the profession tested and approved of the practice. It will presently be seen that skin grafting became immediately active in America, reaching almost synchronously the United States, Canada, and Mexico ; but we prefer, in order to preserve the autonomy of the subject. t>> revert to the two questions which arose in the country of its origination, and which have an important bearing both upon the theory and the practice of 1 Practitioner, vol. viii. p. 36-39. London, 1872. * Loc. cit.. 1S77. Gaz. med. d'Orient, t. xvi. pp. 136, 137. * Loc. cit., p. 3^6. VOL. I. — 35 546 PLASTIC SURGERY. the operation. The first of these refers to the persistence of vitality in the grafts ; and the second to the size of the particles or pieces translated ; ques- tions which, as may be supposed, commanded the attention, not of French observers only, but also of those of other countries, without excluding the members of the medical profession in the United States. Not that these questions were absolutely disposed of in France, but that they were presented in a very formal manner in several papers of note. The first of these, by Paul Bert, antedated skin grafting, so called, and had for its title " Experiments and reflexions upon animal grafting," 1 and entertained the proposition " of the preservation of vital properties in parts separated from the body ;" and declared that "transfusion of blood, animal grafting, restoration, constitute but one single and immense order of facts, which are properly studied simultaneously, and which might be comprehended under one common formula." Then follow his divisions, (1) animal graft ; (2) " marcotte," by slips or shoots ; and (3), grafting by approximation of ani- mals of different species. Under marcotte, Bert ranges the " Indian method, in which the flap is never for a moment separated from the body." It will be observed that Bert treats of anaplasty and autoplasty, and the same may almost be said of Oilier, 2 of Lyons, who, at a later period, discussed the whole subject of animal grafts, giving preference to larger pieces instead of the minute morsels recommended by Reverdin, approaching the boldness, but not quite equalling the venture, of Hamilton, of New York. Paul Bert's remarkable experiments in animal grafting 3 gave as results the following; of less value from the fact of the adhesion of the tails of rats, than from the length of time which had elapsed since their amputation before they were applied to a stump. Thus tails of rats, separated from the animal for 3^ hours, adhered when grafted, and so did others after a lapse of 7-|> 16, 26, 48, 62, 64, and 72 hours, although failure ensued in other cases. And Oilier 4 adduced instances of periosteal flaps 24 hours old, obtained from a rabbit, which adhered when applied to another animal of the same species. Georges Martin, in his Thesis already referred to, upon the duration of the vitality of tissues, etc., brings together 343 grafting operations, which form the object of 60 per- sonal observations, and, in detailing these, records very surprising experiments and their results ; and he quotes Baronio, Gohier, Wiesmann, Dieffenbach and others, and their variable success. But the most worthy of attention are his original experiments and observations, as to the limits of vitality, with cutaneous and dermo-epidermic grafts in the human subject. It would appear that none of his grafts lived and were effective after 108 hours' exposure "in free air" at a temperature of nearly zero, C. [32° F.j, but that when kept in tubes, or confined air, under the same circumstances, the grafts were successful. Another experiment, the temperature being nearly at zero, C, was successful after 96 hours, the morsel having been preserved in free air ; in another, the temperature being 6° C. [42°. 8 F.], the limits were 82 and 96 hours, under the re- spective conditions of free and confined air; when the temperature was 12° C. [53°. 6 F.] they were 72 and 84 hours; when 15° C. [59° F.] the figures were 60 and 72; when 20° C. [68° F.], they were 36 and 36 ; and, finally, a last experiment, at 28° C. [82. °4 F.], showed the limits of vitality to be 6 hours and 7 hours, in free and in con- fined air respectively. M. Martin laments that we have no medicament capable*of prolonging cellular life, but he asks the question, whether certain alkaline solutions may not afford the means. In this connection he quotes M. Caliste, as having proved that muscular irritability continues for a long time in a weak solution of potassa, while distilled water destroys it, rapidly, and M. Pelikan, who saw frogs' muscles, plunged in these solutions, remain intact after fourteen days. Finally, M. Brown-Sequard noticed contractility of the iris fur sixteen days, and accounted for the phenomenon by the residence of the membrane in the alkaline media of the eye. Besides the conditions referred to as favoring adhe- ' .Touni.il f the health of the indi- vidual bearing an ulcer, and the appearance of healthy granulations, a favorable result of skin grafting may be anticipated. XII. Finally, the great benefits accruing from successful^skin grafting far outweigh its drawbacks, which are the pain of the operation, and, unless amputated limbs be utilized, the consecutive pain in the parts yielding the grafts, whether, of course, these be autoplastic or heteroplastic. Note. The author desires to express his acknowledgments to Surgeon J. S. Billings. U. S. A., for his personal kindness in the matter of collecting authorities, and through him to the Library of the Surgeon-General's Office, for the invaluable aid which it has afforded. » Lyon Medical, t. xir. p. 293, 1S73. AMPUTATIONS. BY JOHN ASHHURST, Jr., M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA. The word Amputation, from the Latin am- or ambi- (Greek d^i), signifying "around," or "round-about," and puto, from the root pu (to cleanse) signi- fying to " clean" or " cleanse," and particularly to " trim" or " prune" trees or vines, from its etymological meaning might properly be applied to any operation the object of which was to remove an offending part from the rest of the body, and thus might be made to include such diverse procedures as the removal of tumors, the excision of joints, and the extraction of cataract, as well as the dismemberments, partial or complete, to which it is now habitually limited. Indeed, it was not uncommon, a few years ago, for sur- geons to refer to the operation for removal of the female breast, as an ampu- tation of that part, and we still speak of amputations of the penis and of the cervix uteri ; but, with these exceptions, the term is now confined to opera- tions for removing the whole or part of one of the limbs, and, when we read or speak of "an amputation," we understand that the taking away of a part or the whole of either the upper or the lower extremity is referred to, and that the operation has, as far as it has gone, been a total removal, sparing nothing beyond the line of section. Amputation, the " last resource of surgery," as Velpeau called it, is often spoken of by the public, and even by some unthinking physicians, as the opprobrium of our art; and it is said, very justly, that to have saved one limb is more credit to the surgeon than to have removed, no matter how skilfully, a hundred. It is true that, in a certain sense, the advice to a patient to have a limb amputated, must be regarded as a confession of failure — failure, that is, to be able to effect a cure by other modes of treatment ; but apart from those cases of supreme urgency in which the victim of disease or injury is called upon to choose between mutilation and certain death — when, as Vel- peau significantly remarks, he will probably choose rather to live with three limbs than to die with four — there may be many circumstances under which the surgeon will feel justified in recommending, and the patient will not hesitate in accepting, an amputation, which, though not essential for the preservation of his life, may afford the only reasonable prospect of placing the patient in a condition such as to render that life either agreeable to him- self or useful to others. And it may be observed that, while on the one hand the improvements in modern surgery have removed from the field of amputation many cases in which the operation would formerly have beer considered imperative, yet on the other hand, since the introduction of sur- gical anaesthesia and of improved methods of treating wounds, the operation of amputation itself is a much less dreadful one than it was in the early part of the present century, and may therefore be properly resorted to in many eases which would formerly have been abandoned as hopeless, and left with- (551) 552 AMPUTATIONS. out any treatment at all. Indeed, so far from the operation of amputation deserving to be spoken of in any opprobrious terms, or to be regarded as a brutal procedure, it may well be called, as it was by some of the older writers, u the humane operation;" and, abused as it may have been in some instances, it is doubtful if any other surgical manipulation has upon the whole afforded as much relief from suffering, or saved as many lives. Amputations have been variously classified by authors, but the division commonly employed at the present day, and that which has most practical value, is into amputations in the continuity of a limb, or through the boms of which it is constituted, and those in the contiguity, or through the joints the latter are also called exarticulations, or disarticulations. History of Amputation. The operation of amputation was known to the ancients, but was ordi- narily limited to the severing of gangrenous portions of the limbs by incisions through the parts already dead. Hippocrates, who lived four hundred years before the Christian era, in his treatise on the Joints, speaks of gangrene resulting from occlusion of the bloodvessels, or following fractures, and directs that in the latter cases the mortified parts should be allowed to drop off of themselves, as, the bones having already given way, the separation of the dead from the living parts will occur quickly ; when, however, the bones are entire, the portion which is below the line of blackness is to be removed at an articulation, care being taken not to wound any part which still maintains its vitality, lest, if the operation should cause pain, the patient might faint away or even die in consequence. 1 Celsus, however, who flourished in the reigns of Augustus and Tiberius Ca?sar, directed that when a gangrenous limb was to be cut off, the flesh should be divided with a knife between the living and dead parts, down to the bone — taking care to avoid the articu- lation, and rather taking away some of the healthy tissue than leaving any part of that which was diseased ; when the bone was reached, the healthy flesh was to be pushed back from it, and cut around the bone, so that a part of the latter should be left bare; this was next to be divided with a small saw, as close as possible to the adherent flesh, the sawn edge of the bone smoothed or polished, and the skin drawn down again over it. 2 It is not improbable that Celsus understood the use of the ligature in amputations, as he certainly did in cases of vessels wounded in their continuity, though he gives no special directions for the restraint of hemorrhage either during or after the operation. It will be observed that in recommending the incision through living tissues, and the section of the bone at a higher point than that at which the soft parts were to be cut, this writer was far in advance of his contemporaries, as indeed of many of his successors, and in the latter particular actually anticipated one of the most important improvements in the manual procedure which has been introduced, or rather re-introduced, in comparatively modern times. Galen (A. D. 181-200) repeats the advice of Hippocrates that no living part should be touched in an amputation, and gives as a reason for preferring operations through the joints, that the work will be done more quickly than if the bones have to be divided. 3 The first attempt to prevent hemorrhage during an amputation appears to have been made by Archigenes (A. D. 81-117), who directed that the vessels 1 TlipponratiH opera omnia, edit. cur. C. Or. Kuhn, t. iii. p. 247. 2 A. (3. Celsi Me&ieinae lib. vii. cap. xxxiii. Edit. L. Targae, p. 417. 3 Claudii Galeni opera omnia, edit. cur. C. G. Kuhn, t. xviii. pars i. p. 718. HISTORY OF AMPUTATION. 553 supplying the limb should be tied or sewed as a preliminary measure, or that, in some cases, a fillet should be applied around the limb aa a whole; 1 when the operation was terminated, this band was to be removed, and a hot iron applied if there was much bleeding. Heliodorus, who practised at Rome about the same time as Archigenes, advised that an incision should first be made on the side of the limb which was least muscular; that the bone should be sawn through next ; and that the section of the thickest part of the limb should be kept until the last. 2 Paulus ^Egineta, who is supposed to have lived during the seventh century of our era, also recommended, on the authority of Leonides, that the section of the part containing the principal vessels should not be made until after the division of the bone, and added that the soft parts should be protected from contact of the saw by means of a linen rag (retractor). 3 Turning to the Arabian writers on surgery, we find that Avicenna or Ibn- sina (A.I). 980-1037) mentions the operation of amputation in connection with the general subject of sawing bones, but gives no special directions as to its performance. 4 Rhases, or Razes, who flourished about a century earlier, refers to the use of a retractor, and in the fifteenth book of his Liber Contim ns, or Comprehensive Book (a kind of common-place book treating of all subjects relating to medicine), recommends extraction of the whole bone in cases of caries or " spina ventosa. 5 Haly Abbas (Alee-Ibnool-Abbas), who died at the end of the tenth century, also recommends the use of a retractor, and gives advice as to the mode of making the incision for amputation, almost identical with that of Paulus ^Egineta. 6 Albucasis (Aboo-1-Kasim), who lived about a century later than Avicenna, gives similar directions, but adds nothing new to the subject. 7 The surgical writers of the Middle Ages, such as Theodoric, Bishop of Cervia 8 (died A. D. 1298), Gui de Chauliac, who was the papal physician between 1340 and 1370, 9 and Leonardus Bertapalia, who appears to have flourished in the early part of the fourteenth century, 10 commonly contented themselves with copying or paraphrasing the teachings of their predecessors. I may conclude this brief sketch of the ancient doc- trines of amputation by quoting from a sixteenth century translation of Gio- vanni di Vigo, who lived about A. D. 1510, the following description of the operation in cases of gangrene: it will be observed that while he mentions the cloth to cover the soft parts, he does not speak of using it as a retractor. The passage is also interesting as containing one of the early references to the induction of anaesthesia by inhalation. " The manner to cut the corrupt member is this : First, ye must prove with a provct [probe] howe the mortification of the member goeth, and afterwarde yee must cut the member circle wise, in the fieshie and musculous part, and ye must dissever somewhat the flesh from the bone in the over part of the member. And afterward cutte the rotten flesh from the bone by peece meale, and cover the borders with warm cloutes, that they bee not hurt by the ayre. Then ye must compasse about the over parte with your handes, and reduce the flesh circle wise, and sawe the bone as highe as yee canne, • Archigenis de amputandis partibus, apud Oribasii lib. de luxat. ; Graecorum chirurgici libri, etc. e collect. Nicetae, cura Ant. Cocchii. Florent., 17f)4, p. 154. 2 Heliodori de extremis merabris abscindendis. Ibid. p. 156. 3 Pauli iEginetse Medici Optimi lib. vi. cap. lxxxiv. Edit, princeps. Venetiis, in sedibus Aldi, etc., 1528, fol. 95. « Canonis lib. iv. fen 4, tract. 4, cap. 12. Edit. Cortaei et al. t. ii. p. 172. Venetiis, apud Juntas, 1595. 5 Haller, Bibiliotbeca chirurgica, t. ii. p. 130. 6 Haly Filius Abbas. Liber totius medicine necessaria continens, etc., Pract. lib. ix. cap. lxv. Lugdun., 1523, fol. 283. 1 De chirurgia, lib. ii. sect, lxxxvii. Edit. cur. J. Channing, Oxon, 177^. t. ii. p. 410. 8 Chirurgia, lib. iii. cap. x. 9 Chirurgia, tract, vi. doct. i. cap. viii. 10 Tract, de ossibus, cap. ii. 554 AMPUTATIONS. with a Sawe of sharpe teeth. Which done, ye must cauterise the cutte place, unto the whole parte, and afterwarde ye must cauterise the hone, and then cure the Wounde as other burned Woundes be cured. And because that some command to attoine [anoint?] the member before incision, by application of a medicine wherein Opium entereth, or by the smelling of a Spunge wherein Opium is, that the whole bodie may bee brought a sleepe. Yee shall understand (the reverence saved) they enterprise a daungerous businesse, for this disease sometimes chaunceth of a medicine made with Opium, as writers affirme. Neverthelesse the member may be bound afore incision, in the upper part, because of y e course of y e bloud." 1 Although, as has been seen, Celsus clearly indicated the importance of dividing the bone at a higher level than the soft parts, his teaching in this respect was soon forgotten, and we find, until comparatively recent times, surgeons of authority recommending that the whole limb should be severed at one stroke. Thus Leonard Botal, of Asti in Piedmont, a military surgeon of the sixteenth century, devised an instrument like powerful shears, 2 by which an amputation could be effected by a single blow— an instrument de- nounced by Jules Cloquet 3 as more worthy to have been invented by a butcher than by a surgeon — and Purmannus, of Brandenburg and afterwards of Bres- lau, writing more than a hundred years later, speaks of having seen amputa- tion performed in a similar manner. Indeed in the works of Scultetus, 4 and even of Heister 5 (whose volumes formed the most popular surgical text-book of the last century), may be found illustrations of the severing of parts of the hand or foot with powerful forceps or with chisel and mallet. (Figs. 99, 100.) Fig. 99. Amputation of a foot with cutting forceps. (After Scultetus.) The use of the ligature, in amputations, 6 was first clearly taught by the illustrious Ambroise Pare (A. D. 1509-1590), in the middle of the sixteenth 1 The whole worke of that famous chirurgion Maister John Vigo : Newly corrected, by men skilfull in that Arte. The fourth booke of Ulcers, Chap. 7. At London. Printed by Thomas East, L586, fol. 252. 2 Dionis, Cours d'operations de chirurgie, p. 756. Paris, 1740. 3 Dictionnaire de medecine, edit. 1821, tome ii. p. 240. 4 Armamentarium chirurgicum. Tab. xxvii. xxviii. pag. 64, <5S. Amst. 1(562. 6 Institnt. chirnrgicre, I'. ii. sect. i. cap. xxxiii. (tab. xii. fig. 17). Amst. 1739, 1. 1. pag. 491. c The us.- of the Ligature for vssrls wounded in their continuity had been familiar to surgical writers from tin- time of (Vlsns, and was particularly referred to by Lanfranc, an Italian surgeon who removed to Paris A. D. L295 (Ars ccrmpleta totius chirurgiss. Tract, i. doct. iii. cap. ix.), by (iiii de Chauliac (Chirurgia. Tract, iii. doct. i. cap. iii.) and his follower and commentator Jean Taganll (Institnt. chirurg. lib. ii. cap. xii.), by Vigo (Op. cit. fol. 135), and by Marianus Sanctns (Compend Chirurgise. Tract, do ulceribus. De Chirurgia Seriptores, etc. [ed. Conrad Gtesner], Tiguri, 1555, fol. 161;. HISTORY OF AMPUTATION. 555 century, 1 yet so little was the merit of his teaching recognized that Fabrieiua of Acquapendente (A. D. 1537-1619) 2 returned to the old Hippocratic doc- trine of cutting through dead parts only, while Fabricius Hildanus (A. D. 1560-163-i) 3 employed a red-hot knife to sear the vessels as they were cut, Fig. 100. Amputation with chisel and mallet. (After Scultetus. The original has been closely followed, even to the extent of giving the patient five fingers and no thumb.) thinking this safer and more expeditious than the application of ligatures, and even Wiseman, the " father of English surgery" {circa 1676), though describ- ing Pare's invention, preferred the use of a " royal styptic" or the actual cautery. 4 Peter Lowe, 5 who died in 1612, thought the ligature "reasonable sure, providing it be quickly done ;" but Cooke, of Warwick 6 [circa 1675), refers to Pare for a description of the method of " stitching" the vessels, and adds that it " is almost wholly rejected ;" while the famous quack Salmon (who died in 1700) 7 does not apparently think it even worthy of mention. Next to the introduction of the ligature, the most important improvement in the operation of amputation was the invention of the tourniquet or "gripe- stick" as it was called by the English translator of Le Clerc. 8 In its original form, this instrument, which was also known as the garrot or Spanish wind- lass, seems to have been devised about the same time (1674) by Morel, a French military surgeon, during the seige of Besancon, 9 and by Young, of 1 (Euvres completes, ed. par J. F. Malgaigne. Tome ii. p. 224. 2 De chirurgicis operationibus, cap. xcvi. Opera chirurgica, Lugd. Bat., 1723, pag. 628. 3 Tract, de gangrama et sphacelo, cap. xix. Opera, Francofurt. ad Mam., 16S2, pag. S13. 4 Appendix to Treatise on Gunshot Wounds, chap. ii. Eight Chirurgical Treatises. Sixth edition, vol. ii. p. 225. 5 A Discourse of the Whole Art of Chirurgerie. Third edition. London, 1634. Book II 1 1., chap. 7, page 93. 6 Melliticium chirurgise : or the Marrow of Chirurgery. Fourth edition. London, 16S5. Part IV. Sect. II., page 203. 7 Ars chirurgica. London, 169S, Book I. chap, xxxii. (vol. i. p. 92). 8 The Compleat Surgeon. Fifth edition. London, 1714, page 2S7. 9 Dictionnaire des sciences nieMicales, tome lv. p. 369. 556 AMPUTATIONS. Plymouth, in England, as described in his " Currus Triumphalis e terebintho," published in 1679. x Morel's apparatus consisted of a thick compress, which was placed around the limb, and surrounded with a cord or small rope, under which were slipped two short sticks, by twisting which the cord was Fig. 101. Morel's tourniquet. (After Dionis.) Morel's tourniquet improved. " The common tourniquet." (After Heister.) drawn very tight 2 (Fig. 101). Morel's tourniquet was improved by Le Dran 3 and other surgeons (Fig. 102) by placing an* additional pad immediately over the vessels and below the circular compress, by using only one stick for twisting the cord, and by placing beneath this a piece of paste-board — or, according to Garengeot, 4 of horn or leather (Fig. 103) — so as to render the pressure on the skin less severe, and thus avoid the risk of sloughing, which sometimes followed the use of Morel's instrument. But the greatest im- provement in the tourniquet was that made in 1718 by the illustrious J. L. Petit 5 (Fig. 104) — le grand Petit, as he has been sometimes called to distin- guish him from other less famous surgeons of the same name — and though, with its wooden plates and screw, we should think it but a rude contrivance, it was in all essential points the same instrument as the tourniquet employed at the present day. As soon as surgeons had begun to emancipate themselves from the Hippo- cratic and Galenic doctrine of cutting only dead tissues, it was natural that they should adopt the Celsian method, and we accordingly find that the circu- lar mode of amputation was practised at an earlier period than any of the flap operations. The first important modification introduced into the pro- cedure of Celsus, was the suggestion, about the same time and apparently independently of each other, by Petit, 6 in France, and by Cheselden, 7 in Eng- 1 Sharp's Critical Enquiry into the present state of Surgery, page 277. Second edition. Lon- don, 1750. 8 Dionis, Cours cooperations do chirurgie, Huitieme Demonstration, p. 701. Paris, 1740. Dionis does not mention Morel's name, but Bays that the tourniquet was invented "a long time ago, during the seige of Besan<;on," by "one of the surgeons of the army;" and adds that it lias been used ever since. 3 Trait! des operations o^fxata) ; 10 but in his general remarks on amputation he certainly says nothing which can be reasonably construed into a description of the flap method. 11 Lowdham's and Young's operation was applied to the leg, and consisted in cutting from without inwards a long flap of skin and fascia from over the mus- cles of the caxf. Verduin, 12 of Amsterdam, in 1696, and Sabourin, of Geneva, in 1702, 13 introduced the plan of forming a musculo-cutaneous flap from the calf of the leg, by transfixion, and attempted to control the bleeding by pressing this firmly against the end of the stump; Verduin 's flap was adopted by Garengeot, 14 who, however, ligated the bleeding vessels, and thus perfected the ordinary flap operation of the leg as it is still often practised at the pre- sent day. O'Halloran, 15 an Irish surgeon, likewise employed this mode of 1 f hirurgical Observations and Cases. By William Bromfeild, etc., vol. i. page 151. London, 1773. 2 (Euvres chirursicah's, seconde partie, p. 491. Paris, 1798. » Op. cit., pp. 4-0, 492. * Op. cit., p. 317. 6 La Faye, Histoire de F amputation a lambeau, etc., Mem. de l'Acad. Royale de Chirurgie, t. ii. p. 169. Paris, 1819. 8 Nouveaux elements de meMeoitie opfiratoire, t. ii. p. 300. » Haller, Bibliotheoa ehirurgica, t. i. p. 79. 8 Vide supra, page 553. 9 Op. cit., p. 158. 10 This was rather an anticipation of Kavaton's double-flap method than of Lowdham's opera- tion. 11 Op. cit., p. 150. Vide supra, page 553. 12 Mangetus, H i 1 > M <» 1 1 1 *'<••■ t scriptoruni medicorum, lib. xx. t. ii.,pars ii., p. 493, and Garengeot, Tr.-iiti' des operations, t. iii. p. 393. " La Fay-', loo. cit., p. 17<>. 14 Mem. de l'Acad. Royale de Chirurgie, t. ii. p. 180. 15 The Medical Museum, vol. iii. p. G5. London, 1704. CONDITIONS CALLING FOR AMPUTATION. 559 amputation, but did not close the stump until tlie flap was already covered with granulations. The earliest double-Jiap amputation (if we except Helio- dorus's operation on the fingers), appears to have been practised by Kavaton, 1 a French surgeon, about the year 1739. He applied this method of operating to the thigh, making first a circular incision down to the bone, and supple- menting this by longitudinal incisions in front and behind, making thus two square, muscular, lateral flaps, at the point of junction of which the bone was then divided. Vermale 2 modified and improved this procedure by mak- ing the flaps of a rounded or somewhat oval shape, and by forming them by transfixing the limb with a long knife and cutting from within outwards. La Faye's suggestion 3 to use a knife curved on the flat that it might better slip around the bone, appears more ingenious than practically valuable. The flap operation, in one or other of its forms, was soon adopted by other surgeons, and with various modifications was finally brought into ordinary use through the example mainly of Listen and Guthrie in England, of Du- puytren, Roux, and Larrey in France, and of Klein and Langenbeck in Ger- many. All the various forms of amputation which have been since employed, may be regarded as varieties of these two principal methods, the flap and the circular. Conditions calling for Amputation. It is not intended, of course, in the following paragraphs, to enumerate and describe all the various contingencies which may determine a surgeon to resort to amputation. There is hardly any form of injury, or variety of dis- ease, capable of affecting a limb, which may not, under particular circum- stances, whether as regards the constitution and hygienic condition of the patient, or the individual and peculiar features of the special lesion, necessi- tate a resort to this operation. All that is meant to be done here is to bring together, in a compendious way, brief references to the more important con- ditions which, as a rule, render imperative the removal of a limb, so that the reader may obtain, as it were, a bird's-eye view of the subject, and may thus be enabled to realize to what a vast diversity of cases the "humane operation" of amputation is applicable. Avulsion of a Limb. — In the first place, it can be readily understood that when any considerable part of an extremity has been torn oft' and entirely separated from the body, there is commonly no alternative to immediate amputation. The operation may indeed be said to have been already effected by the force which caused the injury, and the surgeon's part is merely to trim oft' the hanging shreds of tisstte, and put the wound in such a condition that it may heal more readily, and that the resulting stump may be of better shape and more useful than if the process of repair had been entirely abandoned to the efforts of nature. Even though the part be not altogether separated, if it be hanging merely by integument and fascia, the great vessels as well as the bone and most of the muscles having been divided, the surgeon's duty is to amputate. A few authentic cases are no doubt on record in which small portions of the body, tips of the fingers, or bits of the 'nose or ears, have been re-applied after complete separation, and have become reunited : but even these restorations are, in this climate at least, so rare, that their possi- bility may be practically disregarded ; while in respect to the cases which we 1 La Faye, loc. cit. p. 174. Le Dran, op. cit. p. 5fi4. 2 La Faye, loc. cit. p. 175. Le Dran, op. cit. p. 567. 8 Loc. cit. 560 AMPUTATIONS. occasionally find described in journals, of large portions, hands or arms, being thus re-connected with the body, I must confess to entire incredulity. Compound Fractures and Luxations very frequently necessitate removal of the injured part. Most of the primary amputations performed in our large city hospitals are in cases of compound fracture, and though limbs are undoubtedly saved now which in past times would have been sacrificed, yet with the increase of railway travelling and the more general employment of heavy machinery in manufactures, the number of accidents of this nature lias been so augmented that amputation for injury becomes, year by year, a more frequent operation in hospital practice. The propriety of amputation in compound fractures maybe determined by various considerations: — (1) Great comminution of the bones may of itself be a cause for amputation. In the upper extremity, conservative measures may often be successful, loose or partially detached fragments being removed, and projecting ends of bone sawn off if necessary to effect reduction ; but in fractures of the lower extremity, if the fragments which require removal involve the whole thick- ness of the femur or tibia, the resulting limb, should recovery follow, would in all probability be rather an encumbrance than a benefit, and under such circumstances amputation should ordinarily be resorted to. (2) Laceration of a large artery, in connection with compound fracture, usually calls for amputation. Here, again, a distinction may be made between injuries of the upper and those of the lower extremity ; in the case of the former, an attempt may sometimes properly be made to save the limb by tying the vessel in the wound, or even by securing the main trunk above, but in the case of the lower extremity, unless the bleeding artery can be readily found and ligated in the wound itself, amputation will be found the safest mode of procedure. So, too, in case of secondary hemorrhage occur- ring as a complication of compound fracture in the lower extremity, amputa- tion will commonly be necessary. (3) Great contusion and laceration of the muscles, even if the great vessels be uninjured, may be considered to indicate amputation in many cases of com- pound fracture. A limb which has been crushed by the wheels of a railway train, almost invariably requires amputation, the muscles and other deep- seated tissues being torn, and, as it were, pulpefied, while the skin may be comparatively uninjured. In such a case the operation should, as a rule, be performed at a higher level than that at which the skin is found to be sepa- rated from the subjacent tissues, as otherwise sloughing of the flaps will be apt to follow, and a second amputation may, perhaps, be required. (4) Compound fracture into the knee-joint may be considered a cause for am- putation, and the same operation will often be required in cases of compound fracture involving the ankle. In similar injuries involving the other joints of the body, and, under favorable circumstances, in the instance of the ankle, excision should be the surgeon's first thought, and may often be properly substituted for amputation. Compound dislocations of large joints are among the most serious injuries to which the human frame is liable, and; in my judgment, almost always require operative interference; in the case of the hip or ankle, or of the arti- culations of the upper extremity, excision may be preferred, but in the case of the knee amputation is the safer remedy, and may, indeed, be said to be imperatively demanded. Lacerated and Contused Wounds, even when unattended byunjuries of the bones or joints, may require amputation. Operatives in mills not unfrcquently CONDITIONS CALLING FOR AMPUTATION. 561 have their arms caught in portions of the machinery, and drawn between rollers revolving in opposite directions; in many of these eases, provided that there be no fracture, expectant measures may undoubtedly suffice, and I have frequently saved limbs thus injured by the use of irrigation, with cool or tepid water, according to the season of the year. In some instances, how- ever, the destruction of the integument and muscles is so extensive that the inevitable sloughing would render the limb, even if it should be preserved, a mere useless appendage, and, under such circumstances, amputation should be resorted to, as not only greatly shortening the duration of the treatment, but as delivering the patient from many of the secondary risks of wounds to which he would otherwise be liable. The same may be said in regard to cer- tain injuries caused by railway trains or heavily loaded wagons; a foot and ankle from the greater part of which all the soft tissues have been stripped, or bruised into an indistinguishable pulp, can never be anything but a source of suffering and discomfort to its possessor, and under most circumstances should be removed as promptly as possible. In this category, too, may be placed the frightful lacerations sometimes caused by the teeth and claws of wild animals ; these are, of course, more common in countries of which such animals are natives, than in our own ; but they are occasionally met with among the attendants or visitors at menageries, and I have myself had occa- sion to see wounds inflicted by a Polar bear, a lion, and a Royal Bengal tiger. The last-mentioned case occurred during my student days, and the victim, a youn^ woman, was admitted to the Pennsylvania Hospital, where she came under the care of the late Dr. Edward Peace. The injury, inflicted by a blow from the claws of the animal, was a very severe laceration of the arm, involving the brachial artery. Primary amputation at the shoulder-joint was resorted to, and the patient made an excellent recovery. The case of bear-wound occurred in a man who was, a few years since, under my care in the University Hospital ; there was a tolerably severe and painful laceration of the arm and shoulder, but not such as to require operative interference, and the wound healed readily under simple dressings. The case of lion-wound was the only one of the three which terminated fatally. This occurred in a man aged 25, a professional " lion-tamer," who, in the course of his daily rehearsal, placed his head in the lion's mouth, when the animal unexpectedly closed his jaws. The by-standers rushed to the rescue, and with clubs and iron bars forced the wild beast to relax his hold, but, unfortunately, his victim did not make his escape with sufficient promptness, and the lion again attacked him, throwing him down, and this time seizing him by the fleshy part of the thigh. I did not see the patient until the next day, when he was not in a condition to admit of any operation. The injured thigh was already the seat of traumatic gangrene, which had set in within eighteen hours after the reception of the injury ; the limb was enormously swollen, emphysematous and crackling from the gaseous products of decomposition, and discharg- ing from its numerous wounds, some of which were two or more inches in length, a bloody, sanious, and very offensive fluid. The pulse was running at the rate of 172 beats in the minute, and it was quite evident that a fatal issue was impending. Death occurred shortly after the gangrene reached the trunk, the whole duration of the case having been just forty-eight hours. Had amputation at the hip-joint been per- formed before or immediately upon the occurrence of gangrene, there might have been some slight hope of the patient's surviving. This case was under my care at the Epis- copal Hospital in April, 1872. Gunshot Injuries often call for amputation. The increased power of de- struction possessed by modern implements of warfare, to a great extent counterbalances the improvements which have been made in the treatment of wounds ; so that though, by the introduction of the operations of exeision vol. i. — 36 562 AMPUTATIONS. and resection into military surgery, many limbs can now be preserved which would formerly have been condemned to removal, yet the proportion of cases in which the army surgeon is compelled to amputate, is probably almost if not quite as large as when, though surgery was less efficient, the injuries with which it had to deal were less severe. The conical ball, propelled by the modern rifled firearm, splits and shatters the bone which it strikes so severely, as very often to defeat any hope of doing good by expectant treatment ; and when simple extraction of fragments is not sufficient, and the surgeon has to choose between amputation and resection, the former will frequently be found the more eligible operation. Various Lesions of Arteries require amputation. Simple wounds of arteries are, of course, usually amenable to milder measures, and subcutaneous ruptures or lacerations of the great vessels may often be successfully treated by laying open the part, after controlling the circulation with a tourniquet or Esmarch's tube, or even with digital compression, and by securing the artery as if it had bled in an open wound. In certain situations, however, as when the popliteal artery is the seat of rupture, amputation will commonly be needed. Again, traumatic aneurisms, or spontaneous aneurisms which have become diffuse, may require amputation ; this rule particularly applies to aneurisms of the popliteal artery, and of the deep arteries of the leg, and to traumatic aneurisms in the axilla. Amputation has also been successfully practised as a modified distal ligation in cases of subclavian aneurism. Finally, amputation may be demanded in cases of secondary hemorrhage, whether from a wounded artery or from one previously ligated in its continuity. .The reason that amputation is often more successful under such circumstances than any other measure, can be readily understood when it is remembered that secon- dary bleeding almost invariably comes from the distal end of a vessel (where the repair is less perfectly effected than at the proximal end), and that only by amputation can the vis a fronte which induces the supply of blood to the distal end be got rid of. Heat and Cold. — Amputation is not unfrequently rendered necessary by the destructive influence of heat or cold. In cases of frost-bite, the dead parts, if limited in extent, should be allowed to drop off spontaneously ; if a whole hand or foot be involved, the sphacelated mass may be removed by an inci- sion through the dead tissues, and then, when the lines of demarcation and separation have been fully established, a formal operation may be practised. So, too, in cases of burns or scalds, no operation should as a rule be attempted until after the sloughs have all become detached, when, if it be evident that a cure is not to be expected from nature's unaided efforts, amputation may be resorted to with the best prospects of a favorable result. The same opera- tion may also be called for at a later period in cases of great deformity re- sulting from cicatricial contraction, or when, as sometimes happens, old cica- trices become the seat of malignant growths. Mortification from whatever cause, when the death of the part goes be- yond the formation of a mere superficial slough, usually demands amputation. The ordinary ride, and one that under most circumstances should be strictly adhered to, is that no amputation should be undertaken until after the com- plete establishment of the line of separation; the reason is obvious — if the surgeon cut through parts the vitality of which is, as it were, hanging in the balance, the additional injury inflicted by the knife may of itself be sufficient to turn the scale, and an amputation under these circumstances is apt to be followed by a renewal of the gangrenous process. Hence when death of a CONDITIONS CALLING FOR AMPUTATION. 563 part results simply from the intensity of the inflammatory process, as in the cases of frost-bite and burn, already referred to, no operation should be done while the mortification is still extending, but the surgeon should await nature's indication that the limit of the destructive process has been reached, and may then amputate at any point above the line of separation which may be found convenient. There are, however, exceptions to this ordinarily well- founded rule. Thus in the purely local forms of gangrene which result from direct injury, as in severe cases of compound fracture in which for some reason primary amputation has not been practised, the limb should be re- moved as soon as the signs of mortification are unequivocally manifested ; delay under these circumstances would commonly result in the patient's death before time had been given for the formation of a line of separation. Again, in that frightful form of mortification which is variously known as the true "traumatic or spreading gangrene," "bronzed erysipelas," " gangre- nous emphysema," etc., the only hope, and that, it must be confessed, but a slight one, consists in immediate amputation at a point sufficiently removed from the seat of disease to render unlikely a recurrence of gangrene in the stump; this was the form of gangrene which occurred in the case of fatal in- jury by a lion which I have already referred to ; it is most common in con- nection with bad compound fractures and severe lacerated wounds, though it may follow comparatively slight injuries, and is particularly apt to occur in persons who are suffering from previously existing visceral disease, and espe- cially from organic affections of the kidney. There is another form of gangrene which may require immediate ampu- tation, and that is where death of a part results from an arterial lesion at a distant point, as where mortification of the foot depends upon a gunshot wound of the femoral artery. The gangrene in these cases first displays itself through a change in the coloration of the affected part, which is in the beginning pale and tallow-like, and afterwards mottled and streaked, while numbness is succeeded by complete insensibility. Guthrie's advice as to the course to be pursued under such circumstances, appears to be judicious; this is that while the gangrene remains limited to the toes or foot, the surgeon should delay, in hope that it will not extend further; but that as soon as the disease shows a tendency to spread above the ankle, amputation should be performed at that point at which experience has shown that the morbid pro- cess is likely to be arrested, that is, a short distance below the knee. If the upper extremity should be similarly affected, the point at which the arm should be removed would be the shoulder-joint. Dry Gangrene, affecting the extremities of old persons, seldom admits of active treatment, the disease almost invariably recurring in the stump when an amputation is attempted. To avoid this risk, it has been recommended by James, of Exeter, and other surgeons, that, for gangrene affecting the toes, the operation should be done in the upper part of the thigh, where the tissues would presumably be more healthy than at a lower point ; but it is obvious that the constitutional state of the patient, in most cases of senile gangrene, would render such a mode of treatment hazardous in the extreme. Greater success attends amputation for those forms of dry gangrene which are occasionally met with in young persons, as the result for instance of em- bolism ; but even in such cases, the surgeon should hesitate about interfering until the formation of a line of separation shows that nature is making an effort to throw off the portion of which the vitality has been lost. Amputa- tion may also be required in cases of Hospital Gangrene, or sloughing pha- gedena, either after the morbid process has been arrested, on account of the great loss of substance, or even during its continuance, should profuse bleed- ing occur from the opening of a large artery. In the latter case, care should 564 AMPUTATIONS. be taken to amputate through healthy tissues, and every precaution should be observed to avoid the risk of inoculating the wound of operation with the discharges from the original seat of disease. Various Diseases of the Bones and Joints may necessitate removal of the affected limb. If either alone be diseased, less sweeping measures may suffice, excision taking the place of amputation in favorable cases of joint-disease, and the extraction of sequestra, Sedillot's operation of evidement (gouging), or, in some instances, complete sub-periosteal resection, usually proving satisfactory when the bones only are affected without implication of the neighboring articulations. Much, however, as I admire the practice of " conservative surgery," and striving as I invariably do to substitute excision and the other operations which have been referred to, for amputation, in all suitable cases, I cannot doubt that there will always be a considerable resi- duum of bone and joint-affections, in w T hich the "humane operation" will offer the only chance of recovery. Morbid Growths not unfrequently become causes for amputation. It may even happen that a non-malignant tumor, by its size and weight, by its rela- tions to the great vessels and nerves of an extremity, or, if suppuration and ulceration have occurred in it, by the exhaustion caused by profuse dis- charge, may render removal of the affected limb a more promising operation than an attempt to separate the growth from the surrounding tissues ; while in the case of malignant tumors of the extremities, and particularly those involving the bones, including (as clinically malignant) the sarcomata, car- tilaginous growths, etc., amputation is commonly the sole remedy. It is true that, in some few instances, excision of the affected portion of bone has been advantageously resorted to, as in the examples recorded by Lucas and Morris, in which myeloid growths of the forearm were thus successfully dealt with ; but in the majority of cases, amputation will be found the safer measure, and under these circumstances may usually be resorted to with every prospect of a favorable termination. Tetanus has been looked upon as an affection calling for amputation, and a cure has occasionally followed the operation. Laurent has collected seven- teen cases of minor, and twenty-four of major amputation for tetanus, with eleven recoveries in either category, or, taking both together, a proportion of successes of nearly fifty-four per cent. In most instances, however, the cases appear to have been examples of subacute or chronic tetanus, in which a good result may often be obtained by internal treatment alone, and on the other hand the milder operations of nerve-stretching and neurotomy have given at least as good results as amputation ; we may probably say, therefore, in view of all the evidence which has been produced in respect to the matter, that while, if the operation appear to be otherwise indicated, the onset of tetanus may be considered an additional reason for resorting to amputation, this should not be indiscriminately employed in all instances of tetanus originat- ing in wounds of the extremities, without regard to the other circumstances of the particular case. I cannot look upon amputation as a justifiable procedure in cases of hydro- phobia, nor, unless under very exceptional circumstances, in those of poisoned ivounds from the bites of serpents, etc. Deformities. — Finally, amputation maybe sometimes practised in cases of congenital malformation, as in some instances of neglected club-foot^or in of limbs deformed by accident or disease, the result of vicious cicatri- INSTRUMENTS REQUIRED FOR AMPUTATION. 565 cial contraction, union of fractures in bad positions, faulty anchylosis, etc. Amputation in cases such as these, must be considered an operation of election, or of complaisance, and should not be resorted to, therefore, except under cir- cumstances as regards the age and general condition of the patient which would render an unfavorable termination exceedingly improbable, and even then not without a full appreciation of the risks of the operation on the part of all concerned. Instruments required for Amputation. Before undertaking an amputation, as, indeed, before attempting any ope- ration, the surgeon should run over in his mind all the various instruments and appliances that may possibly be required by the several contingencies which may arise. He should see that all the necessary implements are at hand, and in working order; there can be nothing more awkward than for the surgeon, after making his flaps, to discover that the saw has been forgot- ten, or, when the limb has been removed, that he is likely to run short of ligatures, or that the needle with which he proposes to sew up the wound, has no point, or a broken eye. jN T or is the inconvenience to the operator the worst result of this kind of improvidence, for the delay caused in procuring the missing articles may prove very prejudicial to the patient. The instruments needed for amputations are a tourniquet, or other suitable means for controlling the circulation during the various steps of the opera- tion, knives of various forms and dimensions, saws of different kinds, bone- nippers or cutting pliers, a pair of strong forceps for holding bone, artery forceps and tenacula, spring-clips and serre-tines, ligatures, retractors, sutures and suture needles, common dissecting forceps, and scissors. Besides these, the necessary means of dressing the stump should be provided ; laudanum, olive oil, or whatever substance the surgeon intends to employ as a dressing, adhesive plaster, sheet lint or old linen, oiled silk or waxed paper, charpie or oakum, bandages, pins, etc. Tourniquet. — As already mentioned, the first attempt to control bleeding during an amputation appears to have been made by Archigenes, who some- times placed a fillet around the whole limb, and sometimes tied or sewed up the vessels at a point above that at which it was intended to amputate. The fillet answered its purpose very imperfectly, and the invention of Morel, by which sticks were thrust under the band, and twisted around so as to com- press the limb tightly, w T as unquestionably an improvement. Morel's tour- niquet as further modified by Ledran is still employed occasionally with advantage in cases of emergency, under the name of the "garrot" or " Span- ish windlass." The best tourniquet for ordinary use is in all important pi nuts the same as that introduced in the early part of the last century by Petit, and consists of two metal plates, the distance between which can be regulated by means of a screw, and which are connected by a strong silk or linen strap, which is meant to pass around the limb, and which is provided with a buckle to prevent its slipping (Fig. 105). The plan which I have now for a good many years adopted m applying the tourniquet is as follows: The surgeon, taking an ordinary three-inch or four-inch roller bandage, makes, by unrol- ling and again folding one end of it, a somewhat flat compress, which is placed immediately over the main artery of the limb at a point at which its pulsations can be distinctly recognized. This compress is fixed by a few circular turns of the bandage, and the rest of the roller is then laid as a second compress somewhat obliquely across the vessel, so as to force inwards the first compress, 566 AMPUTATIONS. Fig. 105. and keep up the tension even if the tourniquet-plate should he slightly displaced to one or the other side. The tourniquet is next applied, with its plates closely approximated, and placed immediately over the compresses, so as to exercise pressure in the line from the compresses through the vessel, to the subjacent hone. The strap is then drawn quite tight, and se- cured by the buckle, when a few turns of the screw will be found to completely control the circulation. It is desirable that the plates of the instrument should not be separated by more than half the length of the screw, as if separated by its full ex- tent, the instrument becomes, as it were, top heavy, and is apt to slip. It is sometimes supposed that, provided that the compress be placed over the artery, it makes no differ- ence to what part of the limb the tourniquet plate is applied. This is aii error, as can be readily perceived by reflecting upon the mechanism of the instrument. The tourniquet is so arranged that it makes direct pres- sure but at two points ; immediately below the plate, and at a point dia- metrically opposite ; at every other point of the circumference the pressure produced by tightening the strap is oblique or gliding. Hence the inevitable effect of placing the plate elsewhere than either immediately over the artery, or diametrically opposite to it, will be to push the vessel more or less to one side, when the circulation may not be controlled though the instrument be applied as tightly as possible. Hence, The modern tourniquet. Fig. 106 Fig. 107. 'I'll'' li'-ld tourniquet. Signoroni's horse-shoe tourniquet. whenever i1 is practicable^he tourniquet plate should bo fixed as above directed, immediately over the artery; when this cannot be conveniently done, as in the case of the axillary, or in that of the popliteal artery, it should be placed at a poinl diametrically opp6site, over the point of the shoulder in the case of the former, and just above the patella in that of the latter vessel. Various other forms of tourniquet have been devised by surgeons, but none INSTRUMENTS REQUIRED FOR AMPUTATION. 567 of them approach in value to the familiar instrument of Petit. The field ton n liquet (Fig. 106), numbers of which are sometimes distributed to troops in time of war, consists merely of a strap and buckle, with a pad to go over the artery; unless very firmly applied, it is apt to do harm rather than good by obstructing the venous, without controlling the'arterial circulation, and is certainly inferior to the Morel tourniquet or Spanish windlass. Other instru- ments, which seem to me better adapted for the compression treatment of aneurism, or for temporary employment in cases of accidental hemorrhage, than for use in amputations, are the horse-shoe or SignoronVs tourniquet (Fig. 107), Skey's tourniquet (Fig. 108), Hoey's clamp 1 (Fig. 109), and Gross's arterial Fig. 108. Fig. 109. Skey's tourniquet. Hoey's clamp. compressor (Fig. 110). Under certain circumstances, however, as when it is desired to compress the abdominal aorta or common iliac artery preparatory to amputating at the hip-joint, the Petit's tourniquet is inapplicable ; and here the greatest benefit may be derived from the use of one of these other Fie. 110. Gross's arterial compressor. instruments. The compressor first employed in this operation by Prof. Jose] ih Pancoast, and since frequently used in this city (Philadelphia) for hip-joint amputations, was a large-sized Skey's tourniquet, to which Prof. Pancoast added a second pad (Fig. Ill), so as to make very deep and firm pressure 1 This instrument is sometimes credited to Dupuytren. 568 AMPUTATIONS. upon the aorta. former" aclap is the one generally employed in England. I have used both in amputating at the hip-joint, and have no hesitation in declaring my preference for Prof. Lister's instrument, as being much simpler and more readily adjusted than the other. Fig. 111. Fig. 112. Pancoast's abdominal tourniquet. Lister's aortic compressor. There have always been, and, probably, always will be, two schools in operative surgery : that which makes light of the loss of blood, looking upon it as a trilling matter, and that which deprecates any unnecessary expenditure of the " vital fluid," considering every drop that can be saved as of value to the patient. Hence we find that some surgeons have objected to the use of the tourniquet in amputation, preferring to rely exclusively upon compression of the main artery by the fingers of an assistant. It is said that the tourni- quet produces venous congestion, and, in the circular operation, interferes with the necessary muscular contraction ; and of late years it has been imagined that, by inducing venous thrombosis at the point of application, it predis- poses to the occurrence of pyaemia. The last-mentioned objection is hardly worthy of serious consideration : if venous thrombosis, per sc, were the cause of pyaemia, we should have pyremic complications in almost all cases of sim- ple fracture. By taking care to elevate the limb, or even to surround it with a firm bandage applied from below upwards, before screwing down the tourni- quet, the interference with the venous circulation may be reduced to a mini- mum ; and nothing can be easier than to saw off an additional piece of bone, after securing the vessels, if the retraction of the muscles should render it necessary. Guthrie and Hennen speak of the operator compressing the artery with one hand while he amputates with the other; but such unnecessary feats seem to me rather adapted to exhibit the skill and boldness of the surgeon than to promote the welfare of the patient. Safety should never be sacrificed to brilliancy, and there can be no doubt that a well-applied tourniquet renders an amputation safer than the best directed manual pressure; for while this can only arrest the' flow of blood through the main trunk, the tourniquet controls all the arteries at once, and it is often the smaller vessels that give the most trouble. INSTRUMENTS REQUIRED FOR AMPUTATION. 569 Esmarch's Apparatus.— I have already mentioned the plan of elevating the limb and bandaging it from below upwards, before screwing down the tourniquet, in order to prevent the loss of venous blood besides^controllino- arterial hemorrhage. An improvement upon this procedure has been intro- duced within a few years by an Italian surgeon, Silvestri, and by Esmarch an eminent surgeon of Kiel. Esmarch's apparatus (Figs. 113, 114) consists of a gum-elastic bandage and tube. The bandage is accurately applied to the Fie. 113. Fie. 114. Esmarch's elastic bandage. Esmarch's elastic tube. limb upon which the operation is to be performed, from below upwards, and with sufficient firmness to render the part quite bloodless. The elasticity of the bandage renders it unnecessary to make reverses, and with a little care the whole extremity can be covered in without leaving any gaps between the turns. The tube, which may be either round or flattened (as in Fig. 114), is next wound firmly four or five times around the limb, at the point of ter- mination of the bandage, and is secured either by tying or by a hook and chain. The bandage being then removed, the part is left fully exposed, and entirely free from blood. In the early days of " artificial ischaemia," as this method of rendering a limb bloodless has been called, an India-rubber cord was sometimes used instead of the tube, thus making much firmer constric- tion than was really necessary, and leading in some cases to paralysis or even gangrene of the limb to which it was applied, while in other instances the pressure of the bandage, by dislodging clots and forcing them upwards into the larger veins, caused, it is said, pulmonary embolism and death. But the principal objection that has been urged against the employment of Esmarch's apparatus is the liability to consecutive hemorrhage. There is no doubt that, unless special precautions be observed, free capillary oozing will inevitably follow when the tube is removed, and in some cases this may prove a wit serious complication : thus I am cognizant of one case in which, after the use of the tube and bandage in an excision of the knee-joint, capillary bleeding began when the tube was removed, and continued until the patient's death. Various plans have been adopted to prevent this oozing: Xicaise advises compression of the wound with a sponge dipped in a two-per-cent. solution of carbolic acid ; Riedinger applies to the wound a current of induced elec- tricity ; and Esmarch himself recommends that, after tying all the vessels that can be found, the wound should be closed with deep sutures, dressed, and elevated to a vertical position before the tube is removed, and that this position should be maintained for at least half an hour afterwards. The plan which I have myself adopted, and which I can confidently recom- mend as being less troublesome, and at least as satisfactory, as any of those that have been mentioned, is based upon a consideration of the cause of the capillary oozing referred to. The firm pressure of the elastic tube, if con- tinued for more than a very short time, produces temporary paralysis of the 570 AMPUTATIONS. vasomotor nerves of the part affected, and, as a consequence, dilatation of all the vessels ; the normal contraction and retraction of these does not take place, and, when the tube is removed, profuse bleeding occurs and continues until the vessels regain their natural tone. Xow, except in cases of necrosis, etc., in which the bleeding can be restrained by firmly stuffing the wound with lint before the removal of the tube, it is evident that, in order to pre- vent hemorrhage, the arterial circulation should still be controlled after the tube has been taken off, and while the vessels are recovering themselves. This may be conveniently and effectively done by combining the use of the tube with that of the ordinary tourniquet. My plan is to place a tourniquet in position, but not screwed down, over the main artery of the limb, and then to apply the Esmarch tube a few inches above the point at which I intend to amputate. As soon as the principal vessels have been secured — and these should be readily recognized through a knowledge of their ana- tomical relations— the tourniquet plate is screwed down and the tube removed. No bleeding follows, because the circulation is still thoroughly controlled by the tourniquet, and by the time that the remaining arteries requiring liga- tures have been tied, the vessels will have regained their tone, and the tour- niquet can be withdrawn without any risk of bleeding following. In amputations for injury, where there is much laceration of the tissues, I commonly apply the Esmarch tube without the elastic bandage ; in amputa- tions for disease, however, or where there is not much laceration, and, gene- rally, in operations other than amputation, both should be employed. Apart from the very great convenience to the surgeon, in many cases, of having the field of operation free from blood during his manipulations, I am well con- vinced that the judicious use of Esmarch's method will enable a certain number of lives to be saved by operation, which would otherwise inevitably be lost. Various ingenious modifications of Esmarch's apparatus have been sug- gested by Foulis, II. L. Browne, C. B. Nancrede, and other surgeons ; but I have no personal experience of any of these devices, of the practical value of which I confess to have some doubts. M. Houze de l'Aulnoit employs a simple band of caoutchouc, applied while the limb is held in a vertical posi- tion, and dispenses with the preliminary bandage. Amputating Knives. — The knife formerly used for the circular operation had but one edge and a very heavy back, being shaped somewhat like a sickle (Fig. 115); and a very good knife it was, cutting through the soft tissues Fig. 115. Old knife for circular amputations. almost by its own weight, and doing its work in a very satisfactory man- ner. The modern amputating knives, however, which are intended for use in either the circular or the flap operation, have a sharp point and are usually double-edged for an inch or more at the extremity (Figs. 116, 117). The length of the Knife should be about one and a half times the diameter of the limb to be removed, and its breadth from three-eighths to three-fourths of ;in inch. Thus a knife with a cutting edge of eight or nine inches will be sufficiently long for most amputations of the thigh, while one with an edge <>f six or seven inches will be ample for smaller limbs. Double-edged cauina (Fig. 118) are used principally for the forearm and leg, and are con- INSTRUMENTS REQUIRED FOR AMPUTATION. 571 venient in clearing the interosseous space for the application of the saw ; their breadth should not be greater than three-eight] is of an inch. In addi- tion to the amputating knives which have been described, the surgeon should Figs. 116, 117. Modern amputating kuives. Fig. llf Double-edged catlin. be provided with one or more strong bistouries or scalpels (Tigs. 119, 120), which should be about three inches in length, while for removi^s: the finsrers Figs. 119, 120. Bistoury aud scalpel. it will be found advantageous to employ a very slender knife with a heavy back (Fig. 121). Two inches in length and an eighth of an inch in width Fig. 121. Knife for finger amputations. may be considered suitable dimensions for the blade of sucll an instrument. These measurements are rather smaller than those ordinarily given in works on Operative Surgery, but they are such as my own experience leads me to recommend. Indeed, for my own part, I greatly prefer a small knife to a large one, and not unfrequently employ what is called a " metacarpal knife.*' with a three-inch blade (Fig. 122) for the largest amputations, having found Fig. 122. Metacarpal knife. it amply sufficient even for disarticulation at the hip-joint. The handles of amputating knives should be large enough to afford a firm grasp, and if made of roughened ebony are less likely to slip than if of bone or ivory. Saws. — The principal varieties of saw used for amputations are the ordi- nary flat-bladed saw (Fig. 123) and the bow saw (Fig. 124), of which my own 572 AMPUTATIONS. preference leads me to recommend the former. It should be about ten inches long, with a width of two inches and a half, should be very strong, and should Fig. 123. W^f*M*>»-«*'-*>»***************'**J Amputating saw. be furnished with a heavy back, so as to afford additional firmness. The teeth should not be too widely set — -just enough to prevent the instrument Fig. 124. Bow saw. from binding as it passes through the bone. A small saw, with a movable back (Fig. 125), will sometimes be found useful for amputations through the Fig. 125. Small saw with movable back. hand or foot. Other forms of saw have been recommended for use in the operation of amputation, among which I may particularly mention the instru- ments which bear the names of Rust and Butcher (Figs. 126, 127). The Fig. 126. Rust's saw. former seems to me to present no advantage over the ordinary saw, while the latter, though almost indispensable in certain excisions, as of the knee, appears INSTRUMENTS REQUIRED FOR AMPUTATION. 573 to be less well adapted for amputations ; it has been claimed for it, as in its favor, that its use enables the surgeon to saw the bone in a curved direction; Fig. 127. Butcher's saw. but I confess that I regard such a mode of dividing the bone as undesirable, and as unnecessarily incurring the risk of necrosis and subsequent exfoliation. Cutting Pliers or Bone-nippers (sometimes known as Liston's forceps) are used in amputations for the purpose of removing any rough or splintered edges left by the saw, or, in operations on the hands or feet for dividing the phalanges or the bones of the metacarpus or metatarsus. The whole length of the instrument may be from ten to twelve inches (Fig. 128), of which not Fig. 128. Liston's cutting bone forceps. more than two inches should be occupied by the blades. The latter should be sharp, and may conveniently be set at an obtuse angle to the handles, which should be very strong and roughened, so as to obviate any danger of the hand slipping. Strong Forceps for holding a projecting extremity of bone are useful in cases in which amputation is rendered necessary by avulsion of a limb, or by Fig. 129. Fergusson's lion-jawed forceps. a compound fracture in which the injury of the soft-tissues is so extensive that the assistant charged with steadying the part to be removed, cannot 574 AMPUTATIONS. obtain a firm grasp ; often, too, particularly in the circular operation, after the vessels have been secured and the tourniquet removed, it may be thought desirable to take away an additional segment of bone, and then it will greatly facilitate the surgeon's manipulations with the saw, if an assistant holds the projecting end of bone with strong forceps. An excellent instrument for this purpose is the "lion-jawed" forceps of Sir William Fergusson (Fig. 129). Another, still more powerful form of instrument, which bears the name of Farabeuf, is shown in Fig. 130. Fig. 130. Farabeuf s forceps. Artery Forceps and Tenacula are employed to take up the cut arteries (and veins, too, if they bleed), preparatory to tying them. The best form of Fig. 131. Cross-spring forceps. forceps is that shown in Fig. 131, the blades crossing, and being kept shut by their own spring ; the blades themselves should be expanded a little way Fig. 132 Catch forceps. above the points, so that when the ligature is applied it may readily slip down without including the ends of the instrument itself in the knot. Other Fig. 133. Slide forceps. v:iii cties of forceps are made to fasten with a catch (Fig. 132), or with a slide (Fig. 133), but the spring forceps arc much the best. All of these varieties INSTRUMENTS REQUIRED FOR AMPUTATION. iO are included under the generic name of the " bull-dog" forceps, the invention of which is attributed to the late Mr. Liston. Dr. Hodgen, of St. Louis, has devised an ingenious form of artery forceps by which the vessel is drawn from its sheath by the weight of the instrument, a cutting slide serving afterwards to divide the ligature, and thus enabling the operator to tie the artery without the help of an assistant. The tenaculum, or sharp hook (Fig. 134) is, upon the whole, not so conve- nient an instrument as the forceps, though invaluable in certain eases, as Fig. 134. Tenaculum. Fig. 135. when the parts are matted together by inflammatory action of long-standing, so that the vessels cannot be readily seized by the forceps, or when an artery bleeds in close proximity to the bone. In some cases it is even necessary to take up a mass of tissue, including the vessel, with two tenacula, and throw a ligature around the whole, withdrawing the second tenaculum before the knot is finally tightened. Though I have very often practised this ligature en masse, and have never seen any evil consequence result from it, yet it is better when practicable to draw each vessel a little way from its sheath, and tie it separately. The tenaculum should be of sufficient size — an inch to an inch and a quarter in the transverse portion of the hook — and not too much curved. Besides the artery forceps which have been described, the surgeon will do well to have in readiness some serre-jines (Fig. 135) and spring-clips (Figs. 136, 137), which are known here by the name of the late Mr. Xunneley. These are particularly convenient in case, after the removal of the tourniquet, several points should be seen bleeding simul- taneously. These clips can be quickly applied, so as to control the hemorrhage temporarily, and then removed one by one as the surgeon is ready to supply their place by ligatures. Fig. 136. Fig. 137. Nunneley's clips. Ligatures may be made from a great variety of materials, such as catgut, horsehair, or other animal substances, silver or iron wire, or, which I much prefer, fine whip-cord or strong silk:. Animal ligatures were employed by Sir Astley Cooper and by Dr. Physiek, and in the form of the carbolized catgut ligature have been revived by Prof. Lister and his followers, and are habitu- ally used by those surgeons who employ the so-called "antiseptic method." The late Prof. Eve, of Nashville, thought highly of a ligature made from the sinew of the deer, and Mr. Barwell has employed ligatures from the middle coat of the aorta of the ox, and Mr. T. Smith and Mr. Croft those from the tendon of a kangaroo. Metallic ligatures were used, about fifty years ago, in a number of experiments on the lower animals by Dr. Levert, of Alabama, 576 AMPUTATIONS. and similar experiments have been since repeated by Sir J. Y. Simpson and by Dr. B. Howard, of New York. While both animal and metallic ligatures have been employed in operations upon the human subject with sufficient frequency to leave no doubt as to their safety and efficiency, I have seen no evidence to make me think them in any way better than the hempen or silken ligatures which are more generally employed. Indeed silk (which, however, is itself an animal substance) seems to me, upon the whole, the best material from which a ligature can be made. It can be carbolized, if the surgeon wish, and in this form was at one time used by Prof. Lister, and was preferred to catgut by the late Mr. Maunder. Silk is now prepared for the surgeon's use by plaiting the strands instead of twisting them, and the plaited ligature has the advantage of much greater strength as well as of greater readiness in application. Silk ligatures should be about eighteen inches in length, the ordinary skein of silk which contains about six yards thus suf- ficing for twelve ligatures. Before using the silk, it should be well waxed, that the ligatures may not become entangled with each other, and that they may not slip in the surgeon's hands. In applying a ligature, the bleeding vessel is caught and drawn a little forward with either the artery forceps or the tenaculum, and an assistant then throws the thread around it and secures it with a double knot. The ligature should be tightened by a firm and steady pull, without any jerking movement ; the first knot should be made with suf- ficient force to divide the inner and middle coats of the artery, and the second knot adjusted so as to prevent the first from slipping ; if catgut or horsehair be employed, a third knot is desirable. The best form of knot is that known by sailors as the "reef-knot" (Fig. 138); it is much to be preferred to either the " granny" (Fig. 140) or the " surgeon's knot" (Fig. 139). Fig. 138. Fig. 139. Fig. 140. The "reef" or "Bailor's" knot. The " surgeon's" knot. The "granny" knot. It is customary, when many ligatures are applied, to cut off one end of each and bring the other end out at any convenient part — usually one angle — of the wound. For purposes of distinction, both ends of the ligature which surrounds the main artery may be left and knotted together. It has been proposed to bring each ligature out separately by an independent opening through the covering of the stump, so as to allow the edges of the wound to come in contact throughout their whole extent, without interruption ; but apart from the inconvenience and delay which would be caused by such a mode of procedure, the ligature ends themselves, being brought out in one or two groups, 'serve a useful purpose by affording an excellent means of drainage. Short-cut ligatures — that is, with both ends cut short — were much employed by Ilcuncn and a few other surgeons in the early part of this cen- tury, and have been revived in connection with the "antiseptic method" by Prof. Lister and his followers. If short-cut ligatures are used, a perforated, India-rubber drainage tube must be employed to allow the escape of the INSTRUMENTS REQUIRED FOR AMPUTATION. 577 fluids which are always poured out in an amputation-wound after the opera- tion, but if the ordinary form of ligature be adopted, the drainage tube La usually unnecessary. Other means of checking the bleeding after amputa- tion, such as acupressure or "some of its modifications — filo-pressure, etc. — or torsion, may be employed, and each method is advocated by excellent sur- geons. These will be fully described in the article on Injuries of Blood- vessels, in a subsequent volume, and need not be further considered here. I have, however, no hesitation in expressing the opinion that the ligature is more valuable than all of its substitutes put together, and is certainly prefer- able as a means of arresting hemorrage after the operation of amputation. The Retractor is an important part of the necessary apparatus for an amputation, and its value, as has been already mentioned, was fully recog- nized by the surgeons of antiquity. It consists of a piece of stout muslin, six or eight inches wide and three or four feet long, one end being split to the middle into two tails for amputations of the upper arm and thigh, and into three tails for those of the forearm and leg below the knee. In the former case the tails are wound around the bone, and crossed ; in the latter, the middle tail is thrust between the bones and the others are disposed of as before ; both ends of the retractor are then grasped by an assistant and firmly drawn upwards, so as to answer the double purpose of retracting the muscles from the bone and of protecting the soft parts from being injured by the saw. The muslin retractor is made fresh for every case; certainly a cleaner and better plan than to use the leather retractor of Gooch^Bromfeild, 2 and others of our predecessors. Sutures. — Great diversity of opinion has prevailed at different times as to the propriety of using sutures in the dressing of amputation wounds. The ancients employed them as one of the means of arresting hemorrhage, and they continued to be thus used until the general adoption of the ligature; and the eminent surgeon of Guy's Hospital, Samuel Sharp, or Sharpe — he spelt his name both ways — revived the use of the "cross-stitch" (an old device employed by Pare and Wiseman), to prevent retraction of the soft parts and consequent protrusion of the bone, and in both his "Treatise on the Opera- tions of Surgery," and his "Critical Enquiry," lauded it as not less valuable for this purpose than the "double incision" of Petit and Cheselden. < (ther surgeons have reprobated the use of sutures altogether, preferring to secure approximation of the edges of the wound by the use of compresses and bandages, or by the employment of adhesive plaster. There can certainly be nothing more injudicious than to sew up a stump tightly, as if to hermetically seal it, without making any provision for the escape of effused fluids, <»r allowing for the unavoidable occurrence of swelling; such a mode of dressing the wound will, in the course of a few hours, probably send up the patient's pulse and temperature in an early development of traumatic fever, and it will be fortunate if the mistake is discovered in time to cut out the offending stitches before sloughing is inevitable. But provided that there is tissue enough to cover the bone without making tension, and that ample drainage is afforded either by the ligature ends or by the introduction of a tube, sutures may be properly employed after amputation, and present, I think, many advantages over other methods of closing the wound. The best material for the suture is, I think, silver, lead, or malleable iron wire; catgut is unsatisfactory, as not keeping its place for a sufficient length ' Cases and Practical Remarks in Surgery, vol. ii. p. 330. Norwich, 1767. 2 Chirurgical Observations and Cases, vol. i. p. 152. London, 1773. vol. i.— 37 578 AMPUTATIONS. of time, while the metallic has the great advantage over the silk or hemp suture, that it can be loosened by untwisting, if there be too much tension of the part, without being entirely withdrawn. Indeed I make a practice, at the first renewal of the dressing after an amputation, of trying every suture point in succession, and untwisting it a little, if it seems to be applied too closely. The form of suture adapted for amputation wounds is the interrupted suture, and its points should be at least half or three-quarters of an inch apart. If silk be employed, it is tied in a reef-knot (as in the case of liga- tures), but if wire be used, it is twisted with four or five turns, and the ends then cut smoothly off; it is well to take the precaution of twisting all the stitches in the same direction, for greater convenience in untwisting if this should be found necessary. Needles. — The ordinary " surgeon's needle" (Fig. 141) answers every pur- pose in introducing the sutures after amputation, whatever material for the suture be employed. The needle should be rather large, strong, and either straight or but slightly curved. It should be provided with a lance-point, that it may readily penetrate the tissues, and should have a large eye that it may be threaded without difficulty. Needles are made, to be used with wire, with a groove on either side at the eyed end ; but the wire very seldom rests in the groove, and the advantage of this modi- fication is more in theory than in reality. Other needles have been made with a female screw worked in the blunt end, for the wire to be screwed into it ; but the wire is apt to become detached at inconvenient moments, and upon the whole I am disposed to regard the old- fashioned needle as quite as satisfactory as any of its substitutes. If the naps be unusually thick, it may be convenient to employ a needle with a handle, and an eye near its point (Fig. 142), like that employed in the opera- Fte. 142. J.H.GEMRIG. Various forms of needle. Needle with eye near point. tion of strangulating a nsevus. The wire with which a needle is armed should be about eighteen inches long, and should be passed through the eye for an inch or an inch and a quarter of its length, and then folded evenly upon itself, without twisting ; its thickness should be in proportion to the size and weight of the flaps which it is intended to hold together, and it should be flexible and smooth, and quite free from kinks. Fig. 143. Dissecttno Fokcei'S (Fig. 143) are employed to si >ize projecting nerves or tendons which may require to lie cut oil, and to aid in adjusting the sutures. OPERATIVE METHODS EMPLOYED IX AMPUTATION. 579 Scissors of various sizes and shapes are used in an amputation. There should be one pair, strong, and with blades set at an angle (Fig. 144;, for cutting plasters and bandages; a pair of ordinary "surgical scissors," sharp 144. Fig. 145. o Bandage scissors. Scissors curved on the flat. and strong, for cutting ligatures and sutures; and a third pair, with blades curved on the fiat (Fig. 145), also sharp and strong, for retrenching protruding nerves, tendons, and masses of fascia. Besides the various instruments required for an amputation, and the neces- sary dressings, the surgeon should see that there are in readiness plenty of clean sponges of a convenient size; warm and cold water; a hot-water can or spirit-lamp, for boating strips of adhesive plaster, if the ordinary officinal plaster is to be employed — what is sold as the " American Surgeons' adhesive plaster," though somewhat more expensive, is a more convenient article, adhering without being warmed ; an efficient styptic for controlling capillary hemorrhage ; and a little white wax for plugging the medullary cavity of the bone, if that should be the source of troubjlesome bleeding. Operative Methods Employed in Amputation. All the various methods of amputating may, as heretofore mentioned, be regarded simply as modifications of the two principal modes already referred to, the flap and the circular. Thus the oval operation, as perfected bv Scou- tetten and Malgaigne, is a variety of the circular method, while the different plans of Sedillot, Teale, Lee, Stephen Smith, etc., may all be considered as modifications of the flap operation. Circular Method. — M. Fort, one of the most recent French writers on operative surgery, enumerates no less than seven varieties of the circular operation, distinguishing them as the procedures of Alanson, Benjamin Bell, Brunninghausen, Desault, Louis, Malgaigne, 1 and J. L. Petit. The peculiari- ties of most of these methods have been sufficiently indicated in the section devoted to the History of Amputation, 2 and I may add here that the special feature of Brunninghausen's plan consisted in dissecting up a cuff of skin, as done by Hey, Bell, and Alanson, and then cutting the muscles and bone on the same plane, and that of Malgaigne's operation in combining the pecu- liarities of both Desault's and Bell's 'methods, making thus what he called a "quadruple incision." 3 The circular operation, as ordinarily practised at the present day, is in all essential particulars the operation of Hey, Bell, and Alanson, and is performed as follows : — The part to be operated upon having been washed and shaved, and the patient being thoroughly under the influence of an anaesthetic, he is brought 1 Malgaigne himself enumerated nine methods, exclusive of his own. 2 Vide supra, pp. 557, 558. 3 Manuel de medecine operatoire, 3e 6dit. p. 290. Paris, 1S40. 580 AMPUTATIONS. to the side or foot of the hed or operating table, in such a way that the limb to be removed shall project fairly over the edge. The patient should be well protected from the cold, and a coarse blanket, or a tray containing bran or saw- dust, should be placed on the floor to catch the blood. The circulation is then to be controlled by the adjustment of the tourniquet with or without Esmarch's tube, as already described, or in certain situations by the pressure of an assistant's finger, or by means of a wrapped key, as will be particularly explained when we come to speak of amputations at the shoulder. If the application of the tourniquet is entrusted to an assistant, the surgeon should at least see for himself that the compress is accurately placed over the main vessel, and that the strap is drawn sutficiently tight for the pulsation of the artery below to be arrested by a few turns of the screw. The circulation being under control, one assistant is deputed to take special charge of the tourni- quet, a second to manage the anaesthetic, and a third to hold the limb in whatever position may be convenient for the operator. A fourth assistant may hand the instruments, or, which I prefer, these may be arranged in a tray at the surgeon's right hand, in the order in which they are to be used, so that he may readily help himself. The operator should stand with his left hand towards the patient's trunk; thus in amputating the right lower extremity, the surgeon stands at the patient's right side, while in removing the left leg or thigh he stands between the patient's limbs. In amputating the right arm^ he stands facing the patient's feet ; but in amputating the left arm, he faces the patient's head. Almost all of the older surgeons, beside the fillet or band with which they tried to control the circulation, before the invention of the tourniquet, applied other bands, one above and one below the point at which the limb was to be removed ; these were to serve the triple purpose of numbing the patient's sensibility, of preventing the muscles from slipping or being jerked away from the knife, and of furnishing a guide for the surgeon's incision. But, as Bichat 1 very justly observed, with a good eye and a sharp knife (and every surgeon should possess both of these), such clumsy helps to the operation are quite unnecessary. In making his first incision, the surgeon should steady and draw the skin of the patient's limb upwards with his left hand, while, stooping somewhat, he carries his right hand, holding the long knife, around the limb, so that the back of the knife shall be directed towards his own face. Sinking the heel of the knife then firmly into the flesh, he makes a circular sweep around the part, rising as he does so, and thus completes the whole, or nearly the whole, of the cutaneous incision with one motion. A few light touches with the same knife, or with a scalpel, serve to tree any points at which the skin may be still adherent, and permit considerable retraction to be at once effected. If the limb be slender, this degree of retraction maybe sufficient, but it is usually necessary to dissect upjby rapid strokes of the knife, a cuff of skin and fascia, about half as long as the limb is thick. The first incision should go completely down to the "muscles, and, in dissecting up the cuff, the edge of the knife should be kept constantly directed towards the deeper structures, as otherwise the nutritive vessels of the skin will be endangered, and slough- ing will he apt to follow. If the limb be conical (as in the calf of the leg), there will be great difficulty in reflecting the dissected cuff, and the surgeon will then find advantage in making a longitudinal incision on one or the other side — a modification of the ordinary procedure which ISedillot 2 attributes to Lacauchie. This incision supplies a convenient point for bringing out the 1 (Euvres chirurgicales do P. J. Desault. Seoondo partie, p. 490. Paris, 1798. 2 Traito de inedecino oplratoire, tomo i. p. 3122. Paris, 1853. OPERATIVE METHODS EMPLOYED IN AMPUTATION. 581 ligatures, and, if it be made in a somewhat dependent position, servo also as an excellent avenue for drainage. When the skin cuff lias been evenly dis- sected back to a sufficient height, the surgeon again applies the long knife, as before, and cuts through the muscles quite down to the bone. A wide gap is instantly produced by the retraction of the divided muscles, but it still remains to sever their attachments to the periosteum, and to push them up- wards, either with the finger or the handle of the scalpel, so as to leave the bone bare for the extent of about two inches. If the limb contain two boms, the interosseous tissues are divided with the scalpel, or with a narrow, double- edged catlin, and the adjoining surfaces of the bones cleared in the way already described. The retractor is next adjusted — its middle tail, in the case of the forearm or leg, being thrust between the bones with the finger, the handle of a knife, or a pair of forceps — its body carefully spread out over the soft parts, its tail- crossed, and the whole firmly drawn upwards by an assistant. The next Btep is the sawing of the bone, which is to be done at the highest point at which this has been exposed. (Fig. 14(5.) Some writers lay great stress upon the Fi°r. 146. Amputation of arm by circular method. importance of dividing the periosteum with the knife, before applying the saw ; but I must confess, to a belief that in practice this is more often talked about than done. Tho saw should be held lightly at first, and drawn hack- wards (from heel to point) so as to make a groove for itself, and thus avoid splintering the bone; if there are two bones, they are, usually, divided simultaneously, or, if this cannot conveniently be done, the smaller before the larger. Roux and Malgaigne advise, however, and I think with reason, that, in the case of the leg, the tibia should be divided first, and then the fibula at a point about half an inch higher. It is usually directed that the saw should be held vertically, so that the bone may not he broken through by the weight of the limb before its section has been completed. For tire same purpose, the assistant who has charge of the limb should hold it up firmly and not allow it to drop, but at the same time should not elevate it bo much as to make the saw bind. As soon as the limb is off, the surgeon turns his attention to the cut ves- sels, taking up first with forceps or tenaculum the principal arteries, and afterwards securing the muscular and other small branches, loosening the tourniquet for a moment, if necessary, that the gush of blood may indicate their position. If, as I have advised, the Esmarcn tube be used in addition 582 AMPUTATIONS. to the tourniquet, the latter should be screwed down, and the former removed, as soon as the principal vessels have been ligated. Some difference of opinion exists among surgeons as to the advisability of tying veins after an amputa- tion ; while not often necessary, it is so occasionally, for large veins will sometimes bleed profusely even after the removal of the tourniquet ; and the risk of phlebitis and pyaemia which was formerly supposed to be incurred by tying a vein, has been over and over again shown to be purely imaginary. My own practice is to tie them, often indeed including the artery and its vencs co mites in the same ligature, or, in the case of such a large vessel as the brachial or the femoral, tying the artery first separately, and then throwing a second ligature around it and the vein together. The surgeon having secured all the vessels that can be found bleeding, the surface of the stump may be washed with a styptic, in order to check any capillary oozing which may still persist ; various substances may be used for this purpose, such as the " Aqua Pagliari," or the "Aqua Binelli" — the former containing benzoin and alum, 1 and the latter no less than twenty-six different astringents or aromatics of vegetable origin 2 — or, which is as efficient and at least as convenient as any other, simple diluted alcohol. Before closing the wound, the surgeon examines the sawn end of the bone, and, if any projecting spicula has been left, cuts it off with the pliers; he also retrenches any tendons or nerves that hang from the end of the stump, by drawing them out with the ordinary dissecting forceps, and snipping them off with scissors curved on the flat. If bleeding proceed from the bone itself, it may be most conveniently arrested by arming a pellet of softened white wax 3 with a wire (to facilitate withdrawal), and then pressing it firmly against the bone so as to plug its medullary cavity; the wax may be removed at the first or second dressing of the stump, coming away without difficulty along- side of the ligatures. If a vessel in the periosteum bleed, and cannot' be tied, it may be secured by acupressure, applied either by the Aberdeen or "twist" method, or by the third method of Sir J. Y. Simpson. The stump being at length dry, the ligatures are disentangled from each other, and brought out in one or more bundles as may be found convenient. The skin cuff is then drawn down over the face of the stump, and the wound is closed with sutures, converting the circular into a linear incision, and in any direction which the operator may prefer — horizontal, oblique, or vertical — it makes very little if any difference which be chosen. Modified Circular Operation. — This mode of amputation (Fig. 147), which affords an excellent stump, appears to have been suggested more than fort\- years ago by the late Mr. Liston, 4 and was, with an important modifi- cation, extensively practised afterwards by the late Mr. Syme. 5 Liston's plan was to make two semilunar flaps of integument only, divide the muscles by a circular incision where the skin flaps joined, and saw the bone as in the ordinary circular method; Syme's modification consisted in dissecting up a cuff of Bkin for some distance above the point of junction of the semilunar flaps. In either form the procedure may he looked upon as an ordinary cir- cular operation, in which the cuff of skin has been slit upon both sides, and the angles trimmed off'. It is particularly adapted for operations on muscular 1 Bulletin de Therapeutique, t. xlii., ami Sedillot, op. oit. p. 218. 2 Bouchardat, Annuaire de Therapeutique pour L843, p. 227. 3 Riedinger prefers a plug <>f oatgut, while others employ a pledget of lint or a plug of wood. Wax, however, seems to me to lie the best material. 4 Elements <>( Surgery (1840), edited by Prof. S. I). Gross, p. 642. Philadelphia, 1846. 6 Principles of Surgery, 4th edition, pp. 148, 149. London, 1806. OPERATIVE METHODS EMPLOYED IN AMPUTATION. 583 limbs, where it fully merits Mr. Skey's 1 encomium, that it "is really a good operation," and I prefer it to any other for amputations at or above the middle of the thigh. Amputation of thigh by modified circular method. Elliptical Operation. — This, which is often spoken of as a variety of the oval method, and, on the other hand, as a modification of the operation by a single flap, is attributed by Sedillot, Guerin, and other French writers on Operative Surgery, to a Belgian surgeon, Soupart, of Liege, but was practised Fie. 148. Amputation at elbow by elliptical method. as an improvement on the circular method, in amputations below the knee, by Sharpe, 2 of Guy's Hospital, in the middle of the last century. Ir is par- ticularly adapted to amputations at the knee- and elbow-joints, and especially the latter. (Fig. 148.) The incision constitutes a perfect ellipse, coming bel< m the joint, on the least vascular side, by a space equal to the diameter of the limb, and the resulting flap being folded upon itself, so as to make a short i Operative Surgerv, page 309. Philadelphia, 1 Sol. 2 Treatise on the Operations of Surgery, page 226. Ninth edition. London, 1 i 69. 584 AMPUTATIONS. curved cicatrix on the side of the vessels, thus making an excellent, non-ad- herent covering for the bone. Oval Opekation. — The oval operation, or that of Scoutetten, may be regard- ed as a modification of the circular method, the skin cuff being slit upon one side, and the corners trimmed off. Occasionally practised in the latter part of the last and at the beginning of this century, by Lassus, Larrey, Guthrie, and other surgeons, this mode of ampu- tating was first reduced to a system by Scoutetten, of Lille, in 1827. 1 We may recognize two sub- varieties of this operation (Fig. 149):— (1) Method of Scoutetten..— In this (Fig. 149, A), an incision is begun on the outer side of the limb, and carried obliquely downwards for a distance about equal to its diameter ; then continued trans- versely across the inner side of the limb (or that which contains the great vessels), and obliquely up- wards again to meet the first incision at an acute angle. Or the same object may be accomplished by making first two oblique incisions, resembling an inverted ^, and joining them below by a transverse cut. (2) Method of Malgaigne.— This (Fig. 149, B), which is called by French writers the operation en raquette, from the " racket-shaped" form of the wound, is preferable as affording a better cov- ering for the bone at the upper part of the incision. Malgaigne particularly recommended this operation for ampu- tation of the thumb, but it i$ equally applicable to other parts ; it consists in making a longitudinal incision on the outer side of the limb, extending a short distance above and twice as far below the point at which it is intended to amputate; the lateral branches of the oval incision are made to start from the junction of the middle and lower third of the longitudinal incision. In both of these varieties of the oval method, the wound is brought together in a longitudinal direction, the operation herein differing widely from the elliptical method described above, in which the resulting cicatrix is a transverse one. Amputation of fingers by oval method. A, method of Scoutetten ; B, method of Malgaigne (en raquette). Sixole Flap Operation. — This was the original method of Lowdham, and, as improved by Verduinand Garengeot, may still be occasionally resorted to with advantage. In most cases, no doubt, either the double flap or the cir- cular operation, or <>ne of the modifications of the latter which have already been referred to, will enable the surgeon to obtain sufficient covering for the bone while dividing it at a lower point than could be done were the flap to be taken altogether from one side; but it may well happen, in a case of com- pound fracture or laceration, from violence by railway or machinery, or in a case G4. According to Lisfranc (op. cit., tome i. p. 744), who always liked to differ from Velpeau, the oval operation originated with Le Dran ; but 1 can find no ac- count of it in my copy of the latter author's work (Paris, 1742). OPERATIVE METHODS EMPLOYED IN AMPUTATION. 585 surgeon should take his flap from the sound part exclusively, and will thus probably be enabled to preserve a greater length of the affected limb than he could in any other way. The circulation being controlled in the ordinary manner, the surgeon, with a strong and rather short knife, begins his incision on the lower surface (so that the path of his knife may not be obscured by the flow of venous blood), and marks out a tolerably square, or at least not a pointed, flap, which should embrace, beside the skin and fascia, part or all of the subjacent muscular layers, according to the thickness of the part. This flap is rapidly dissected up, and the section of the soft parts completed by making a transverse or slightly curved incision, convex forwards, through the tissues on the other side of the limb. The bone is next cleaned by a few touches of the knife, the muscles pushed upwards and the retractor adjusted, and the amputation then completed as in the circular method. The single flap operation may also be done by transfixing the limb with a long knife, and cutting from within outwards; but the flap can be better shaped, by pur- suing the other plan, and where there is no superabundance of available tissue, as in the cases which I have supposed, it will certainly be preferable. The single flap operation is thought by Prof. Spence, of Edinburgh, to be in most cases preferable to any other. It is also employed by Carden, of Worcester, and by Wharton, of Dublin. Double Flap Operation. — Of this method we may recognize several varie- ties, as Ravaton's, Vermale's, Sedillot's, Langenbeck's, Teale's, and Lister's. (1) Ravaton's meth od consists in making a circular incision down to the bone, and then adding a longitudinal incision on either side, so as to make two flaps, each half the thickness of the limb. In this form, the operation is seldom if ever resorted to at the present day, the flaps being unwieldy, and the protruding muscles causing an undesirable degree of tension when they are brought together. (2) Vermale's method is the ordinary double-flap operation of modern times. In employing this mode of amputating, most writers, following List on, 1 advise that the surgeon should stand with his left hand towards the part to be removed; my own practice, however, has been to adopt the same position as that which I have recommended for the circular operation, entrusting the entire care of the limb to an assistant, and keeping the left hand towards the patient's trunk, ready to grasp the artery if by any chance the tourniquet should slip. This plan is in accordance with the advice of Malgaigne, 2 and I feel sure that it will be found the most satisfactory. The patient having been prepared for the operation in the way described when speaking of the circu- lar method, the surgeon with his left hand grasps and slightly raises the tissues of which the flap is to be formed, and then, keeping (as advised by Lisfranc) 3 his right elbow close to his body, introduces the long pointed knife at the side of the limb which is nearest to himself; then pusning it around and across the bone with a firm but gentle movement, and somewhat elevating the handle of the instrument after the point has passed the hone, he completes the transfixion of the limb by bringing the knife out at a point diametrically opposite to that at which it entered. Keeping the blade now in a plane cor- responding to the long axis of© the limb, he forms his first flap by cutting with a rapid sawing motion, at first in a longitudinal direction, and then obliquely towards the surface. The flap thus made, which should have a o i Op. oil., p. 637. 2 Op. cit., p. 295. 3 Precis de Medecine operatoire, tome i. p. 737. Paris. 1845. 586 AMPUTATIONS. length of at least half the diameter of the limb, is then turned back and entrusted to an assistant, while the surgeon re-enters his knife at the point of original puncture (this time passing on the other side of the bone), brings it out as before, and cuts the second flap, which in shape and size should be as closely symmetrical as possible to that first formed. (Fig. 150.) The retractor is next adjusted; any remaining fibres divided by a few touches of the knife; and the bone sawn as in the circular operation. Fig. 150. Amputation of forearm by double-flap method. If the flaps are made antero-posteriorly, the anterior flap is usually formed first ; if lateral flaps are preferred, the outer should be made before the inner. The general rule is that that flap should be last cut which contains the prin- cipal artery. (3) Sedillofs method, which that author describes as a " mixed procedure," 1 differs from Vermale's, in that the surgeon, instead of making his knife " hug" the bone, keeps the instrument away from it in transfixing the limb, so as to include but a small portion of muscular tissue in each flap; the remaining muscles, together with the great vessels, are then divided by a cir- cular incision, and the rest of the amputation completed as in the ordinary circular method. The flaps are somewhat shorter, as well as thinner, than those of Vermale's operation, which is certainly an advantage if the limb be a very large one. I have, in amputating the thigh, sometimes varied Sedil- lofs procedure by cutting superficial flaps from without inwards, as in Lan- genbeck's method, and then completing the operation by a circular sweep of the knife, in the ordinary way. The stump which results from Sedillofs plan of operating, closely resembles that obtained by the modified circidar method, over which it does not appear to me to present any marked supe- riority. Some surgeons, having regard to the gradual atrophy of muscular tissue which always occurs in a stump, attempt to save, as they think, time and trouble, by making their flaps from skin only; but not only is there consid- erable risk of the Baps sloughing, under these circumstances, hut the stump thus obtained is less serviceable than when the flaps contain muscle also; for 1 Op. cit., tome i. p. 331. OPERATIVE METHODS EMPLOYED IN AMPUTATION. 587 although it is a fact that the true muscular substance gradually disappears IV' mi a stump, the fibrous sheaths of the muscles remain, and, becoming condensed into a thick and resisting mass, form a useful pad for protecting the Bawn extremity of the bone. (4) Langenbeck's method, which has already been incidentally mentioned, consists in cutting double flaps from without inwards. This plan presents the advantage of enabling the surgeon to shape his tlaps more accurately, and to better insure their symmetry, than when they are formed by transfixion. In making antero-posterior tlaps by this method, the posterior flap, contrary to the rule before given, should be cut first; the reason for this is that if the hinder flap were left to be formed last, the line of incision would be obscured by the blood flowing from the anterior portion of the wound. Langenbeck's method may sometimes be advantageously combined with Vermale's, one flap being cut from within outwards, and the other by trans- fixion ; in some localities, as the leg, this is the plan ordinarily adopted, the subcutaneous position of the tibia rendering it very difficult to cut an ante- rior flap here except in this way. This combination-flap method is also very well adapted for amputations of the thigh just above the knee. Another combination of these two methods was practised by Dupuytren and Larrey, who cut through the skin from without inwards, and then completed their flaps by transfixion. 1 (5) Teak's Method, or Amputation hy a Long and a Short Rectangular Flap. — This mode of operating, which unquestionably affords a most admirable stump, was first practised by its inventor, the late Mr. Teale, of Leeds, in June, 1855. 2 There are two flaps cut from without inwards, as in Langen- Fkr. 151. Amputation of forearm by Teale's method. beck's method, but with the peculiarity that they are rectangular, and that while they are equally wide, one is just four times as long as the other | Fig. 151). The long flap is taken from the side of the limb on which there is 1 Lisfranc, op. cit., tome i. p. 733. 2 On Amputation by a Long and a Short Rectangular Flap. F.R.C.S., etc., page 13. London, 1858. By Thomas P. Teale, F.L.S., 055 AMPUTATIONS. least muscular tissue, and which does not contain the principal vessels ; both flaps include all the structures down to the bone. The surgeon begins by ascertaining, with a piece of string or tape-measure, the circumference of the limb at the point at which it is to be removed ; half of this circumference - gives the dimensions in each direction of the long flap, which must represent a perfect square. This flap having been marked out upon the limb with ink or crayon, the dimensions of the short flap are similarly indicated, its width being likewise half the circumference of the limb, but its length only one-eighth, or one-fourth the length of the long flap. It is very important that the flaps should be accurately marked out upon the limb before beginning the operation, as- otherwise, when taken from a conical limb, the long flap will almost certainly be cut narrower at its extremity than at its base. The long flap is cut first, with a strong, short knife ; turned up, and given in charge to an assistant ; the short flap being made, the retractor is applied, and the rest of the operation completed as in the circular method. In closing a " Teale stump" with sutures, the ends of the flaps must be first brought together, and the lateral wounds sewed up subsequently. (Fig. 152.) Fig. 152. Stump resulting from amputation by Teale's method. The advantage of this mode of amputating is that it furnishes a firm cushion of soft tissues to cover the end of the bone, and that it allows the cicatrix to be entirely withdrawn from pressure in the adjustment of an arti- ficial limb ; its disadvantage is that, when the limb is a large one, the peculiar form of the flaps requires the bone to be sawn at a much higher point than would otherwise be requisite, and thus not only gives a very short stump, but, at least in the case of the thigh, considerably enhances the danger of the operation. Tims, in a case of injury, should the laceration of the soft parts extend as high as the patella, and the thigh be six inches in diameter — not by an}' means an excessive measurement — the long flap would have to be nine inches square (half the circumference), and the bone, instead of being divided in its lower third, as it would be in the circular or the ordinary double-flap operation, would be sawn above its middle, and the risk to the patient thus materially increased. In order to obviate this disadvantage of Teale's method, the next plan to be described was suggested about twenty years ago by Prof. Lister, then of ( Uasgow, but now of King's College, London. (0) Lister's Method. — This mode of amputating was originally recom- mended by its distinguished author for operations in the thigh and leg only, but it is equally applicable, as I have found by experience, in other situations also. Lister's operation niav be described as something midway between that of Teale and the old operation of Ravaton. In the latter, as will be remem- OPERATIVE METHODS EMPLOYED IN AMPUTATION. 589 bered, the flaps were rectangular, and of equal length ; in Teale's operation, they are likewise rectangular, but the outer or anterior flap is four times aa long as the other. Prof. Lister's suggestion is that the flaps shall be so pro- portioned that the line of cicatrix shall come just beyond the edge of the bone, while this can be left considerably longer than in the Teale operation ; for the thigh and leg, he directs that the principal flap shall have a length of one-third of the limb's circumference, and that the length of the smaller flap shall be one-half that of the larger. He also rounds oft', somewhat, the angles of the flaps, and makes the posterior flap of skin and fascia only. I have employed this form of amputation, or at least one embracing the same prin- ciples, in the upper extremity, and with excellent results; I have preferred, however, to keep the rectangular form of the flaps, as in Teale 's method, and to make both flaps include muscle as well as skin and fascia. Relative Advantages of Different Modes of Amputating. — In the writings of the older surgeons may be found frequent controversial disquisi- tions on the alleged superiority of one or another mode of amputating over all other plans, and it is within my own recollection that some distinguished operators never resorted to any but the circular incision, while others as invariably employed some variety of the flap method. For my own part, I have long been convinced, both by individual experience and by operations which I have seen done by others, that the particular form of operation chosen, is of comparatively slight importance: provided that sufficient cover- ing be secured for the bone, it matters little whether that covering be in the form of a circular or oval cutf, or of one or two flaps, or whether the corners of the latter be angular or rounded. I shall not dispute, with Liston, 1 the judgment of those "philosophers of the modern Athens/' who provoked his wrath and sarcasm by asserting that the wound-area of a cir- cular amputation was less than that exposed by the flap operation ; nor shall I deny that the arteries are apt to be cut obliquely in removing a limb by the latter method ; but, though I confess to a growing fondness for the old- fashioned circular incision, and find myself employing it more commonly year by year, when the special circumstances of the case do not render it less desirable than some other procedure, yet I cannot conscientiously say that I think that the form of operation adopted exercises any marked influence upon the result. The judgment manifested in determining whether an ampu- tation shall or shall not be performed, and the care taken in the after-treat- ment of the patient, are of much more importance. At the same time, the operation which may be best adapted to one parti- cular case, may be less well suited to another; and the surgeon should be sufficiently familiar with all the methods which have been described, to enable him to choose that which is most appropriate in the special circum- stances with which he is concerned. If I were to give any general rule. I should say that for the forearm, the circular operation was the best, and for the upper arm, either that or the modified circular; the latter operation I should prefer for the upper part of the thigh, and either it or the simple circular for the lower part of the leg ; for the lower part of the thigh, and for the ?//>/« r part of the leg, I should recommend the flap method — antero-posterior flaps being chosen in the former, and an external flap in the latter situation. The oval and elliptical operations are particular! y well fitted for amputations at the joints, while the single-flap and Teale's or Lister's methods will serve a useful purpose where the disease or injury involves less of the tissues on one side of the limb than on the other. 1 Op. cit., p. 642. 590 AMPUTATIONS. Simultaneous or Synchronous Amputations. It not unfrequently happens that, as the result of injury or disease, two or even more limbs in the same patient may be so hopelessly disorganized as to call for amputation. Should both or all the operations be done at once? or should the patient be allowed to recover from the effects of one operation before another is attempted? That French surgeon, Faure, against whom Velpeau 1 directed the shafts of his sarcasm, and who proposed that the sur- geon should do a single amputation by slow and easy stages, stopping to rest for four or five days after each, and thus prolonging the whole duration of the operation for a fortnight or so, would no doubt have advised without hesita- tion that but one operation should be done at a time ; and in certain cases this advice would be judicious. Thus, in a patient suffering from chronic bone-and-joint disease, scrofulous or syphilitic, it may be good practice to remove the part which causes most suffering, and postpone further operative interference for months, or even years ; for even if the other affected parts should not recover themselves (which is always possible), the patient's life would be less endangered by successive operations performed at considerable intervals, than by two or more amputations performed at the same time. Even in cases of gangrene following frost-bite — a not unfrequent cause of double amputation — it may be proper to remove one of the affected members as soon as the line of separation is established, and to postpone the second operation until the patient has recovered from the first. But in most cases of double or multiple injury, requiring amputation, at least in civil life, the only hope of the patient lies in prompt removal of all the crushed parts. In military surgery, it is somewhat different; gunshot fractures of limbs are often attended with less immediate danger than simi- lar compound fractures resulting from other causes, in which the soft parts are more involved ; and hence the army surgeon may be justified in amputa- ting only the worst-hurt limb, at first, and in treating the other for a time ex- pectantly, even though he may feel sure that a secondary operation will event- ually be required. The prospect of recovery under these circumstances is of course greater than when several limbs have to be removed simultaneously, and hence most of the successful multiple amputations recorded have occurred in military practice. Quadruple amputations, or amputations of both upper and both lower extremities, have proved successful in the hands of Dr. Alfred Muller, Acting Assistant Surgeon, U. S. A., Dr. Begg, of Dundee, and M. Champenois, a surgeon of the French army. Other cases are referred to by Morand, by Prof. Longmore, and by Soutliam of Man- chester, and two are mentioned by H. Larrey, one patient having been seen at the " Invalided," i" Paris, and the other in Algiers. In none of the eight cases do all the operations appear to have been synchronous, though in Champenois's case three limbs were removed on one day, and the fourth two days afterwards. Dr. Koehler, of Schuylkill Haven, Pennsylvania, has recorded a successful synchronous, triple amputa- tion (both legs and one arm) in a boy of thirteen, and similar cases are attributed by Prof. Agnew 2 to the late Dr. Stone, of New Orleans, and to an unnamed surgeon of York, Pennsylvania. Another successful triple amputation (not synchronous) has been reported by Leseleuc, of Brest. J. Ritter has reported two cases of triple ampu- tation for gangrene following frost-bite, and other triple amputations have been recorded by Marten, Bruberger, and Field, of Texas. Double synchronous amputations are not very rare, but (except when the feel "i- hands only are involved) are, unfortunately, not usually successful; 1 Op cit., tome ii. p. 3.06. 2 Principles and Practice of Surgery, vol. ii. p. 374. pi. hi. tisF&M £ijuclW^ucm>CtmfmUtUmi of tcf( tVg euui ucjlU Hip jmul c 1\«h « paUeul iu {fie C?6x*{vil«*£ of Hie %mv*,.u1.j of !'4\:im.Hjfvmtia . SIMULTANEOUS OR SYNCHRONOUS AMPUTATIONS. 591 eleven such cases, under my own care, have given seven deaths and but four recoveries. In one of these, the right thigh and left leg were simultaneously removed for railway injury by my friend and assistant, Dr. II. R. Wharton; the patient, who was an adult, recovered without a single unfavorable symp- tom. Another case, which has furnished the subject of the accompanying plate (Plate III.), is worthy of being narrated in more detail : — George , aged fifteen, was admitted to my ward in the University Hospital, while I happened to be in the building, on the afternoon of June 4, 1879, having a short time before fallen from and been run over by a train on the Philadelphia, Wil- mington and Baltimore Railroad, which passes not far from the hospital. The ri^ht limb had been absolutely torn off above the knee, the femur being badly shattered and the skin and fascia completely separated as far up as the groin. The left leg was also crushed in its lower third, both bones broken obliquely, and the soft parts greatly lace- rated. Slow but steady bleeding was going on from the left leg, while on the right side it was only restrained by digital compression of the iliac artery, which had been promptly instituted by Dr. Palmer, the house surgeon, with the aid of two or three senior students who were in the ward when the patient was brought in. Notwithstanding the lad's apparently desperate injuries, I found him in a condition which, while far from pro- mising, did not absolutely forbid an operation, and — surgical instinct forbidding non- interference while hemorrhage was actually present — I determined, with the skilful assistance of Dr. R. A. Cleemann, who was visiting the hospital with me, to amputate. Bleeding being temporarily controlled by a pair of Esmareh's tubes, rolled one around the left leg and the other around the stump of the right thigh, the patient was carefully etherized, and then, having adjusted a Lister's aortic compressor so as to command both iliac arteries, I amputated at the right hip-joint, cutting antero-posterior flaps from without inwards, as in Guthrie's method, making the posterior flap first, and being obliged to include, in the anterior, a good deal of the skin which had been torn up and separated in the original injury. The vessels having been secured, a fold of oiled lint was temporarily placed between the flaps, and then, finding that the patient's pulse per- mitted it, I turned to the left leg, which I immediately amputated at its middle by the modified circular method. Both the elastic tube and the tourniquet were used on this limb, in the way described on page 570. All bleeding vessels having been tied, both wounds were closed with silver wire sutures, and simply dressed with lint soaked in olive oil (not carbolized), covered with oiled silk, and kept in place with adhesive strips and roller bandages. During the operations, I had an assistant give repeated hypodermic injections of ether — a syringe-full at a time — and I find by my notes that it was estimated that a fluidounce of ether was consumed in this way. After the patient was put to bed — for I had operated while he lay on the stretcher on which he had been carried to the hos- pital — the ether injections were continued until he had rallied enough to be able to swallow, and then five grains of carbonate of ammonium were given by the mouth every half hour until thorough reaction had occurred. This was further promoted by the use of external heat, and, though the patient seemed almost moribund when the operations were completed, his condition rapidly improved, and his convalescence from that time proceeded without an unfavorable symptom. An alcoholic dressing was sub- stituted for the oiled lint after the first forty-eight hours; the last ligature came from the leg-stump on the eighth, and the femoral ligature from the hip-wound on the twelfth day. The patient was kept in hospital until January, 1880, his wounds having then been entirely healed for about four months. As far as my reading goes — and I am confirmed by the opinion of un- valued friend the late Dr. G. A. Otis, Surgeon U. S. Army, whose familiarity with the literature of hip-joint amputation was probably greater than that id' any man now living — this is the only case recorded in which a successful primary amputation at the hip-joint has been performed synchronously with another major amputation. Among my unsuccessful double amputations, I count two cases in which the right arm was removed at the shoulder-joint, in one, in connection with amputation in the lower third of the left leg, and in 592 AMPUTATIONS. the other in connection with amputation of the left upper arm at its middle. Besides cases of double major amputation, I have twice had occasion to remove portions of both feet (in one instance the whole foot, on one side) for gangrene resulting from frost-bite; in both of these cases the patients recovered. The particulars of all the cases referred to are compendiously shown in the an- nexed Table: — Table Showing the Particulars of Eleven Cases of Double Synchronous Amputation. No. Sex and Age. Nature of Lesion. Operation. Result. Date. Remarks. 1 Male Crush of both Amputation of right leg at Died in 1865 Episcopal aged 5 lower extremi- middle (circular) and left 3 hours Hospital. years ties thigh at upper third (modi- fied circular) 2 Male Crush of both Amputation of both legs at Died in 1866 do. aged 35 lower extremi- knee (flap) 8 hours years ties 3 Male Crush of both Amputation of right arm at Died in 1867 do. adult upper extremi- ties middle (circular) and left arm at upper third (oval) 3 days Injuries of head also. 4 Female Frost - bite of Amputation of both feet Recovered 1871 Episcopal adult both feet through metatarsus (an- teroposterior flap Hospital. 5 Male aged 49 years Frost - bite of both feet Amputation of right foot through metatarsus (flap) and left foot at ankle (Syme) Recovered 1876 do. 6 Male Avulsion of right Amputation at right hip- Recovered 1879 University aged 15 and crush of joint (flap) and of left leg Hospital. years left lower ex- tremity at middle (modified circu- lar) 7 Male Crush of right Amputation of right leg at Died in 1879 do. adult leg and left foot middle (modified circular) and left foot at ankle (Syme) 9 hours 8 Male Crush of both Amputation at right knee Died in 1880 do. adult lower extremi- ties (nap) and of left leg at lower third (modified cir- cular) 4 hours Injuries of head also. 9 Male Crush of right Amputation at right shoul- Died in 1880 Episcopal aged 32 arm and left der-joint (Larrey) and of 4 days Hospital. years foot left leg at lower third (circular) Injuries of head also. Slight re- actionary hem- orrhage. 10 Male Avulsion of right Amputation at right shoul- Died in 1880 University aged 25 and crush of der-joint (Larrey) and of 11 hours Hospital. years left upper ex- tremity left arm at middle (modi- fied circular) Injuries of head also. 11 Male Crush of both Amputation at right knee Recovered 1880 University adult lower extremi- ties (flap) and of left leg at upper third (flap) Hospital. Operation by Dr. H. R. Wharton. It is, I think, better in these synchronous amputations, provided that the circulation is thoroughly controlled with tourniquets, to complete both ope- rations, as far as the knife is required, before pausing to ligate the divided vessels; and, under any circumstances, both limbs should be removed before either stump is dressed. Before the days of anesthesia, it was sometimes recommended that both operations should be done actually at the same moment, by separate surgeons, it being thought that if the patient's attention DRESSING THE STUMP. 593 were divided between two focuses of suffering, he would feel less pain from either, than if the operations were performed consecutively ; whatever may have been the advantages of such a procedure in former times, there is no occasion for such a course now, and the operations will be certainly more apt to be done well if only one is done at a time. Dressing the Stump. "We have carried the description of an amputation as far as the closing of the wound with sutures ; this is, at the present day, almost universally done before the patient recovers from the influence of the anaesthetic that has been administered, and, provided that ample drainage is secured either by means of the ligature ends or by the use of a tube, the plan is a good one, as avoid- ing the infliction of pain at the time when the patient is least able to bear it. There was merit, however, in the custom of our ancestors of allowing a wound to " glaze," as they called it — that is, to become smooth and sticky from the presence of lymph — before it was closed ; and if there be any reason to fear consecutive hemorrhage, it is a good plan to simply introduce the stitches, without tightening them, and to lay a piece of oiled lint in the wound (as advised by Mr. Butcher, of Dublin), so as to prevent prema- ture adhesion. This may readily be removed, and the wound finally closed, after reaction has occurred, without giving the patient any additional pain. If the stump be a light one (as in the forearm), it is not desirable to employ any means of approximation other than the sutures, though a short strip of plaster may be laid transversely over the ends of the ligatures, to keep them from being caught in the dressings and perhaps pulled upon before they have become loose. If, however, there be heavy flaps, it will' be well to give additional support by applying a few narrow adhesive strips between the sutures, and in a longitudinal direction. Under no circumstances should a transverse strip be carried completely around the stump ; any such source of eircular compression will probably cause oedema, and may even lead to gan- grene, or possibly, as in a case recorded by Sir James Paget, 1 to death. Another mistake, which should be most scrupulously avoided, is the closing of the wound so tightly as to hermetically seal it; there is inevitably a con- siderable flow of sero-sanguineous fluid after an amputation, and if this be confined within the wound, instead of being allowed to escape, painful dis- tension results, and interference with primary union, not to speak of the danger of septicaemia from decomposition. Various modes of dressing stumps have found favor wdth modern sur- geons; with perhaps one or two exceptions, all are better than the old plan, which still prevailed within my recollection, of applying a large piece of lint smeared with some unctuous substance (often cut in the form of a Maltese cross, and folded closely around the stump), then a thick nest of charpie, and finally a rather tight bandage. I shall describe briefly several of the stump dressings which have obtained most favor in recent years, concluding with that which, in common with many other surgeons, I am myself in the habit of employing, and which I would venture to designate as the "simple dressing for amputations." Cold-avater Dressing. — Introduced into British surgery by Liston, this is still a favorite mode of dressing amputation wounds in military practice, and 1 Clinical Lectures and Essays, p. 63. Second Edition. London,. 1819* VOL. I. — 38 594 AMPUTATIONS. Irrigating apparatus for cold-water dressing. Fig. 153. was very extensively employed during our late war. The stump is simply laid upon a pillow protected with a piece of oil-cloth and a towel or fold of linen, and then another piece of linen, or lint, wrung out of cold water, laid over it, and constantly moistened by an attendant, or, if practicable, by the adjustment of an irrigating apparatus (Fig. 153). There is no better or more soothing application to a recent stump, in hot weather, than this simple cold-water dressing ; it, how- ever, requires constant supervision on the part of the attendant, and, unless care be taken to arrange the pillow and oil-cloth so that the drip may fall into a bucket or basin suitably placed, the water will flow backwards into the bed and keep the patient constantly wet, thus exposing him to great discomfort, as well as to the risk of becoming chilled, and, perhaps, falling a victim to pneumonia or other internal inflammation. Hence while recognizing the advantages of this mode of dressing in army practice, or in cases of emergency, I do not recom- mend its general employment. In connection with the cold-water dressing of ampu- tation wounds, I may briefly mention the continuous bath of Langenbeck and Lefort, recently revived by Prof. Hamilton, of New York, and, with the modification of carbolizing the bath, so as to make it antisep- tic, by Prof. Verneuil, of Paris. Air Dressing. — I would venture to propose this name for the plan of treat- ing amputation wounds recommended by Mr. Teale, of Leeds, and Prof. Humphry, of Cambridge, and advocated with the great ability and eloquence which characterized all his writings, by the late Sir J. Y. Simpson, of Edin- burgh. Mr. Teale, after directing that the wound should be closed with sutures, says : — 1 " After the patient has been carried to bed, the stump is laid on a pillow, over which a large sheet of gutta-percha tissue has been spread. No dressing whatever is required in the early part of the treatment. A light piece of linen or gauze is thrown loosely over the stump and pillow, and these are protected from the pressure of the bedclothes by a wire-work guard. . . . The attendants and nurses must be strictly enjoined not to lift the stump from the pillow without the authority of the surgeon. As there are no dressings to be soiled, and therefore to require removal, the stump generally need not be raised from the pillow for many days, or even for two or three weeks. When there is a discharge of matter, the nurse must remove it frequently by a soft sponge from the subjacent gutta-percha without lifting the stump." Prof. Humphry, 2 refering to the well-known fact that wounds of the face not unfrequently heal by the first intention, says : — " This is due, in great measure, to the vital qualities of these parts, and, in some degree, also, I apprehend, to the fact that they are usually exposed to the air, their edges being held in contaol merely by sutures. For some years we have adopted this plan after amputations, and all, or nearly all, other operations. The integuments are united by sutures placed at intervals of about an inch ; and the wound, as well as the adjacent surf':i<'<\ is left quite exposed to the air ; no plaster, bandage, or dressing of any kind being placed upon it." 1 Op. cit., page 0. 2 British Medical Journal, October., 1860, p. 840, quoted by Simpson, Acupressure, page 130. Edinburgh, 1864. DRESSING THE STUMP. 595 And Sir J. Y. Simpson, discoursing on " The General Inutility of Dress- ings," says : l — " I believe . . . that after the sides and edges of a wound are properly approxi- mated and adjusted with its metallic stitches, the best dressing, as a general rule, is nothing, absolutely nothing. ... I have found that occasional streams of cold air directed upon the wound or its vicinity from a pair of bellows prove both most beneficial locally in keeping down morbid heat and irritation, and are most grateful to the feelings of the patient." Pneumatic Occlusion and Pneumatic Aspiration. — In contrast to the views of the writers just quoted, who attributed a positively curative action to the contact of atmospheric air, we may next consider the modes of dress- ing recommended by several French surgeons who, by preventing exposure of amputation wounds to air, endeavor to place them in a condition analogous to that of subcutaneous injuries. As pointed out by II. Larrey in the dis- cussion before the French Imperial Academy of Medicine, the germ of these ideas may be found fairly set forth in the Treatise on Wounds of Caesar Magatus, 8 a Franciscan Monk and Professor at Ferrara, who lived from 1579 to 1647 ; but the first practical application of the method in modern times, may probably be attributed to Chassaignac, 3 who, in connection with his sys- tem of drainage tubes, recommended that the wound should be closely covered with strips of plaster, and so excluded from the air. Pneumatic Occlusion. — The name of "Pneumatic Occlusion" was given by M. Jules Guerin to a method of dressing wounds of all kinds, including those made by amputation, which he described before the Academic deMSdetine, in Febru- ary, 1865. 4 The apparatus required for this mode of treatment consists of (1) an exhausted metallic receiver, provided with gauge and stopcock ; (2) a series of envelopes or sleeves of vulcanized India-rubber, of various forms and dimensions, ending in vulcanized India-rubber tubes, which are firm enough to resist atmospheric pressure ; and (3) a series of very fine elastic envelopes which are capable of adapting themselves to the inequalities of the part to which they are applied, and which are permeable to the atmosphere, and are placed inside of the others. The stump is first surrounded with the thin elastic envelope, and then placed inside of the India-rubber sleeve, the neck of which is made to clasp the limb with sufficient closeness to prevent its slipping; the exhausted receiver is then attached, and, the stopcock being turned, the air and gases contained in the sleeve pass into the receiver, and the former, with the fine enveloping tissue, yielding to atmospheric pressure, mould themselves to the surface of the stump, which they hermetically seal. A somewhat similar apparatus, but employed with a different purpose — that of keeping the stump at an even temperature — had been previously sug- gested by Jules Guyot, whose mode of treatment was designated as the In- cubation Method. Pneumatic Aspiration is the name given by M. Maisonneuve 5 to a method of dressing stumps, not unlike that of M. Guerin, which has just been de- scribed. It consists — 1 Acupressure, etc., page 116. Edinburgh, 1864. 2 Caesaris Magati Scandianensis De Rara Medicatione Vulnerum, etc. Venetiis, 1676. 3 SSdillot, op. cit., tome i. p. 342. 4 Bulletin de l'Academie lmpe>iale de Medecine, tome xxxi. p. 396. 5 Practitioner, vol. i. p. 1. London, 1868. 596 AMPUTATIONS. " ... in submitting the stump of the amputated limb to continued suction (vacuum), so as to draw off all the liquids as fast as they are formed, and to convey them away before they have had time to putrefy. This is how the process is carried out ; after having stopped the hemorrhage in the usual way, by means of ligatures to the vessels, I clean the wound with the greatest care, wash it with alcohol, and wipe it with a dry cloth. I bring the edges together with a few strips of diachylon, but with- out opposing an obstacle to the flow of the secreted liquids. I then apply a layer of lint soaked in antiseptic liquids, such as tincture of arnica, solution of carbolic acid, or other suitable substance, and finally I fold the whole in a few bands of linen soaked in the same preparations. It is only after this preliminary dressing that the apparatus for exhausting the air is applied. The apparatus consists (1) of an extremity of India-rubber, shaped like a lady's muff, and intended to embrace the stump, and a tube of the same sub- stance ; (2) of a vessel of four or five litres (3^ quarts to one gallon) capacity, provided with a mouth-piece pierced with two holes; and (3) of an exhausting pump, fitted with a flexible tube. The stump covered with its bandage is first placed in the ' India- rubber muff,' whose orifice embraces exactly the integuments of the limb, and the tube is placed in connection with one of the holes in the mouth-piece of the vessel. To the other aperture I adapt the tube from the exhausting pump, and then I work the piston. In a short time the air of the vessel is in great part drawn off, and the remainder is rarefied. The liquids of the dressing, mixed with those which proceed from the wound, follow the air, and flow into the vessel. The ' India-rubber muff",' deprived of the air it had contained, applies itself closely to the limb. The pressure of the atmosphere exercises — through the intervention of the India-rubber — a considerable compression of the stump, and thus keeps the divided surfaces in contact, and, combined with the continued exhaustion produced by the rarefaction of the air in the vessel, prevents all accumulation of liquid, and thus promotes and favors rapid cicatrization." Could any systems of dressing be more unlike than those which we have just considered, and the " air-dressings" of Teale, Humphry, and Simpson ; and yet the advocate of each mode deplores the great mortality of amputa- tions in the hands of other surgeons, and confidently puts forward his own method as that which by clinical experience he has proved to be the best. It has for many years been the boast of modern surgery that it had aban- doned the old doctrines of "digestion" and " mundification" of amputation- wounds, and that it now endeavored to promote the quick healing of stumps by primary union. And yet in two of the most highly lauded methods of dressing employed at the present day, no attempt is made to close the wound for days after the operation ; I allude to the perchloride of iron dressing of M. Bourgade, of Clermont-Ferrand, and to the open method of dressing stumps employed by Prof. J. R. Wood, of ISew York. Perchloride of Iron Dressing. — The practice of cauterizing an amputa- tion-wound is an old one, 1 but the principle upon which M. Bourgade found-; his method, first brought before the International Medical Congress of Paris, in 1868, differs from that upon which the older surgeons acted. Re- calling the well-known facts that recent wouvds are more prone to absorb sep- tic materials, whether from their own secretions or from the atmosphere, than granulating surfaces, and that septic poisoning is less common after ope- rations performed with the caustic than after those accomplished by the use of the knife, M. Bourgade 2 endeavors to render the latter as inoffensive as the former, by applying f<> the whole cut surface a strong solution of pcrchlo- ride of iron (Pravaz's solution, sp. gr. 30° Baume). Hemorrhage having been arrested, and the wound carefully washed, the whole surface is covered with charpie saturated with the solution in question, care being taken that the action of the drug is exerted equally on all parts, bones and vessels, as 1 See the quotation from Vigo, supra, page 554. 2 Fort, Cours de medecine operatoire, p. 150. Paris, 1880. DRESSING THE STUMP. 597 well as muscles and connective tissue. Wet charpie is then placed outside to diminish the irritation of the skin, and this constitutes the whole dressing. The perchloride of iron "combines with" the tissues with which it is in con- tact, and at the end of twelve hours forms a thick, solid magma, a " touo-h cuirass," which completely isolates the subjacent tissues from the influence of surrounding agents. Suppuration begins from the sixth to the tenth day — sometimes later — and the charpie, becoming detached, leaves a sloughy- looking surface which soon becomes covered with healthy granulations. "The wound is then dressed with aromatic wine, and the flaps may be brought together so as to induce union by "secondary adhesion." Open Method. — This mode of dressing stumps, wjiich, except as to the use of sutures, somewhat resembles that which I have called the "air-dressing"' of Teale and Humphry, is principally advocated by Prof. James R. Wood, "of New York. 1 " After a limb has been amputated, the flaps are not even approximated, but left entirely open. A pillow of oakum is placed under the stump, which is allowed to rest upon this support until the wound is nearly healed. A small piece of gauze is placed over the contour of the stump, and a cradle is placed over the limb, so that the clothes may not come in contact with the painful extremity. This is all the dressing that is employed : no sutures are used except in the lateral skin-flap method, as will be described." [One or two stitches are placed at the anterior angle of the wound, so that the flaps may cover the bone, but the rest is allowed to gape.] " No adhesive plaster is employed, no oil-silk is placed over the stump, no bandage is applied, no dry charpie is stuffed into the wound, no fenestrated compresses are placed between the flaps ; in other words, the stump is left entirely alone, just as the surgeon made it in his amputa- tion. The wound is thus allowed to drain freely, and the stump is gently washed at frequent intervals by means of an Esmarch's wound-douche. The water in this irri- gator is impregnated with crystals of carbolic acid, and, after this ablution, balsam of Peru (which makes a fine stimulating application) is poured over the granulating sur- face. The discharge which falls from the wound is removed every few hours in order to secure perfect cleanliness The stump is then washed at frequent inter- nals until suppuration has nearly subsided in the wound, and then the flaps are gradu- ally approximated by means of strips of adhesive plaster." The historian of Prof. Wood's cases, Dr. F. S. Dennis, professes his faith in Pasteur's and Lister's doctrines as to the evil effects produced by micro- scopic organisms floating in the air, but believes that their bad influence may be sufficiently neutralized by frequently washing the stump with carbol- ized water in the manner described. We have next to consider two modes of dressing which aim at the entire exclusion of these organisms ; the antiseptic dressing of Prof. Lister, and the loadding-dressing of M. Alphonse Guerin. Antiseptic Dressing. — In a certain sense, almost all of the modern modes of dressing wounds may be termed "antiseptic," and indeed it is not unusual for the advocates of "Listerism" to claim all the good results obtained by sur- geons who do not follow their mode of practice, as due to an unconscious or involuntary antisepticism, while the bad results are attributed to careless or wilful neglect of antiseptic precautions. But hy the name antiseptic dressing, in this article, I mean the peculiar mode of dressing stumps advocated by Prof. Lister, formerly of Glasgow and Edinburgh, but now of King's College, London, and founded in a firm belief in the baleful influence of bacteria and other micro-organisms, and in the absolute necessity of excluding them from the wound. The antiseptic agent commonly employed is carbolic acid, but 1 Dennis, Treatment of Amputations by the Open Method. New York Medical Journal, vol. xxiii. p. 8, 187tS. 598 AMPUTATIONS. Prof. Lister has quite recently announced that an equally good effect may be obtained from the oil of eucalyptus. The second volume of this work will contain an Article specially devoted to the Antiseptic System, and I shall there- fore merely say in this place that, the operation having been performed under a spray of carbolized steam (one to forty), and the instruments, sponges, etc., having been throughout kept thoroughly antiseptic — the limb itself should have been first washed with a 1-20 solution of carbolic acid — the vessels are tied with carbolized catgut, and the wound (amply furnished with drainage tubes) closed with "antiseptic sutures;" the "protective" dipped in a 1-40 solution is next adjusted, and covered with one or more layers of "antiseptic gauze," dipped in the same solution ; then with numerous layers of dry gauze; next with one of mackintosh ; and lastly with a final layer of gauze, and a bandage of the same material. The outer dressings are not renewed until the discharge has begun to soak through them, while the inner dressings are sometimes allowed to remain for weeks together. Wadding Dressing. — As in Prof. Lister's dressing the bacteria and micro- cocci are met and destroyed, in their effort to reach the wound, by successive layers of gauze impregnated with carbolic acid, so by M. Guerin's device they are mechanically arrested by a huge thickness of cotton-wadding, and, unable to get either in or out, miserably perish in its meshes. All hemor- rhage from the stump having been checked, M. Guerin washes the wound, and indeed the whole limb, with carbolized water, has it gently dried, and held immovably in one position by assistants, while the dressing is applied. Sutures may or may not be used. Drainage tubes are not required. A thick pad of cotton is first placed over either flap, and then two strips of wadding, three inches wide and ten or twelve long, are applied with their middle to the end of the stump, and their extremities folded down upon the limb above and below; these strips are crossed by two others of similar dimensions, and a fifth, applied circularly, holds them all in position. A long band of wad- ding is then employed like a bandage, to completely cover in the stump and the limb to a point half way between the two nearest joints; the amount of cotton used is to be enough to make the diameter of the covered limb at least three times that which it naturally possesses. Ordinary bandages are next applied over the wadding, the first turns being quite loose, and the bandages then gradually made more and more tight, until the final turns exercise a very energetic but equable compression over the whole stump. Usually thirteen bandages of eleven yards each are required for this purpose. When the dressing is complete, the limb can be moved in any direction, or the stump struck, without giving the patient any pain. If in the course of a few r hours, any blood is found leaking through the bandages, a thick square of wadding and an additional bandage are applied. The dressing must be ex- amined every day during the first week, and, if necessary, still more bandage added so as to keep up firm compression. The dressing is allowed to remain, as a rule, for from twenty to twenty-five days; it should be applied, and, when necessary, reapplied, in a special room and not in the ordinary ward. 1 For want of space I can merely mention the "Bordeaux 3fethod" wdiich may !><• considered as in sonic degree a combination of Lister's and Guerin's plans, embracing ihc \\m~ of drainage tubes, very accurate adjustment of the flaps with sutures and collodion, washing the stump with carbolized water, and covering it with cotton ; 2 and the Earth Dressing of Dr. Addinell Hewson, 3 1 Fort, op. cit., pp. 159 >t seq. 2 Ibid., p. 177. 3 Earth as a topical application in Surgery. Philadelphia, 1872. DRESSING THE STUMP. 599 which, as its name implies, consists in the use of prepared earth or dried clay, placed in immediate contact with the wound. What is the legitimate inference to be derived from a consideration of the various and very dissimilar methods of dressing stumps which have now- been referred to — methods, it must be remembered, which have been, each without exception, lauded by their promoters as superior to all others, and, in the opinion of their advocates, proved to be so by the unerring test of clinical experience? Is it not that the particular mode in which a stump is dressed is, after all, of comparatively little importance, and that we must look for information as to the probable result of an amputation, rather to the nature of the lesions which render the operation necessary, and the consti- tutional condition of the patient, than to the influence of any extraneous circumstances? This question will be referred to again when we come to consider the statistics of amputation, and is merely suggested here in con- nection with the mode of treatment next to be described, and which I have ventured to call the simple dressing for amputation wounds. Simple Dressing. — In the first place, let us consider what are the requisites for a good stump dressing. There must obviously be ample means provided for drainage; or pain, if not worse, will be caused by the accumulation and retention of the sero-sanguineous flow which inevitably follows an amputa- tion. Hence, as already mentioned, care must be taken not to apply the stitches too close together, and, if sufficient drainage be not afforded by the ligatures, one or two fenestrated India-rubber tubes may be laid in the wound and brought out at the angles. Then, whatever dressing is employed should not be liable to stick to the wound, lest it interfere with the exit of discharges and cause pain when it is renewed ; hence wet dressings are preferable to salves or ointments, and upon the whole I know of nothing which answers a better purpose than pure laudanum, the use of which in dressing stumps I learned many years ago from that excellent surgeon Dr. Joseph Pancoast. The lau- danum is no doubt antiseptic, from the alcohol which it contains, and its use is certainly very soothing to the patient ; it prevents, to a great extent, if not entirely, that painful jerking of the stump which is so apt to follow ampu- tation. Mr. Bryant accomplishes the same purpose by bandaging the stump firmly to a padded splint, but with the laudanum dressing this is unnecessary, and the stump will be found to rest very comfortably upon a soft pillow, which should be covered with a piece of India-rubber cloth and a clean towel. At the second dressing, forty-eight hours after the operation, I commonly substitute diluted alcohol for the laudanum, and continue this dressing until the wound is nearly healed, after which the ointment of the oxide of zinc may be employed instead. While my preference is for pure laudanum, as a first dressing, I have occasionally used, with excellent results, diluted lau- danum, or lead-water and laudanum, or simply olive oil. I have no particu- lar objection to carbolized oil, if it be not so strongly impregnated with the acid as to produce irritation of the skin, but have seen no advantage from its employment. Whatever material be employed for the dressing, this must be kept moist; otherwise it will adhere to the edges of the wound and produce irritation. This object is best accomplished by saturating with whatever preparation is employed, a large piece of lint, laying it underneath the stump, folding it over the end, and then again (doubled) from either side, so that on top of the stump are placed five layers of wet lint, constituting a reservoir from which the medicated fluid is gradually drawn downwards. The whole should be covered moreover with oiled silk, or some other impermeable tissue which will keep 600 AMPUTATIONS. the part moist for at least forty-eight hours. After the second dressing, I renew the applications every day, and the waxed paper (which is much cheaper than oiled silk) may conveniently be substituted. As long as wet dressings are employed, no pads of charpie or oakum are necessary, but the dressing, with its impermeable envelope, may be simply held in position by the turns of a light, loosely applied, recurrent bandage. In the later stages of the case, when the wound is dressed with zinc ointment, a little oakum may be loosely applied externally, as a means of mechanical protection. After-treatment of the Stump. — When the dressings are to be removed, the bandage should be cut, and the oiled silk and lint laid off from the stump before this is raised from the pillow ; the surgeon at the same time examines the sutures, untwisting or cutting any that are too tight, and, if a plug of wax has been applied to the medullary Cavity of the bone, gently withdraws it by pulling on the wire to which it is attached. An assistant then slips his hand under the stump, carrying it well down towards the end, and then firmly but gently lifts the part, and supports it while the soiled dressings are removed, the stump washed and dried, and the new dressings adjusted. This is not a painful process ; patients often dread the manipulation beforehand, but it is very seldom that they complain at the time, and they almost in- variably experience a decided increase of comfort when the dressing is com- pleted. The icashing of the stump is to be very gently effected with a clean soft sponge, or bunch of tow or oakum — the late Mr. Callender employed a camel's hair brush — and tepid water, colored with a little Condy's fluid (solution of permanganate of potassium), which is an excellent deodorizer and disinfect- ant. As far as possible, the water should be allowed to flow over the stump without touching this with the sponge itself. The part is then gently sopped until it is dry, with a clean, soft towel, and the new dressings adjusted. When the wound has fairly well healed, and the stump is no longer sensitive, the washing may be more thorough — a little oil of turpentine being employed to remove the adhesive plaster which sticks to the skin, and the whole well douched afterwards with soapsuds and water. If silk sutures have been used, they may be properly taken away on the third or fourth day ; metallic sutures may be allowed to remain much longer, indeed often until the wound is firmly healed. The ligatures should be allowed to drop of themselves, but the surgeon may gently feel them, to ascertain if they are loose, after a week in the case of the smaller, and after ten days in that of the larger vessels. Under no circumstances should a ligature be rudely -pulled away. Apart from the risk of hemorrhage, I have more than once known the somewhat forcible withdrawal of a ligature, attended by slight bleeding, showing that the granulating surface had been broken, to be fol- lowed in a few hours by a chill and the development of fatal pyaemia. If short cut animal ligatures have been employed, they are commonly dissolved in the fluids of the stump, and are not seen after the operation. If acupressure has been used, the pins or needles may be taken from the smaller vessels on the second, and, from the larger, on the third, fourth, or fifth day, according to circumstances. If drainage tubes have been employed, they may be withdrawn about the end of the first week. I have called this the simple dressing for stumps, but, it may be asked, is not the air-dressing simpler still ? jSTo doubt it is — inasmuch as nothing is less than something — but I do not think it as satisfactory. Prof. Humphry's remark as to the rapid healing of face wounds is certainly true ; but it is also true that face wounds heal quite as rapidly, and with much less discomfort to STRUCTURE AND DISEASES OF STUMPS. G01 the patient, if covered with a strip of lint kept wet with glycerine and water, than if left dry. Moreover, I had the opportunity, some years ago, of seeing a number of amputations treated after Teale's method by a very careful sur- geon, and I can honestly say that I have never seen so large a proportion of inflamed and sloughing stumps before or since. I have no doubt that Prof. Wood's " open method" is better than Teale's or Humphry's, as avoiding any risk of undue tension by sutures ; but the abandonment of all effort to obtain primary union seems to me to be a step in the wrong direction, and one not compensated for by any other feature of the plan in question. Besides, I believe that positive benefit is derived from the constant contact of an anodyne fomentation. Structure and Diseases of Stumps. Structure of Stumps. — When first formed, a stump contains all the tissues utilized in the amputation (unless these have sloughed before the occurrence of cicatrization), but soon afterwards various changes are observed, which continue progressively for a long time afterwards. Thus the muscular sub- stance gradually disappears, and, no matter how full and plump the stump may have seemed at first, it in time assumes a withered look, and the skin forms, as it were, a loose bag around the end of the bone. The fibrous and tendinous portions of the muscles remain, however, and undergo conversion into a dense fibre-cellular mass which protects the bone, and renders it less liable to cause ulceration of the overlying skin or cicatricial tissue when sub- jected to pressure. The bone itself undergoes changes, becoming rounded off, and a button of new osseous tissue closing the medullary cavity, which is to a great extent obliterated. The vessels, at first filled with clots reaching to the nearest anastomosing branches, become in time changed into firm fibrous cords, continuous with the vessels above. The nerves are thickened, and become bulbous at their extremities, constituting a form of neuroma; these bulbous enlargements consist mainly of fibro-cellular tissue, but are abund- antly supplied with nerve fibrils. In connection with these alterations of structure, met with in the stump itself, very, curious changes have been noted in distant organs. Thus Dr. Dickinson, Dr. Lockhart Clarke, and M. Vulpian, have observed localized atrophy of the spinal cord which corresponds to the side on which the ampu- tation has been practised, and similar changes have likewise been noticed by Drs. Webber, Genzmer, Dickson, Leyden, and Dreschfield. Berard, many years ago, observed atrophy of the anterior roots of the spinal nerves cor- responding to the amputated part, and Chuquet and Luys have observed atrophy of the brain on the side opposite to that of the amputation. A patient who has submitted to one of the large amputations is apt to become fat: this is apparently due to the fact that, while the supply of nutri- ment continues the same as before the operation, the demand for it is dimin- ished by a part of the body having been removed, and accumulation of fat is the consequence ; this is still further aided, in the case of amputations of the lower extremity, by the resulting inability to take the proper amount of exercise. Among patients of the lower class, the enforced idleness which often follows as a necessary sequel of amputation, is unfortunately apt, in many cases, to lead to the formation of intemperate habits. Diseases of Stumps. — Any of the tissues which enter into the structure of a stump may be morbidly affected and give rise to pain or other annoyance. 602 AMPUTATIONS. Sloughing of the skin and connective tissue which cover the stump, is occa- sionally met with, and may be due to bruising of the parts by the injury which rendered the amputation necessary ; to undue tension, from original insufficiency of covering, or from subsequent swelling conjoined with too tight closure of the wound by sutures, etc.; or to constitutional causes, as in cases of senile gangrene, or of that frightful affection which has already been alluded to, the true " traumatic or spreading gangrene." Sloughing is more apt to occur after flap amputations than after those done by the circular method ; but I have once seen the entire cuff of a circular operation slough off as cleanly as if it had been cut by a knife. The treatment of a sloughing stump consists in removing all sources of tension, by cutting stitches, etc., and apply- ing a fermenting or charcoal poultice till the dead parts are removed, when an attempt may be made to diminish the size of the remaining wound by the judicious use of strapping. Erysipelas or Diffuse Cellulitis may attack a stump, and either forms a serious complication. The treatment consists in removing all the sutures, applying a soothing dressing (such as diluted alcohol, or olive oil), wrapping the limb in cotton, and administering full doses of the tincture of the chloride of iron, which may be conveniently combined with the solution of acetate of ammonium, as in the following formula : — R. Tinctune ferri chloridi f3j-f3ijj syrupi f §ss, liquoris ammonii acetatis f^vss. M. Sig. " A tablespoonful every two hours." Hospital Gangrene is a very serious affection when following a recent ampu- tation, but is fortunately not very common at the present day. The treatment consists in thoroughly cauterizing the whole surface of the wound with bro- mine or a strong solution of permanganate of potassium (3j to f Sj), and bringing the patient under the constitutional effect of opium. AVhen the disease is arrested, the wound will often heal with great rapidity, but occa- sionally the destruction of tissue may have been so great as to necessitate a second operation. Spasm of the muscles of a stump is a painful complication, which is chiefly nit I with a few hours after the recovery from anaesthesia, and which, by causing the limb to bo jerked off the pillow on which it rests, tends to inter- fere with primary union. The treatment ordinarily recommended, is the application of a tolerably firm bandage, with or without a splint, and the interna] administration of anodynes. As already mentioned, this complica- tion is very seldom met with when the laudanum dressing is employed. Cases of persistent and intractable choreic spasm of a stump, occurring some time after amputation, have been recorded by Dr. S. "Weir Mitchell and Dr. H. C. Wood. "Retraction of the musdes sometimes occurs and continues progressively for many days or even weeks after an amputation, and occasionally constitutes a really serious complication by interfering with the healing of the stump, causing troublesome ulceration of the cicatrix (if healing has already oc- curred), and giving the part a peculiar, pointed appearance which has sug- gested the name of conical or sugar-loaf stump, & condition which may also depend upon sloughing, <>r upon hypertrophy of the bone. The ulcer on the end of the stump, caused by muscular contraction, is called the meclianical ulcer, and is often very intractable. The treatment consists in the application of a firm circular bandage, from above downwards, so as to relieve tension by restraining the action of the muscles, and, as it were, coaxing the soft STRUCTURE AND DISEASES OF STUMPS. 603 parts downwards, until the ulcer has had time to heal. Another plan is to employ extension by means of a weight, applied either with the ordinary adhesive plaster stirrup, as in fractured thigh, or, as advised by Mr. Bryant through the medium of an arched splint attached to the front and back of the limb. The last resort, in a case of conical stump which is constantly re- ulcerating, or which is too tender to permit the use of an artificial limb, is resection of two or more inches of the end of the bone; an operation which happily is attended with very little risk, and of which the result is usually quite satisfactory. Contraction of the tendons in the neighborhood of the stump may cause trouble, by giving rise to deformity and dragging upon the cicatrix ; this is particularly observed in connection with the medio-tarsal, or Chopart's, ampu- tation of the foot, after which operation, the natural arch of the foot being destroyed, the tenclo Achillis may be drawn upwards by the gastrocnemius and soleus muscles, and a painful form of talipes equinus result, the cicatrix being forced against the sole of the shoe in walking. This occurrence can usually be prevented by taking care to make the flaps of ample size, and by the judicious use of bandages, splints, and weight extension, if any tendency to retraction be noticed. Tenotomy may be resorted to if other means prove insufficient. Hemorrhage from a stump may occur at any time before the wound is com- pletely healed, though it is not usually looked for after the safe separation of all the ligatures. I have, however, known fatal hemorrhage from the femoral artery, in a syphilitic subject, to occur four weeks after amputation of the thigh, and when all the ligatures had come away and the patient had been going about for some time. Sometimes the bleeding comes from small ves- sels which were not noticed at the time of the operation, but which begin to spout when reaction occurs (consecutive or reactionary hemorrhage). Secondary hemorrhage from a stump may be due to the bleeding vessel having been imperfectly secured in the first instance — as by tying it too near the cut end, so that the noose can slip off before repair is complete, or by including too much tissue with the artery, so that in a day or two the knot becomes loose — or to a diseased condition of the arterial coats themselves, rendering them liable to ulceration, or, more rarely, to the formation above the ligature of an aneurismal swelling which subsequently undergoes rupture. Capillary oozing or parenchymatous hemorrhage sometimes occurs after amputation, and appears to be due to thrombosis of the venous trunks interfering with the return circulation. The treatment of hemorrhage from a stump, if the bleed- ing be but slight in amount, consists in elevating the part and applying cold (by means of an ice-bag), and moderate pressure, and in administering ergot, digitalis, and opium; but if these means fail, or if it appear that a la rue vessel is bleeding, more decided measures must be adopted. If the pro- cess of healing be not far advanced, the stump should be reopened, the surgeon breaking up the recent adhesions with his fingers, and the bleed- ing artery should then be tied in the wound, it being sometimes necessary for this purpose to dissect the vessel up for a short distance, and thus free it from the surrounding tissues. If, however, the hemorrhage has not occurred until the greater part of the stump is firmly healed, it will probably be better to secure the artery immediately above the wound rather than in the wound itself; this may be done by cutting down and applying a ligature, but may be much more readily accomplished by acupressing the vessel according to Simpson's first method — passing a long pin deeply across the known course of the vessel, so as to go below it, and, if necessary, increasing the pressure by applying a pad of lint or cork, and a figure-of-eight ligature, externally. 604 AMPUTATIONS. This is one of the few cases in which acupressure seems to me to possess greater advantages than the ligature, and I would urgently recommend it as the best means of controlling hemorrhage under these circumstances ; the pin can be introduced without the necessity of etherizing the patient, and the operation, when the patient is already very much weakened by bleeding, is altogether a much less formidable one than cutting down and searching for the artery. Ligation of the main artery at a distance from the wound, though recommended by Liston, is now generally regarded — and I think justly — as a bad operation, particularly in the lower extremity ; it adds a serious complication in itself, exposes to considerable risk of gangrene, and is moreover often ineffectual in permanently arresting the hemorrhage ; in the upper extremity, it may be sometimes resorted to with advantage, but when the lower limbs are concerned a better plan is to acupress the vessel in the way already described, and, if necessary, re-amputate when the patient has rallied enough to bear a second operation. Aneurismal enlargement of the arteries of a stump has already been alluded to as being an occasional cause of hemorrhage. Mr. Erichsen, in his " Science and Art of Surgery," describes and figures a remarkable case of aneurismal varix occurring after amputation at the ankle. Neuromata, or painful nerve-tumors, are often met with in stumps. The bulbous enlargements of the cut ends of the nerves occur, indeed, as already pointed out, in all stumps, but the term neuroma is not ordinarily employed, unless these enlargements are painful. The pain, which in these cases is sometimes very distressing, is due, according to Weir Mitchell, to the exist- ence of a true neuritis, or of a state of sclerosis which results from inflam- matory changes. The treatment is unfortunately not very satisfactory ; if the pain were evidently connected with any distinct tumor, resection of the growth, and of two or three inches of the nerve with which it was connected, would be indicated ; under other circumstances, it would be proper to cut down and forcibly stretch the nerve which supplied the painful region, or, if this failed, to excise a couple of inches from the continuity of the nerve and turn its distal end downwards, so as to prevent reunion ; or, if the whole face of the stump seemed to be neuralgic, a re-amputation might be properly re- sorted to. These various operations, however, though perfectly justifiable under the circumstances supposed, by no means insure complete relief from suffering. The late Dr. Nott placed on record a remarkable case in which the patient submitted to no less than three re-amputations of a neuralgic stump, and three nerve-excisions, and yet was not cured at the end of this persevering treatment. As palliative measures, where an operation is not con- sidered necessary, the application of leeches, ice, and counter-irritants, may be of service, as may the topical use of the strong tincture of aconite root, or hypodermic injections of morphia. Relief was obtained, in a case recorded by Girard, by the repeated employment of electro-puncture. Periostitis, osteitis, or osteomyelitis, or all of these affections simultaneously, may attack the bone of a stump, and in some cases may lead to very serious consequences. Subperiosteal suppuration, unless the pus be promptly evacuated by a free incision, is apt to lead to extensive necrosis, 1 and sometimes, by im- plicating the epiphyseal junction, 2 or even secondarily the neighboring joint, 1 Subperiosteal suppuration sometimes receives the name of acute necrosis, but the necrosis is a consequence of the disease rather than the disease itself. 2 The sequence of events is usually the other way, epiphysitis preceding subperiosteal suppura- tion. (See Macnamara, Lectures on Diseases of Bones and Joints, pp. (j'J, 75. Second edition. Lon- don, 18bl..j STRUCTURE AND DISEASES OF STUMPS. 605 may place the patient's life in jeopardy, and require re-amputation. Diffuse suppurative osteomyelitis is always a very grave affection, often ending in pyaemia and death, and particularly when it occurs in the femur, a bone spe- cially exposed to this destructive form of inflammation when its medullary cavity is laid open, as it necessarily must be in most amputations of the thigh. Konig reports a cure, in a ease of this kind, effected by scooping out the dis- eased medulla and stuffing the cavity with cotton saturated with a strong solution of chloride of zine ; but, ordinarily, the best mode of treatment con- sists in re-amputating at the nearest joint — an operation which, though appa- rently of a desperate character, has proved very sueeessfnl in the hands of Roux and Arlaud, and has been advantageously resorted to by Sir J. Fayrer, even after the development of pyemic symptoms. Necrosis is a very common affection of stumps. In most cases the death of bone is limited to a more or less perfect ring, corresponding to the line of section, and is apparently due to the bruising of the part by the teeth of the saw ; when, however, the necrosis follows upon osteitis, subperiosteal suppu- ration, or osteomyelitis — or all combined — it is sometimes very extensive, and may involve almost all that remains of the shaft of the bone. Every patho- logical or surgical museum embraces specimens of the long, conical, and often tubular sequestra which are found under these circumstances, and which are simply the result of inflammatory action of a high grade. An ingenious attempt has been made to explain the occurrence of these sequestra by attri- buting it to injury of the nutritious artery, which is, of course, often divided in amputations ; but it seems to have been overlooked that a precisely similar form of necrosis occurs as a result of osteitis in cases in which no operation at all has been performed. Not only is the sequestrum often tubular, but it is not unfr3 juently lined, as well as surrounded, with living bone — the medulla undergoing a retrograde metamorphosis into osseous tissue at the same time that an involucrum is being formed by the periosteum. This fact was long ago observed by Copland Hutchison, 1 and more recent illustrations have been recorded by several writers, including M. Demarquay, of Paris, Prof. Markoe, of New York, and Dr. Packard, of this city; the first philosophical explanation of the occurrence appears to have been given by M. Oilier, of Lyons. The treatment of necrosis in a stump consists in removing the seques- trum as soon as it has become loose ; this can usually be effected without difficulty by simply seizing the sequestrum with forceps, and drawing it out with a rocking or twisting motion; occasionally, however, the dead bone may be firmly held in place by the periosteal formation of new bone around it, or even by osseous bands extending from this to the ossified medulla — under which circumstances the involucrum must be cut away until the source of obstruction is removed. Under no circumstances can simple necrosis in a stump, no matter how extensive, necessitate re-amputation. This operation may, however, as already mentioned, be required by what is sometimes called acute necrosis, but which should more properly be termed diffuse subperiosteal suppuration. Caries is sometimes met with in the bone of a stump, usually when the am- putation has been performed for scrofulous or syphilitic disease, or, if for injury, when the patient is a subject of one of these diatheses. The treatment, lie- sides the adoption of suitable constitutional measures, consists in injecting the sinuses which lead to carious bone, with tincture of iodine, one of the mineral acids properly diluted, or, which I have sometimes used with advan- 1 Some Practical Observations in Surgery, illustrated by cases, page 130. London, 1816. 606 AMPUTATIONS. tage, the preparation introduced by M. Notta under the name of the " Liqueur de Villate," which may be made according to the following formula : R. Zinci sulphatis, cupri sulphatis, aa gr. xv ; liquoris plunibi subacetatis, f^ss ; acidi acetici diluti vel aceti albi, f3iijss. — M. As a last resort, the stump may be laid open and the carious bone removed with osteotrite and gouge, or, possibly, a re-amputation may be found necessary. Hypertrophy of the bone after an amputation, has already been alluded to as one of the causes of a conical or sugar-loaf stump. This is observed in patients who have not attained their full growth, and principally in amputations of the leg and upper arm ; its occurrence in these rather than in other situations, is accounted for by the well-known physiological fact that, owing to the direc- tion taken by the nutritious arteries in the several bones, and the consequent period at which the epiphyses become united to the diaphyses, the chief growth of the lower extremity is from tne epiphyses in proximity to the knee, while that of the upper extremity is from those of the wrist and shoulder. Hence amputations of the thigh and forearm remove the principal sources of growth for the portions of bone which remain, while amputations of the upper arm and leg leave these sources of growth, and in a few years the bones of stumps in these situations may be too long for the soft parts which were originally ample for their covering. If any treatment is required in a case of this kind, resection of the overgrown bone is the only remedy likely to be of service. Adventitious bursce are sometimes formed over the bones of stumps from pressure of the pad or artificial limb used in walking. If such a bursa should become painful, the mechanical arrangement of the prothetic apparatus em- ployed should be altered, so as to relieve the part from pressure; and if this be not sufficient, an attempt may be made to cause obliteration of the bursa by injecting tincture of iodine, or establishing a seton ; or excision of the bursa itself may be resorted to. Prothetic Apparatus and the Adaptation of Artificial Limbs. One of the earliest records which we have of a successful effort to supply the place of an entire limb lost by amputation, is given in the history of Francois de la Noue, a celebrated Huguenot officer, born A. D. 1531, who losl his left arm at the siege of Fontenay. Having at first refused amputa- tion — his arm was shattered by the shot of an arquebuse — preferring to die rather than to be incapacitated for fighting, he was at length persuaded by his friends to submit himself to the surgeon's hands, and the Queen of Ka- varrc herself held his arm during the operation. An iron arm supplied the place <>f the missing member, and gave its bearer the sobriquet of "Bras de Fer;" the artificial limb served to hold his horse's bridle, and enabled the gallant captain to engage in fresh battles with renewed ardor. 1 Ambroise l?are describes and figures several varieties of artificial arms and legs — the former made of iron, boiled leather, or glued paper, and the latter of wood. These, he obtained, lie says, from a locksmith of Paris, named " le petit Lor- rain," and their mechanism was so perfect as to enable the wearer to imitate the natural movements of the parts which had been lost, and even to hold a pen for writing. 8 Among the artificial legs is one for " poor men," which is 1 See Malgaigne's edition of Pare, already quoted, tome ii. p. G17, note. 2 Op. cit., tome ii. p. 015. PROTHETIC APPARATUS AND THE ADAPTATION OF ARTIFICIAL LIMBS. 607 in all essential particulars the same as the "box-leg," which we still often see at the present day. The chief objection to the iron arm made by "le petit Lorrain" was its weight, which was so great that it could only be worn for short periods ; and it is told to the praise of the Nuremberg mechanic who about the same time, or possibly earlier, made the iron hand worn by ( S-oethe's hero, Gotz von Berlichingeii, that the artificial member supplied for that gallant soldier's use weighed but three pounds. Very ingenious substitutes for lost limbs are available at the present day, and the mechanic's art is enabled to supply any deficiency, from the Ins- of a single finger to that caused by an amputation at even the hip or shoulder-joint. Prothetic Apparatus for the Upper Extremity. — The simplest form of artificial arm for an amputation above the elbow, consists of a neatly-fitting sheath of leather terminating in a block to which can be attached a hook, a knife, a fork, or, for show purposes, a wooden hand ; by curving the arm, as suggested by Mr. Bigg, at a point corresponding to the missing elbow, the appearance of the artificial limb is very much improved, while a joint, allow- ing of motion at the elbow by means of a concealed wheel and ratchet, moved by the other hand, makes the limb still more useful. In cases of amputation at the shoulder-joint, apposition is effected by means of a leather cap covering the shoulder and side of the chest. For stumps below the elbow, a similar apparatus is applicable, of course without the joint. Such a contrivance as that above described is usually all that patients ask for, and I have known great use made of even a simple sheath and fixed hook : indeed, the large majority of men who lose an arm, do not employ any artificial substitute, finding that, with a little practice, one arm can reasonably do the work of two. For special cases, however, something more is required. The natural motions of the wrist can be imitated ; a spring placed within the artificial thumb allows a pen to be held between that and the forefinger, and thus enables the patient to write; and finally an ingenious arrangement of lever-, springs, or pulleys, concealed in the hand, permits the fingers to be moved as in the natural member. With M. Bechard's artificial arm, two hands are furnished — one naked and one gloved — to replace each other according to the needs of the occasion. Among the most ingenious forms of artificial arm Fisr. 155. Artificial arm. which have been devised, may be specially mentioned, besides that of Bechard, those of Van Petersen and Charriere, and, among less expensive appliances, that invented by M. de Beaufort, which has been further usefully modified by Mr. Heather Bigg. The power, in cases of amputation above the elbow, is derived from the opposite arm, through the medium of cords of catgut, but in Bigg's apparatus for amputation below the elbow, is derived from the 008 AMPUTATIONS. mutilated arm itself. The accompanying illustrations (Figs. 154-157) show the mechanism of the artificial arm and hand manufactured by Mr. Kolbe, of Fie. 158. Artificial hand. Fig. 157. Mechanism of artificial hand exposed. India-rubber hand. Fiff. 159. this city (Philadelphia), which are among the best in the American market. Fig. 158 shows an ingenious artificial hand, made of India-rubber by Mr. Marks, of New York. Prothetic Apparatus for the Lower Extremity. — Artificial legs are of much more value in a practical point of view than artificial arms, which are indeed not seldom voluntarily laid aside by those who possess them, or are only worn upon special occasions. The simplest form of artifi- cial leg is the " box-leg" (Fig. 159), adapted for the reception of the bent knee after amputation at what was formerly called the " point of election," a short distance below the tubercle of the tibia. This apparatus is, as already remarked, almost identical with the " poor-man's leg," described by Ambroise Pare more than three centuries ago. An improvement over this is the "-bucket" or "socket-leg," which is adapted to the extended limb, and is so arranged as to prevent pressure upon the cicatrix at the end of the stump. For amputation below the knee, a socket closely fitting the limb is employed, with a leather thigh-band or lateral straps, or, which is much better, a limb with two buckets, one for the leg and the other sur- rounding the thigh, thus completely taking ofi' the weight from the end of the stump, and, at the same time, greatly facilitating the act of throwing the leg forward in walking. For amputa- tions above the knee, the bucket should be so arranged as to transfer all pressure to the tuberosity of the ischium. Care must also be taken so to adjust the artificial limb that the centre of gravity of the bod} 7 shall fall within its base, as in the normal con- ~~ikle . of ._ devised a limb for use after amputation at the hipjoint, in which motion is permitted at points corresponding to all three articulations of the lower extremity. Among the more elaborate forms of artificial leg which have acquired popularity in modem times, may be mentioned the "Anglesey leg" (so called — at ila- & •■- li affords, has always been a favorite in this country. Fig. 100 shows the me- chanism of a leg made by Mr. Blanck, of Philadelphia, which closely resem- Box-leg. PROTHETIC APPARATUS AND THE ADAPTATION OF ARTIFICIAL LIMBS. GOO bles the "Palmer leg," and is really a very useful and satisfactory piece of mechanism. Various ingenious devices have been adapted in < >r< ler to provi< Le lateral and rotatory, as well as antero-posterior motion at the ankle-joint, those specially worthy of mention being found in the forms of apparatus made respectively by Dr. Bly, of Rochester, Mr. Marks, of New York, and Mr. Kolbe, of Philadelphia. The peculiarity of the "Bly leg" (Figs. 161, 162), Fig. 160. Fig. 161. Fig. 162. Mechanism of ankle in the " Bly" leg. B, glass ball ; C, tendons: G, leg piece. The " Bly" leg. A, spring for toes ; B, glass Tjall for lateral motion at ankle; C, artificial tendon; D, attachment for knee spring; li,km-e spring; F, knee tendon ; H, cord to limit motion of knee; S, ankle springs ; N, nnt to regulate springs. which is now manufactured by Mr. Fuller, of Rochester, N". Y., is that the a"hkle-joint is formed by a ball of polished glass playing in a vulcanite socket, motion being afforded by means of India-rubber "compression" springs, with cords which represent the natural tendons. The "Marks leg" (Fig. 103) dis- penses with a joint altogether, the necessary motion in different directions being provided for by the flexibility and elasticity of the foot itself, which is made of India-rubber surrounding a smaller wooden frame. The "Kolbe leg" (Figs. 164, 165) affords lateral motion at the ankle by giving the steel ankle bolt a globular enlargement at its centre, corresponding to hemispheri- cal depressions in both foot" and leg pieces, the ends of the bolt passing loosely through holes in the metal side straps, and being furnished with India-rubber supports so as to permit the necessary movements. vol. I. — 39 G10 AMPUTATIONS. The use of metallic springs, in artificial limbs for the lower extremity, is now very generally abandoned in favor of those made from India-rubber. Far. 163. India-rubber foot of the " Marks" leg. Air. Heather Bigg, of London, has modified the mechanism of the " Bly leg," by' employing but a single tendon, which passes through the axis of the Fig. 164. Fig. 165. The " Kolhe" \eg. A H, joint of toes ; B, ankle; C, knee ; F F, artificial tibialis amicus ; G G, artificial quad- riceps femoris ; E I and I) K, artificial gastrocnemius and eoleus. Mechanism of ankle in the " Kolbe" leg. joint, while retaining the ball and socket character of the articulation. No artificial leg should bo applied until the stump is thoroughly healed and solid, three months being the minimum interval which should be allowed to elapse after the amputation. Mortality and Causes of Death after Amputations. The rate of mortality after amputation has always been a favorite subject of study with workers in surgical statistics, and, as already pointed out, al- MORTALITY AND CAUSES OF DEATH AFTER AMPUTATIONS. Gil most every inventor of a new method of operating, or new mode of dressing from the days of Benjamin Bell 1 to our own, has adduced figures to prove that his plan is better than that of his predecessors. But the circumstances of cases are so different, that the statistics thus furnished have, so far, been of very little value. If it could be shown that by any special form of opera- tion — -as, for instance, Teale's — -or under any special mode of dressing — as, for instance, Lister's or Guerin's — a large number, say a hundred, con- secutive cases of (1) primary amputation, (2) in the lower third of the thigh, (3) for compound fracture by railway injury, (4) in healthy young men between 20 and 25 years of age, (5) operated on in any particular hospital, and (6) with a certain, definite degree of care exercised in the constitutional and hygienic after-treatment, furnished decidedly better results than the same number of consecutive cases of precisely the same character, and under pre- cisely the same circumstances, except as regards the form of operation or mode of dressing ; such a demonstration would afford a powerful argument in favor of the particular plan recommended. But such a demonstration has not been as yet furnished, nor, indeed, as far as I know, even attempted, by the advocates of any of the methods which have been referred to ; and a mo- ment's reflection will show how useless it must be to compare tables of cases which are really not comparable, either in regard to the age and general con- dition of the patients, the nature of the lesions requiring operation, the hy- gienic surroundings, the care given to after-treatment, or other particulars. Nor can the practice of one surgeon, taken as a whole, be fairly compared with that of another; for they may operate under very different circum- stances: one in a richly endowed and well-ordered hospital, the other in a par- simoniously conducted almshouse; one chiefly upon children, the other almost exclusively upon adults; one principally in cases of chronic joint-disease, the other in cases of very severe and complicated injuries. Again, one surgeon advises and practises the operation of joint-excision, and only amputates in the worst cases, while his colleague amputates in all cases, and of course has better statistics. While, however, I would deprecate any attempt to decide the question of the best mode of operating, or of dressing stumps, by any figures now avail- able for the purpose, I am far from undervaluing the importance of statistical investigation, in winch indeed I have myself done a good deal of work. Certain points in reference to the results of amputations can only be (and, I think I may say, have been) established by statistical inquiry, such as the comparative risks of primary and secondary operation, of operations for injury as compared with those for disease, etc. But before giving the figures which I have collected in reference to these questions, I beg to submit the accompanying Table, containing the record of the first one hundred con- secutive, single, major amputations which I have performed, ipsis m/mibus, during the last nineteen years, taken from my note books. My experience in double amputations has already been given (page 592). I have, besides, done seventeen partial amputations of the hand or foot, all of which have ended in recovery ; this is exclusive of finger and toe amputations, of which I have kept no record. 1 Benjamin Bell, after deploring the large mortality which had hefore his time attended ampu- tation, declared : " In the present improved state of the operation," that is, with the triple inci- sion, of which he considered himself the inventor, " I do not imagine that one death will happen in twenty cases ; even including the general run of hospital practice : and in private practice, where due attention can he more certainly bestowed upon the various circumstances of the ope- ration, the proportion of deaths will be much less." (System of Surgery, Seventh edition, vol. vii. p. 254. Edinburgh, 1801.) 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May July r-H (M O CO CO tH in co r~- 00 en to » » e a t» HNM t- 13- t- ^ PR &4 GIG AMPUTATIONS. O to o i— i H < H £> o gs to O <; O H to o O © P3 Q to P3 to O o H iJ P DC W H a to h- 1 o W W c o U .5 H 1- t, en c - £ "* 2 43 o ^ ft' ►»■=»'§ ti 3 3 03—03 .5 b£? Ill S'S 1 fe 1 t>- 03 C J ft J <^> ^ 5 50 ft S ? fig, . © c 2 a 3 a c rt fe 1 g § a ~ 03 en a o • S s ;£ s- J3 en .£ 8 w t, rt S t, ofl i! e Pn _ ^ V- m « 3) A P, . a 03 £ e3 >% (►» 0) oi .2 T3 T3 d 9 33 - Fh CO — O CN — 1 P* 3 2* 2 en q en ! 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From a death-rate of two in three, which was considered a favorable exhibit by the pioneers in this operation, 1 the mortality, even in city hospitals receiving a fair share of accident-cases, has fallen to one in three or four; 2 and when we consider that a large proportion of our operations are now done for injuries of the gravest character, such as were simply not known in the days of our ancestors, it will be seen that the improvement has been still more marked. And while it, of course, cannot be denied that the death-rate of the operation is still a very high one, it will be found, by an analysis of the causes of death after amputation, that most cases which terminate fatally, do so in consequence of circumstances totally unconnected, if not with the operation, at least with the particular form of the operation, and with the special mode in which the after-treatment is conducted. Thus, taking my own Table of one hundred cases, the deaths are twenty-eight; rather less than the average of hospital practice, but still a large number. But upon looking further, we find that six patients died shortly after the operation, 3 as a direct result of their injuries, and that these six cases included one amputation at the hip, one at the shoulder, and two high up in the thigh. Four cases died in from two to twenty hours, from the shock of the operation, these four including one hip and one shoulder-joint amputation, and one high up in the thigh ; two of the four were more- over intermediate operations, which are well known to be especially apt to prove fatal. Three deaths occurred from secondary hemorrhage ; one of these was after amputation of the forearm by the double flap method, the bleeding coming from the interosseal artery ; the brachial was ligated, but gangrene followed, and hemorrhage recurred and ended fatally eight days afterwards. In a second case, one of amputation of the arm, death occurred on the third day from hemorrhage from the brachial artery which had been secured by acupressure, a mode of treatment which, under the fascination of Sir James Y. Simpson's eloquent writings, I was then using. The third case was one of thigh amputation for acute destructive inflammation of the knee, resulting from syphilis in its worst form, such as we seldom witness at the present day ; the ligatures had come away safely, and rather early, and the patient had been out of bed for about a week, when bleeding from the femoral artery occurred on the 28th day, and death followed in a few hours. Two deaths were from tetanus (existing, in one case, before the opera- tion), two from delirium tremens, and one from acute mania. Eighteen of the twenty- eight deaths in my Table are thus accounted for, and of the remaining ten, six are put down as from exhaustion, and four as from pyaemia. Of the six patients who died from exhaustion, three were over 50 years of age, and all over 35 ; five cases proved fatal in from four to six days (three thigh and two leg amputations), and one, a forearm-ampu- tation which had been complicated by secondary hemorrhage, on the 23d day : this death might have been attributed to pyaemia, or other form of septic poisoning, but that a careful autopsy failed to reveal any lesion significant of such a condition, while it did reveal advanced visceral disease of the heart, liver, and kidneys. All of the six patients were persons in feeble health, and five of them obviously unfavorable subjects for any operation. The first of the four deaths from pycemia occurred on February 2, 1869, and the last on February 2, 1871, the two others having occurred on February 3, and February 7, 1870. Thus, for more than ten years, I have not lost a case of ampu- tation from pyaemia. These four deaths all took place in the same ward of the Epis- 1 Benjamin Bell says: " Before the invention of the tottrniquet, this operation [amputation] was attended with so much hazard, that few surgeons ventured to perform it : nay, long after the introduction of this instrument, the danger attending it was so great, that more than one-half perished of all who had resolution to submit to it." (Op. cit., vol. vii. p. 254.) 2 I am, of course, aware that statistics giving a much smaller death-rate have been published by various hospitals ; but on examining these cases in detail it will generally be found that they embrace a small proportion of amputations for injury, and a large proportion of amputations for disease. 8 One in 2 hours, one in 7 hours, one in 8 hours, one in 18 hours, one on 2d day, one on 3d day. 618 AMPUTATIONS. copal Hospital, and from these limitations of time and space, and from the fact that I dressed stumps then precisely as I did before and have done since, I am disposed to attribute them to local and climatic rather than to any other causes. Table showing Causes of Death in Twenty-eight Fatal Cases of Major Amputation. Direct result of injury hock Secondary hemorrhage Tetanus . Delirium tremens . Acute mania Exhaustion Pyaemia . Total 1 6 4 28> Deducting six deaths from the direct result of injury, and three from delirium tre- mens and acute mania — which have certainly no connection with the operation per se — the mortality would be reduced to a little over 20 per cent., or one in five. My first 50 cases gave 18 deaths (including all that have occurred from pyaemia), or, making the corresponding deductions, 14 out of 46, a mortality of 30 per cent. ; while my second 50 cases gave but 10 deaths, or, with the corresponding deductions, 5 out of 45, a mor- tality of only 11 per cent. The mortality after amputation is influenced by various circumstances which are quite independent of the skill of the operator, the most important being the age, constitutional condition, and sex of the patient, his hygienic sur- roundings before and after the operation, the nature of the lesion for which amputation is performed, the period of operation, and the part of the body in- volved. A few remarks upon each of these points will conclude what I have to say as to the causes of death after amputation. Age of Patient. — Amputations in children are usually successful. The remarkable case of synchronous amputation of the hip and leg, which I have recorded on page 591, would not have ended in recovery had the patient been an adult. Statistics showing the effect of age in determining the results of amputations have been collected by several writers, among whom I may par- ticularly mention M. Malgaigne, of Paris, the late Mr. Callender, Mr. Holmes and Mr. Golding-Bird, of London, Dr. Gorman, of Boston, and Dr. Morton, of Philadelphia. The last-mentioned surgeon, 2 from an analysis of 982 cases of amputation treated in the Pennsylvania Hospital during 50 years, from 1830 to 1879, gives the following Table showing the figures bearing upon this point: — Table showing the effect of Age on the Results of Amputation at the Pennsylvania Hospital. Cured. Died. Total. Mortality per cent. From 1 to 10 years, there were .... " 10 " 20 """... . " 20 " 30 """... " 30 " 40 """... . " 40 " 50 " " 50 " GO """... Upwards of 60 """.... 70 218 220 132 3 63 24 10 11 40 75 61 36 14 8 81 258 295 193 99 38 18 13+ 15+ 25+ 31+ 36+ 36+ 44+ Total number of cases .... 737 245 982 25— ' I have not included among tin- fatal eases that of a woman who, two weeks after her stump had completely healed, aborted of a six months' child, and subsequently died, after the opening (by another surgeon) of a pelvic abscess. 2 Surgery of the Pennsylvania Hospital, etc., p. 33. By Thomas G. Morton, M.D., and William Hunt, M.D., Surgeons to the Hospital. Philadelphia, 1880. 3 Clerical error in original Table corrected. MORTALITY AND CAUSES OF DEATH AFTER AMPUTATIONS. 619 Mr. Golding-Bird 1 has in a similar manner analyzed the results of 559 am- putations practised at Guy's Hospital during 15 years, from I860 to 1874 (in- clusive), and shows that they were as follows: — Table showing the effect of Age on the Results of Amputation at Guy's Hospital. Cured. Died. Total. Mortality per cent. Patients less than 20 years old .... " from 20 to 40 " .... " oyer 40 years old ..... 121 145 95 33 78 87 154 223 182 21.4 34.9 47.8 Total number of cases .... 361 198 559 35.4 Dr. Gorman's 2 statistics, derived from the practice of the Boston City Hos- pital, give the results of 285 terminated cases of amputation in persons whose age was ascertained. The results are shown in the following Table : — Table showing the effect of Age on the Results of Amputation in the Boston City Hospital. Cured. Died. Total. Mortality per cent. Patients less than 20 years old .... " from 20 to 40 " .... " over 40 years old ..... 50 94 40 22 47 32 72 141 72 30.5 33.3 44.7 Total number of cases .... 184 101 285 35.4 Mr. Holmes's statistics 3 are derived from the practice of St. George's Hos- pital, and embrace 500 cases. I have re-arranged his table so as to make it correspond in form with those which I have already given. Table showing Effect of Age on Results of Amputation at St. George's Hospital. Cured. Died. Total. Mortality per cent. Patients less than 5 years old ..... 4 1 5 20.0 " between 5 and 10 years old 18 2 20 10.0 " " 10 " 15 " 33 4 37 10.6 « u 15 « 20 " 53 15 68 22.6 " " 20 " 30 " 90 30 120 25.0 " " 30 " 40 " 57 38 95 40.0 " " 40 " 50 " 46 29 75 31.3 « (i 50 tt 60 tt 25 26 51 50.9 u u go " 70 " 12 11 23 47.9 " over 70 years old 4 2 6 33.3 Total number of cases ..... 342 158 500 31.6 Mr. Holmes particularly points out, in regard to these cases, that two of the three deaths in patients less than 10 years of age were totally unconnected 1 Guy's Hospital Reports, 3d s., vol. xxi. p. 253. 2 Medical and Surgical Reports, Second series, 1877, p. 291. Dr. Gorman's Tables embrace in all 299 cases, but in 3 cases the result was not determined, and in 11 more the age of the patient is not given. 3 St. George's Hospital Reports, vol. viii. p. 269. 620 AMPUTATIONS. with the operation, and that, on the other hand, the patients over 60 years of age presented more than ordinarily favorable cases — four of the amputations in those over 70 having been of the forearm, and in those between 60 and 70 hardly any of the amputations having been for injury of the lower extremity. The late Mr. Callender, in 1864, presented to the Royal Medical and Chi- rurgical Society of London, 1 statistics of 358 amputations performed during ten years at St. Bartholomew's Hospital. The deaths at different ages in 227 of these cases, are shown in the following Table : — Table showing effect of Age on Results of Amputation at St. Bartho- lomew's Hospital. Cured. Died. Total. Mortality per cent. Patients less than 10 years old . ; ' between 10 and 20 years old 20 " 30 " " 30 " 40 " " 40 " 50 " 50 " 60 " 60 " 70 " " 70 " 80 " 8 50 46 26 23 16 4 1 3 13 7 13 9 3 5 8 53 59 33 36 25 7 6 0.0 5.6 22.4- 21.2 36.1 36.0 42.8 83.3 Total number of cases ..... 174 53 227 23.3 M. Malgaigne's figures 2 embrace 560 cases, of which 299 terminated fatally. Table showing the Effect of Age on Results of Amputation in Parisian Hospitals. Cured. Died. Total. Mortality per cent. Patients less than 5 years old . " between 5 and 15 years old " " 15 " 20 " " 20 " 35 " " 35 " 50 " " 50 " 65 " " more than 65 ... . 2 44 45 91 50 20 9 3 22 36 102 76 50 10 5 66 81 193 126 70 19 60.0 33.3 44.4 52.8 60.3 71.4 52.6 Total number of cases ..... 261 299 560 53.3 My own Table tells a similar tale of mortality increasing with advancing years ; the larger mortality between the ages of 20 and 30 than between those of 30 and 40, is explained by the circumstance that the cases in the former category embraced two fatal amputations at the hip-joint, and one fatal (in- termediate) amputation at the shoulder-joint. 1 Transactions, vol. xlvii. p. 75. 2 Archives Gcnerales de Medecine, Mai, 1842, pp. 59, 61. MORTALITY AND CAUSES OF DEATH AFTER AMPUTATIONS. 621 Table showing Effect of Age in One Hundred Cases of Amputation. Cured. Died. Total. Mortality per cent. Patients less than 10 years old .... " between 10 and 20 years old " " 20 " 30 " . . " " 30 " 40 " . . " " 40 " 50 " . " more than 50 " " of uncertain age ; "adults" 7 26 15 13 5 4 2 2 8 5 5 6 2 7 28 23 18 10 10 4 0.0 7.1 34.7 27.7 50.0 60.0 50.0 Total number of cases 72 28 100 28.0 In order to show the correspondence with each other of these statistics derived from different sources, I have compiled the two following tables, showing (1) the percentage of mortality at the three periods of life: under 20 years, from 20 to 40, and over 40— the classification adopted by Mr. Golding-Bird ; and (2) the percentage of mortality before and after 30 years of age — the division adopted by Mr. Holmes : — Table showing Percentage of Mortality at Different Ages. 1 Whole number of cases. Mortality below 20 years, per cent. Mortality betweeu 20 and 40, per cent. Mortality over 40 years. per cent. General death-rate, per cent. Pennsylvania Hospital .... Guy's Hospital ...... St. George's Hospital ..... St. Bartholomew's Hospital Boston City Hospital ..... Author's cases 2 ...... 982 559 500 227 285 96 15.0 21.4 16.9 4.9 30.5 5.7 27.8 34.9 31.6 21.7 33.3 31.7 37.4 47.8 43.8 40.5 44.7 55.0 25.— 35.4 31.6 23.3 35.4 27.+ Total number of cases 2649 16.7 30.1 43.4 29.4 Table showing Percentage of Mortality before and after Thirty Years * of Age. 3 Whole number of cases. Mortality below 30 years, per cent. Mortality over 30 years, per cent. General death-rate, per cent. St. George's Hospital ...... St. Bartholomew's Hospital ..... 500 227 96 19.8 20.8 13.3 17.2 34.2 42.4 34.5 42.1 25.+ 31.6 23.3 27.+ Total number of cases .... 1805 19.2 37.4 26.7 These Tables, the figures of which are sufficiently large to afford informa- tion of value, show, it seems to me, very conclusively, the influence of age on the results of amputations ; they show (1) that in persons less than twenty years old, the operation is a comparatively safe one, but that in patients from twenty to forty, it is nearly twice, and in those over forty, not far from three 1 M. Malgaigne's statistics do not give the ages in such a way as to be included in this Table. 2 Age in 4 cases not stated. 3 M. Malgaigne's, Mr. Golding-Bird's, and Dr. Gorman's Tables do not show how many patients were under and how many over thirty years of age. 4 Age in 4 cases not stated. 622 AMPUTATIONS. times as apt to be followed by death as during the earlier period ; and (2) that in persons more than thirty years of age, amputation is almost twice as fatal as in those who are younger. Constitutional Condition. — The influence of pre-existing constitutional affections on the results of injuries and surgical operations in general, has been forcibly set forth by Prof. Verneuil in a preceding article of the present volume (page 307), and the same lesson has been taught by Dr. Brinton in his remarks on Operative Surgery in General (page 463). It remains for me therefore, in this place, merely to adduce certain particular illustrations of the truth of these doctrines as applied to amputations. Mr. Birkett 1 has recorded the results of 167 single amputations, mostly performed by himself in the wards of Guy's Hospital. Of the whole number of cases, 53 proved fatal, 10 dying from the immediate effects of the injuries for which the ope- ration was performed, and 22 (or more than half of the remainder) being proved by post-mortem examination to have been the subjects of chronic disease of the viscera, while in fifteen more the patients' powers of nutrition were evidently impaired before the operation. Mr. Holmes, in his two papers, 2 has recorded 500 cases, of which 148 proved fatal : in 33 of these, the patients' death was inevitable, resulting from causes unconnected with the operation ; and in 57 more, death, though probably not inevitable, was mainly due to visceral disease or other morbid conditions existing prior to the amputation. Mr. Bryant's Table of 300 cases 3 shows that well-marked visceral disease was the cause of death in 13 per cent, of all fatal cases, and in Mr. Calender's Tables of 358 cases, 4 the mortality from the same cause was over 16 per cent., while Dr Chevers, in his Inquiry into the causes of death after injuries and surgical operations (not exclusively amputations), 5 found that of 153 fatal cases, the kidneys were markedly diseased in at least 72, the liver and spleen also being often affected, and that "in a rather large proportion of these cases, the disease of the liver, spleen, and kidneys had evidently existed for a very considerable time previous to the patient's receiving the wounds or injuries which became the apparent primary causes of death." Sex. — The influence of visceral disease upon the mortality of amputations, is, of course, largely concerned in rendering the operation more fatal among adults than among children — healthy viscera being the rule in childhood ; and the same influence is no doubt shown in the slightly greater risk in per- sons of the male than in those of the female sex — men, at the period of life at which most amputations are performed, being, from their habits and modes of living, probably more apt to be the subjects of visceral disease than women of the same age. This point may be illustrated by Dr. Steele's Tables of 507 eases of amputation in Guy's Hospital during the fifteen years from 1854 to 1868. 6 The mortality among males was 37.7 per cent., but among females only 21.5 per cent. In Malgaigne's 560 cases 7 of major amputation derived from various French hospitals, the male mortality was over 55 per cent., the female less than 47 per cent. ; and in Trelat's 1144 cases, 8 also derived 1 Guy's Hospital Reports, 3d s., vol. xv. p. 502. 2 St. George's Hospital Reports, vol. i. p. 291, and vol. viii. p. 269. 1 Medico-Chirurgioal Transactions, vol. xlii. p. t>7. 4 Ibid.; vol. xlvii. p. 75. 5 Guy's Hospital Reports, 2d s. vol. i. p. 78. 6 Guy's Hospital Reports, 3d s. vol. xv. p. (500. I hare not utilized Dr. Steele's statistics as to the effects of age, because his Tables are overlapped by those of Mr. Golding-Bird, which are somewhat larger. 7 Archives Generates . 'VI. Philadelphia, 1880. " Traite de Chirurgie d'Armee, pp. 722-736. Paris. 1863. 12 Circular No. 6, S. G. 0. Washington, 1865 ; and Medical and Surgical History of the War of the Rebellion. Part Second, Surgical volume. 13 Supra, p. 612. 14 Circular No. 6, S. G. O. Washington, 1865, p. 43. AMPUTATIONS OF THE FINGERS. G31 SPECIAL AMPUTATIONS OF THE UPPER EXTREMITY. Amputations of the Fingers. The surgeon is frequently called upon to amputate a part or the whole of a finger, or even several ringers, in cases of injury by gunshot wound or ma- chinery, neglected felon, destruction of the interphalangeal joints by syphilitic disease, etc. As no artificial substitute can possibly replace even for a moder- ate degree of usefulness, the natural finger, it should be the surgeon's aim to save every portion that can possibly be preserved; hence, if part of a phalanx can be left, this should be done, rather than amputate at the joint above. The only exception to this rule is in the case of the proximal phalanges of the middle and ring fingers; as there is no special flexor tendon for these parts, they are apt, if preserved, to project stiffly, and to rather hinder than assist the usefulness of the rest; hence when, in these fingers, it is necessar v to remove all except the proximal phalanges, it is proper to take these away also, and amputate at the phalangeo-metacarpal joint. In the case of the forefinger, however, even part of a phalanx is of value, as affording a point of opposition to the thumb, while in the little finger, the proximal phalanx may be kept in order to give greater symmetry to the hand than it would otherwise possess. Amputation through a Phalanx may be most conveniently done by the flap method; either by the old plan of Heliodorus (generalized by Ravaton), of making a circular incision down to the bone, and then forming" two scpiare flaps by adding longitudinal incisions on either side ; or by shaping antero- posterior, semicircular flaps from without inwards. The bone may be divided either with a small saw or with cutting pliers, and the wound accurately closed with three or four points of the metallic suture. Two vessels usually bleed — the digital arteries on either side — and these can commonly be con- trolled by passing the stitches through their mouths, without the use of ligatures. The whole hand and forearm should be placed upon a well-padded splint, and thus kept at rest for about a week after the operation. Amputation through either of the Interphalangeal Joints may be readily effected by the single (palmar) flap, or by the double flap method. The circular operation has also been em- ployed in disarticulations of the phalanges, Fig. 166. but seems to me to be less advantageous than the flap method in this locality. The most important point to be borne in mind, in these operations, is that the joint is always found below the prominence of the knuckle, which is caused by the projection of the upper bone, as shown in the accom- panying illustration (Fig. 166), suggested by a cut in M. Fort's excellent work on Opera- tive Surgery ; in the case of the last or distal „, , . , . . . ^ , . . . -. s -i t n •• • 7- -i Skeleton of a finger, showing the relation of phalanx, the line ot the joint is one line {■£% the knuckles to the joints. 632 AMPUTATIONS. Amputation of finger by palmar flap method. inch) below the most projecting part of the knuckles; in that of the middle phalanx, two lines (\ inch) below; and in that of the first or proximal phalanx, four lines (J inch) below the corresponding prominence. It will be found convenient, in disarticulating the phalanx, to employ a slender and rather short knife, with a heavy back. (Fig. 121.) (1) Single Flap Operation. — The flap is usually and preferably taken from the palmar surface (Fig. 167), which affords a firm covering for the stump, and one which at the same time possesses tactile sensibility. Le Dran, how- ever, preferred to take a flap from the side of the linger, 1 while La Roche and Walther took one from the back ; 2 the only advantage of this plan was that the resulting cicatrix was less apparent, whence A. Gruerin tells us that it was called the "rich man's operation." 3 The palmar flap may be cut either by transfixion or from without in- wards, and its formation may con- stitute either the first or second stage of the operation. If the flap is to be made first, the patient's hand should be held in a supine position, and the knife entered, in the case of the last phalanx a little below, and in that of the middle phalanx on a level with, the palmar crease corresponding to the articulation. The flap should be a little longer than the diameter of the finger, and its width should be as nearly as possible half the circumference; its ends should be rounded, but not too much bevelled, for fear of sloughing. If transfixion is employed (Lis- franc's method), the knife must be kept close to the bone, or the flap will be too narrow. The flap having been formed, the knife is turned with its edge towards the joint, at the upper part of the wound, and, the palmar and lateral ligaments having been divided, disarticulation is effected, and the structures on the back of the finger severed at a single stroke. A better plan is, I think, to attack the joint from its dorsal surface, the hand being held prone, and the finger flexed till the joint has been opened and the lateral ligaments divided ; then the knife, placed at the bottom of the wound, is turned flat- wise, and, the finger being extended, a flap of sufficient length and breadth is cut by a sawing motion. A. Guerin prefers to make the flap first, by trans- fixion, as in Lisfranc's method, and then, having pronated the patient's hand, to open the joint and effect disarticulation from the dorsal surface. (2) Double Flap Operation. — Where the surgeon has the opportunity of choosing his mode of amputating through one of the interphalangeal joints, the single palmar flap method gives, I think, the best result; but it may happen, in cases of lacerated wound, etc., that the palmar tissues are deficient, and that the operator must either utilize the structures on the back of the finger, or remove more of the bone than is desirable. Under these circum- stances both a dorsal and a palmar flap may be formed, by cutting from with- out, inwards, disarticulation being then effected, and the operation completed, in the manner already described. This, which is the plan recommended by Richerand and Gouraud, seems to me to be in every way preferable to the lateral-flap operation of Maingault. Amputation of an Entire Finger. — Disarticulation at the metacarpo- phalangeal joint of any of the fingers may be conveniently accomplished by 1 Dnbreuil, Manuel d'Oporatious Chirurgicales, p. 86. Paris, 18G7. 8 Ibid. 3 Op. cit., p. 108. AMPUTATIONS OF THE FINGERS. 633 the oval method of Scoutetten, or, which is better, its modification, the ope- ration u en raquette" of Malgaigne; by the double (lateral) flap method; or, in the case of the thumb, by taking a single flap from either the dorsal or the palmar surface. The circular and elliptical operations have also been em- ployed in this situation, but are less desirable than those above mentioned. (1) Oval Method. — The simple oval method, or that of Scoutetten (see Fio-. 149, a, page 584), has the disadvantage of often not affording a sufficient covering for the head of the metacarpal bone, and I shall, therefore, describe Malgaigne's modification only, which is not open to this objection. In per- forming this operation (Fig. 149, b), the hand of the patient should be pro- nated, and the surgeon begins by making a longitudinal incision of half or three-quarters of an inch over the head of the metacarpal bone ; from the lower third of this wound, the knife is carried obliquely downwards on the right side to the interdigital web, then transversely across the base of the finger, and finally obliquely upwards to again join the longitudinal incision. All the tissues down to the bone should be divided, when, the joint having been exposed by a little dissection, the extensor and flexor tendons, and lateral ligaments, are severed, and, disarticulation being thus completed, the sides of the wound are finally brought together in an antero-posterior direc- tion. In the case of the forefinger, however, the point of the oval should be on the radial, and in the case of the little finger, on the ulnar side of the joint ; and in these cases the wound should be closed transversely. (2) Double Flap Method. — In this operation (Fig. 168), lateral flaps are cut from without inwards, from either side of the finger which is to be removed. This plan, which is known as Petit's, is I think better than either that of Rossi, who made both flaps by transfixion, or that of Lisfranc, who cut one flap from without inwards, before disarticulating, and the other subsequently from within outwards. Sharp's and Ga- rengeot's methods, in which antero-posterior flaps were employed, are also less desirable than Petit's. The ad- vantage of this operation over the oval method, is that is does not leave a pocket of palmar tissue, in which pus may accumulate; but, on the other hand, the oval method leaves the palm entirely free from the cicatrix, and thus gives at last a better result, though the wound may not heal as quickly as after the flap operation. (3) Single Flap Method. — This operation, which is known as Chassaignac's, seems to be less advantageous than either the oval or double flap method, except in the case of the thumb. The flap may be taken from either the dorsal or palmar surface, the latter plan being, I think, preferable. The joint is opened at the back, and, after disarticulating, the flap is cut from within outwards as in the case of the interphalangeal amputations which have already been described. Some surgeons advise that the head of the metacarpal bone should be removed, in these amputations, in order to render the loss of the finger less apparent by permitting the others to come more closely together ; but what is gained in symmetry, is no compensation for the loss of strength in the hand, thus entailed; there is, moreover, a positive risk in thus opening the deep structures of the palm, suppuration in that part being extremely painful, and apt to extend upwards along the planes of connective tissue in the forearm, thus causing prolonged disability and even endangering life. Amputation of entire finger by double flap method. 634 AMPUTATIONS. Fig. 169. Amputation of two fingers by oval method. Amputation of two Adjoining Fingers simulta- neously, at their metacarpal articulations, may be effected by the circular, oval (en raquette, Fig. 169), or elliptical methods, or by taking a flap from the palm (Lisfranc), or from the side of one finger (Chassaignac). A better, if less brilliant, plan is, I think, to amputate each finger separately by whatever method seems best adapted to the particular requirements of the case. Amputation of the Four Fingers simultaneously, may likewise be done by the circular, elliptical, or palmar-flap methods, the elliptical operation being brobably the best of the three. Here, too, I think that the surgeon will usually do better to forego bril- liancy, and remove each finger separately in whatever way may seem best. Amputations of the Hand. Partial amputations of the hand are not unfre- quently required in cases of laceration by gunshot in- jury or by machinery, and there are no cases which more than these test the ingenuity and skill of the surgeon in preserving for his patient a useful member. The thumb is of more value than any other part of the hand, and an effort Fig. 170. should be made to save every portion that is not hopelessly injured. I have removed all of the hand, except the thumb, through the metacarpus ; have saved the thumb and forefinger, removing the rest of the hand quite up to the wrist ; and have similarly preserved the thumb and little finger (Fig. 170), or even a single finger, with its metacarpal bone, the w T hole car- pus being removed, and the part of the hand that was left being allowed to be gradually drawn up in contact with the bones of the forearm. Amputation of the Thumb through its Metacarpal Bone may be best effected by the oval (en raquette) method, the point of the oval being placed on the outer side, and the bone divided at the required point with strong cutting pliers. This operation is very seldom practised. Amputation of the Thumb with its Metacarpal Bone may be conveniently effected by either the oval (en raquette), or the flap method, and, if the latter l)c employed, the flap may be taken either from the outer (radial) side of the hand, or from the palmar surface. (1) Oval Method.— If this operation be practised, the point of the oval should be placid upon the dorsal surface, and should be prolonged upwards as far as the carpo-metacarpal articulation ; the sides of the wound are brought to- ,0? J f ' ,nf, lii'"^** Result of partial amputation of hand, the thumb and little finger being preserved. AMPUTATIONS OF THE HAND. 635 gether in a longitudinal direction, and the resulting cicatrix is small and well protected. (2) External Flap Method. — The formation of the flap may be either the first or the last step of the operation. If the former plan is to be adopted, the patient's thumb is forcibly abducted, the hand being supinated for the right and pronated for the left side. The knife is applied to the interdigital web, and made to cut its way upward with a sawing motion until the joint is reached ; then the edge of the knife is turned outwards, disarticulation effected, and, the tissues being pushed to the radial side, the flap is made by cutting downwards for a sufficient distance, grazing the bone, and finally outwards. If preferred, the flap may be formed first, either by transfixion or by cutting from without inwards, disarticulation effected from the outer side of the joint, and the tissues of the interosseous space divided as the last step of the operation. (3) Palmar Flap Method. — This variety of amputation, which is known as Chassaignac's, gives a result closely approximating to that of the oval method. In the case of the right thumb, the flap is made by transfixion, a strong but slender knife being inserted just in front of the carpo-metacarpal joint, thrust downwards till its point emerges at the interdigital web, and then made to cut its way out opposite the metacarpophalangeal joint, thus forming an oval flap from the palm; disarticulation is next effected (Fig. 171), and "the ends of the first wound united by cutting through the dorsaf tissues from without inwards. In the case of the left thumb (Fig. 172) the dorsal incision is made Fig. 171. Fig. 172. Amputation of right thumb by palmar flap method. The flap has been formed, and the knife is effecting dis- articulation. Amputation of left thumb by palmar flap method. first, disarticulation effected from behind, and the knife, being thrust in front of the bone, made to cut the palmar flap of the requisite size and Bhape, as it is brought out with a sawing motion. Of these various methods, I "decidedly recommend the first (oval method), as, though less brilliant, giving a better result than either of the others. _ Amputation through One or More Metacarpal Bones may often be prac- tised with advantage. The oval method (en raquette) may be conveniently 636 AMPUTATIONS. Fig. 173. adopted in these operations, the point of the oval being placed upon the dor- sal, or, in the case of the fifth metacarpal , upon the inner (ulnar) surface. In many cases, however, the laceration of the soft parts will he such that no regular procedure can be followed, but the surgeon will be compelled to secure a covering for the bone from any portion of tissue which is uninjured. Amputation of the Fifth Metacarpal Bone may be effected by either the oval {en raquette), or the internal flap method, the former, as in the case of the thumb, being preferable, inas- much as the resulting cicatrix is smaller and better protected. The point of the oval may be placed either on the dorsal, or on the inner (ulnar) surface of the hand, and prolonged upwards as far as the carpo-metacarpal joint. If the flap method (Fig. 173) be employed, the flap, which is formed from the tissues on the inner (ulnar) side of the hand, may be made either before or after dividing the interosseous structures, and either by trans- fixion or by cutting from without Amputation of fifth metacarpal by internal flap method. lllWarClS. Amputation of the Metacarpal Bone of either the Fore, Middle, or Ring Finger, or of two or more of them simultaneously, may be best done by the oval {en raquette) method, the point of the oval being placed upon the back of the hand, beginning from a third to half an inch above the line of the articu- lation. In order to gain more ready access to the joint, Seclillot advices that a short transverse incision should be made at the upper end of the oval, so as to mark out two triangles of tissue, which may then be raised as lateral flaps. Amputation of the Ulnar portion of the Metacarpus, involving the fourth and fifth metacarpals, or these together with the third, may also be conve- niently done by the oval method, the point of the oval in this case being placed on the ulnar side. Dorsal and palmar flaps are employed by some sur- geons in the performance of this and the preceding form of amputation, but the flap method, in this situation, seems to me more complicated, and in no respect more advantageous, than the simpler oval operation which I have described. Amputation of the Entire Metacarpus, except the Thumb, is, however, besl done by taking a palmar flap, cut from without inwards. An excellent stump is thus produced, and, the thumb remaining, one which will prove of great value to the patient. Amputation of the Entire Metacarpus, including the Thumb, and Am- putation between the two rows of the Carpus, may both be effected by either the circular, elliptical, or antero-posterior flap method. Neither of these operations, however, presents any particular advantage, and both seem to me less desirable than amputation at the wrist, suppuration being apt to occur in the inter-carpal joints, when they have once been opened, and ne- crosis of the carpal bones often following, and of course delaying recovery. AMPUTATION AT THE WRIST. 637 Excision may be sometimes substituted for amputation of a metacarpal bone, when the finger itself is not injured, but such an operation is not usu- ally very satisfactory. Prof. Joseph Pancoast has successfully adapted a fin- ger which had lost its metacarpal bone, to another metacarpal bone which had, in turn, lost its finger. After all amputations of the hand, as after those of the lingers, the part should be kept upon a splint until the deep parts of the wound have united. The risk of amputation below the wrist is very slight. I have kept no record of my own finger amputations, but do not recall any w r hich have terminated unfavorably. Thirteen cases of partial amputation of the hand, of which I have notes, all ended in recovery. The following Table exhibits the mortality of these operations in hospital and army practice ; the death- rate of finger amputations is seen to be but about one in thirty, and that of amputations through the hand, about one in fifteen. Table showing the Mortality of Amputations of the Fingers and Partial Amputations of the Hand. Fingers or Thumb. Fartial of Hand. Authority. Cases. Deaths. Mortality per cent. • Cases. Deaths. Mortality per cent. Malgaigne 1 .... Legouest 2 ..... Otis 3 Morton 4 ..... Author 5 ..... 165 320 5739 15 45 129 9.4- 14.4- 2.2 9 53 950 58 13 1 21 50 11.1 39.6 5.4- 0.0 0.0 Totals 6224 189 3.3 1083 72 6.6 Amputation at the "Wrist. The whole hand may be removed at the radio-carpal articulation, by either the circular, the elliptical, or some variety of the flap method. The result- ing stump is usually a very good one, and possesses the advantage of allowing .the retention of the motions of pronation and supination, but, on the other hand, is said to be less well fitted than a shorter stump for the adaptation of an artificial hand. Circular Method. — The back of the hand and forearm having been shaved, if necessary, and the tourniquet adjusted so as to control the circula- tion through the brachial artery, an assistant grasps the hand and holds it firmly, wdiile the surgeon with his own left hand draws the skin of the fore- arm upwards, and makes his first incision on a level with the carpo-meta car- pal articulation of the thumb and fifth finger, from an inch to an inch and a half, therefore, below the joint of the wrist. As the integuments in this situation are ample, and loosely attached, it is usually possible to retract them sufficiently, after the first incision, by the aid of light touches of the knife, without any regular dissection ; when the wrist is reached, the part is held in a position midway between pronation and supination, and the 1 Archives Generales de Medecine, Avril, 1842, pp. 413, 416. 2 Traite de Chirurgie d'Armee, p. 721. Paris, 1863. 3 Medical and Surgical History of the War of the Rebellion, Part Second, Surgical volume, p. 1019. 4 Surgery of the Pennsylvania Hospital, etc., p. 32. s Supra. 638 AMPUTATIONS. joint opened from the radial side. Disarticulation having been effected, the cut vessels are secured (three or four commonly require attention), and the wound is closed transversely. Elliptical Method. — This is, upon the whole, probably the best operation in this particular situation. The lower segment of the ellipse may be made from either the palmar or the dorsal surface of the hand, the former plan being preferable as giving a firmer covering for the ends of the bones. The patient's hand being supinated, the surgeon begins his incision, with a strong, short-blacled knife, about three-quarters of an inch below the styloid process of the radius, curves it downwards through the tissues of the palm to a point about an inch lower, and then upwards again to three-quarters of an inch below the styloid process of the ulna; the hand is then pronated; and the ends of the first incision joined by another, slightly curved upwards, and crossing the back of the hand about half an inch below the joint. The cuff thus marked out having been dissected upwards as far as necessary, disarticu- lation is effected from the radial side, and the operation terminated as in the circular method. The wound forms a curved cicatrix on the dorsal side of the stump, the bones being covered by the firm tissues of the palm. Flap Methods. — Of these, the best is the single palmar flap method (Fig. 174), the flap being cut from without inwards, and the result of the operation Fig. 174. J3/ Amputation at wrist by palmar flap method. closely approximating to that of the elliptical method, as just described. The formation of a flap by transfixion, as practised by Lisfranc, is attended with much difficulty, and is now generally abandoned. Another plan is to employ two flaps — either lateral or antero-posterior — but I do not recommend this mode of procedure. A better plan (but still inferior, I think, to either the palmar flap or the elliptical method), is that of Dubrueil, who makes a single external flap, from the tissues around the metacarpal bone of the thumb. Amputation at the wrist joint appears to be seldom performed either in civil or in military practice; I have myself done it but once, for gunshot injury, in a lad of seventeen who made a good recovery. The death-rate, as shown by the following Table, appears to be unduly high — a circumstance AMPUTATION OF THE FOREARM. 639 which is due to the large proportion of cases derived from the records of the French army in the Crimea, in which service amputations of all kinds proved to be of exceptional gravity. Table showing the Mortality of Amputations at the \Vrist. Authority. Malgaigne Trelat . Legouest Otis Aggregates Cases. Deaths. 16 27 6 77 36 66 7 186 49 Mortality per cent. 0.0 22.2 46.7 10.6 26.3" Reference. Archives Gen. de Medecine, Avril, 1842. Legouest, Traite de Chirurgie d'Ariuee, p. 722. Paris, 1863. Ibid. Med. and Surg. History of the War, etc. Amputation of the Forearm. The best operation in this situation is, under ordinary circumstances, the circular, though very good stumps may be made by several of the flap methods. The amputation may be done at any part of the limb, the disad- vantages supposed by Larrey to attend division of the tendinous structures at the lower part of the forearm, being more imaginary than real, and there being a positive advantage in making the stump as long as practicable. Circular Method. — If the limb be conical, as it usually is except in very thin persons, there may be some difficulty in turning up the tegumentary cuif, in the circular operation, when it will be advisable to slit the cuff upon the ulnar side. If the tendons elude division, in amputating at the lower part of the limb, the knife may be slipped beneath them and they may be out from within outwards. In sawing the bones, the limb should be placed in a position midway between pronation and supination, so that both bones may be divided at the same level. Five or six vessels commonly require ligation, in forearm amputations, and of these the anterior and posterior interosseous are those that give the most trouble, from their tendency to retract between the bones, where it may be difficult to discover them. Flap Methods. — The most brilliant operation is that made by taking antero-posterior flaps (see Fig. 150, page 586), the posterior flap being shaped from without inwards, and the anterior being cut either in the same way, or by transfixion, according to the fancy of the operator. I have more than once known consecutive hemorrhage to follow this particular form of opera- tion, apparently from the interosseous artery having been divided obliquely, and as a consequence not being properly secured by the ligature ; hence I have been led to prefer, in this situation, either the circular operation or Teak's method, in which this complication is more readily avoided. In practising Teale's method (Figs. 151, 152, pp. 587, 588), care must be taken to mark, out the flaps by measurement before attempting to cut them, as otherwise, from the conical shape of the limb, the long flap will be apt to be made too narrow at its distal extremity. In any of the flap methods, trouble may be experienced from the tendons projecting beyond their sheaths. Should this occur, each tendon should be separatelyseized with forceps, drawn down, and cut off at as high a point as possible. 1 Omitting Legouest's cases, the mortality would be about 12 per cent., which would, I believe, be a fairer statement. 640 AMPUTATIONS. Mixed Methods. — Sedillot makes superficial flaps, and divides the deeper tissues circularly, while on the other hand Richet makes a circular incision through the skin and fascia, and then forms muscular flaps by transfixion. I see no advantage in either of these/ proceedings over those more commonly adopted. The mortality after amputation of the forearm is, as shown by the Table on page 630, 19.4 per cent., or about one in five. It would appear from Otis's statistics, 1 that the results are slightly more favorable for amputations at the middle of the forearm than for those at either extremity, though among the smaller number of cases embraced in Gorman's Tables, 2 amputations of the middle third proved the most fatal. Amputation at the Elbow. This operation appears to have been first performed by the illustrious Ambroise Pare, 3 in the case of a soldier whose arm became gangrenous after a severe wound from an arquebuse. The patient was attacked with tetanus fifteen days after the operation, but eventually made a good recovery. Amputation at the elbow may be performed by either the elliptical, the circular, or one or other variety of the flap method, the first-named plan being, I think, upon the whole the best. Elliptical Method. — The lower segment of the ellipse should be placed upon the back of the forearm (see Fig. 148, page 583), where the tissues, though not very thick, are resisting, and accustomed to support pressure. The arm being semiflexed, the point of the knife is entered nearly an inch below the internal condyle of the humerus, curved upwards over the front of the forearm nearly to the line of the joint, and downwards again to a point an inch and a half below the external condyle ; the arm being then forcibly flexed, the ellipse is completed on the back of the forearm by a curved incision passing nearly three inches below the tip of the olecranon. The cuif thus marked out is rapidly dissected upwards as far as necessary, when the mus- cles of the front of the forearm are cut about half an inch below, and the ulnar nerve as far above the joint, and disarticulation is effected from the outer side. Some surgeons leave the olecranon in situ, sawing across its base ; but it is apt to become necrosed under these circumstances, and, altogether, I see no advantage to be gained by its retention. The vessels requiring liga- tion, in this operation, are the brachial — or the radial and ulnar, according to the exact line of the deep incision — with some smaller anastomotic branches. The wound is closed transversely, forming a small curved cicatrix in front of the bone, which is well covered. Circular Method. — In this operation, which also makes a good stump, the first incision is placed two and a half or three inches below the line of the joint. It is better not to cut through the muscles, but to adopt Velpeau's plan, ami dissect up the cuff of integument to the necessary height, and then effeel immediate 6. Paris, 1731. 2 M6moirea de I'Aoadfimie Royale de Chirurgie (an 1740), t. ii. p. 166. 3 Cours d'Op6rations <1<; Chirurgie, p. 758. Paris, 1740. Paris, 1819. AMPUTATION AT THE SHOULDER. 645 from an amputation by this method is seen in Fig. 178, from a photograph of a lad under my care many years ago at the Episcopal Hospital. Air. Spence has modified this operation by making the first (longitudinal) incision much longer, as if for excision of the caput humeri, and making the branches of the oval more nearly transverse than in Larrey's method. External Flap Method. — This method was first described in print by M. Grosbois, who claimed it as his own in a thesis published in 1803, but it is believed by Velpeau, Sedillot, and other French authorities, to have really originated with Dupuytren, whose name it commonly bears, and who, we are told, 1 practised it with " great dexterity," on the occasion of the " concours" for the chair of operative surgery (February 15, 1812). 2 It is a modification of the early opera- tion of Le Dran and La Faye. The principal flap is an external, or, more strictly, a postero- external one, which embraces the thickness of the deltoid muscle (Fig. 179). Grasping this part with his left hand, the surgeon enters the point of his Fig. 179. Result of shoulder-joint amputation by Larrey's method. Amputation at left shoulder by external flap, or Dupuytron's method. knife about an inch in front of the acromion process of the scapula, and pushing it directly across the joint and its capsule, brings it out at the pos- terior axillary fold ; the knife is then made to cut at first directly down- wards, and then outwards and backwards, with a sawing movement, form- ing a large flap which is taken in charge and held out of the way by an 1 Dictionnaire des Sciences Medicales, t. i. p. 496. Paris, 1S12. 2 Id. op., Biographie Medicale, t. iii. p. 556. Paris, 1821. 646 AMPUTATIONS. Fig. 180. assistant. Disarticulation is then effected as in the oval operation, by rotating the arm successively inwards and outwards so as to render the muscles tense before they are cut, and the operation is termi- nated by slipping the knife behind the bone, and cutting a short flap which con- tains the brachial artery. The same precautions against hemorrhage should be observed here which were described in the account of Larrey's operation. A modification and, I think, an im- provement of this method, originally practised by Cline, and first described in this country by Dr. J. A Smith, of New York, in a letter to Dorsey, 1 consists in cutting a deltoid flap of curved outline from without inwards, then disarticu- lating, and finally completing the opera- tion in the way already described. Fig. 180 shows the appearance of a stump re- sulting from this variety of the operation. Result of shoulder-joint amputation by Dupuy- . _-, , , tren's method. ANTERO-POSTERIOR I LAP METHOD. This, which is known as Lisfranc's operation, gives a resultihg wound not unlike that obtained by the oval method, to which, however, it seems to me to be inferior. It is described by its inventor as his second method. 2 Supposing that it is the left arm which is to be removed, the surgeon, causing it to be held three or four inches away from the body, seizes the shoulder with his left hand, and with his right introduces a long knife on the outer side of the posterior fold of the axilla, in front of the tendons of the latissimus dorsi and teres major, the blade of the knife being pushed along the posterior surface of the hume- rus and its edge being directed outwards and forwards. The knife is steadily thrust onwards until its point reaches the head of the humerus, when the hand is first raised (to clear the head of the bone), then slightly depressed, and finally raised again and carried outwards, till the point is beneath the triangular space which exists between the caput humeri and the acromion and coracoid processes. Counter-puncturation is next effected by thrusting the point of the instrument through the skin, and a posterior or more strictly a postcro-external flap, extending two or three inches below the joint, is then cut from without inwards. This flap is held out of the way by an assistant, while the surgeon slips the knife around the head of the bone from behind forwards, and then cuts an anterior or antero-internal flap, another assistant grasping the artery before it is divided, as in Larrey's method. In amputating the right arm, the anterior flap may be cut first, if the surgeon is ambidextrous, but it is better to use the right hand, standing behind the patient, and making the posterior flap by transfixion from above downwards. Amputation at the shoulder-joint is in appearance a most formidable operation, and yet its results are upon the whole fairly successful. The 1 Elements of Surgery, etc. By John Syng Dorsey, M.D., 2d edit., vol. ii. p. 309. Philadel- phia. 1818. 2 Precis de Medeeine Operatoire, t. ii. p. 186. AMPUTATION ABOVE THE SHOULDER. 647 following Table shows the mortality of the operation according to different authorities. Table showing the Results of Amputation at the Shoulder-joint. Authority. Oases. Deaths. Mortality per cent. Reference. Malgaigne 13 10 76.9 Arch. Gen. de Medecine, Avril, 1S42, p. 409. Trelat 27 17 62.9 Legouest, Chirurgie d'Arniee, p. 725. Paris, 1863. Legonest . 207 135 65.2 Ibid. Macleod . 173 69 39.8 Surgery of the Crimean War, p. 346. Phila., 1862. Otis .... 841 246 29.2 Surgical History of the War, Part Second, pp. 468, 613. Spence 27 9 33.3 Lectures on Surgery, vol. ii. ; Med. Times and Gaz., 1875, 1876 ; Edin. Med. Jour- nal, 1879. Golding-Bird . 11 4 36.3 Guy's Hosp. Reports, Third series, vol. xxi. p. 260. Butlin and Macready 7 3 42.8 St. Bartholomew's Hosp. Reports, vol. xiv. p. 114. Morton 30 9 30.0 Surgery of the Pennsvlvania Hospital, p. 32. Philadelphia, "l880. Chadwick. 26 11 42.3 Boston Med. and Surg. Journal, May 1, 1871. Gorman . 20 8 40.0 Med. and Surg. Reports of Boston City Hospital, Second series, p. 292. Author 1 . 5 2 40.0 Supra, page 612. Aggregates . 1387 523 37.7 Comparing these figures with those given in the Table on page 630, it is seen that the death-rate of shoulder-joint amputation, which is less than two in five, is not much greater than that of amputation of the leg, and very much less than that of amputation of the thigh. Amputation above the Shoulder. This operation, which consists in removing at the same time the entire arm together with part or all of the scapula, and perhaps a portion of the clavicle, appears to have been first performed by Cuming, in 1808, though the famous case of the miller, Samuel Wood, whose arm and scapula Avere torn off by a rope becoming wound around his limb, and who recovered without any bad symptoms, occurred in 1737, and had long been familiar to surgeons. 2 Xo universally applicable directions can be given for the performance of this operation, the surgeon, in cases of injury, being compelled to use for his flaps whatever tissues are sufficiently sound for the purpose, and the lines of in- cision varying, in operations for tumors of the part, in accordance with the size and shape of the particular growth concerned. Lisfranc's advice appears to be judicious; that the arm should be first disarticulated, and the axillary vessels secured, and that the scapula should be removed subsequently. This bone may be readily exposed by either a crucial or a T-shaped incision, and its detachment effected, as advised by Fergusson and Pollock, by cutting from below upwards. Separation from the clavicle may be accomplished 1 Besides the five cases tabulated above, I have twice (unsuccessfully) amputated at the shcul- der-joint synchronously with other major amputations. (See Table on page 592. J 2 Cheselden, Anatomical Tables, Tab. xxxviii. p. 43. Boston, 1796. 648 AMPUTATIONS. Fig. 181. either with cutting pliers or with a chain saw. (Fig. 181.) The gravity of the operation varies, of course, with the extent of bone re- moved ; if this be limited to the acromion, the case is but little more dangerous than an ordinary shoulder- joint amputation, but if the whole or greater part of the scapula be taken away, the risk is very much increased. Statistical writers have very com- monly confused this operation with that of excision of the scapula, either without interference with the arm, or subse- quent to previous amputation. This operation will be described in a future volume. The annexed Table contains a summary of fifty-one 1 cases to which I have references, which are properly designated as amputations above the shoulder. Table of Amputations above the Shoulder. No. Operator. Result. No. Operator. Result. No. Operator. Result. 1 Asiari Cured 19 Hamilton Cured 37 Parise Died 2 Bland c < 20 Hay ward it 38 Pirondi " 3 Bower " 21 Hendry " 39 Ross Cured 4 Brice if 22 Herr Died 40 Soupart " 5 Buchanan Died 23 Hunter " 41 Syme " 6 Busch Cured 24 Jackson " 42 Tirifahy " 7 Charles " 25 Jessop Cured 43 Twitchell l L 8 Clot it 26 Langenbeck Died 44 Watson " 9 Crosby a 27 Lewis " 45 Wheelhouse " 10 Cuming " 28 Lund Cured 46 Whishaw " 11 Esmarch " 29 McClellan " 47 Wood (( 12 Fayrer Died 30 McGill Died 48 Id. U 13 Fergusson Cured 31 Macleod " 49 Young it 14 Id. Died 32 Mussey Cured 50 Surg, at Penn. it 15 Gaetani Bey Cured 33 Niepce " Hospital 16 Gilbert " 34 O'Grady (< 51 Surg, referred (1 17 Gross Died 35 Parise (i to bv Dr. Otis 18 Gund rum Cured 36 Id. << The above 51 cases gave 38 recoveries and 13 deaths, a mortality of only 25.5 per cent. There are besides at least 14 cases on record in which recovery has followed accidental avulsion of the arm and part or all of the scapula, 2 so that if we should hike these figures without allowance, we would conclude that the operation was really one of little risk. It is at least sufficiently suc- cessful to justify the surgeon in resorting to it in suitable cases. 1 Velpean says that Larrey did this operation " several times," and "more than once" with success. (Nouveaux Elements de Medecine Operatoire, t. ii. p. 465.) 2 Dr. Stephen Rogers, of New York, collected twelve cases, in papers in the American Journal of the Medical Sciences for October, 1868, and the New York Medical Journal for December, 1870. A thirteenth ease, recorded by Kathaletzky, is noted in the London Medical Record for Dec. 17, I -7::, and a fourteenth is reported by Dr. Ellis-Jones, a Welsh surgeon, in the Lancet for Aug. 20, 1881. AMPUTATIONS OF THE TOES. 649 SPECIAL AMPUTATIONS OF THE LOWER EXTREMITY. Amputations of the Toes. Amputation through the Phalanges of the toes is very seldom resorted to, it being almost always better to disarticulate through the interphalangeal or metatarso-phalangeal joint. If the operation were thought necessary, it could be conveniently done by cutting antero-posterior flaps from without inwards, and dividing the bone with strong cutting pliers. Amputation at any of the Interphalangeal Joints is best done by the plantar flap method, as in the case of the fingers. The joint is opened from the dorsal surface, and the nap formed, after disarticulation, by cutting from within outwards. Fig. 182. Amputation of a Toe at its Metatarso-phalangeal Joint is more often required than either of the operations described above. It may be done by either the lateral flap or the oval {en raquette) method (Fig. 182), the latter plan being the best. The most important point to be remembered is that the interdigital web is placed about half way between the joint and the extremity of the toe, and that hence the articulation is situated higher than it appears to be. The point of the oval should invariably be placed upon the dorsum of the foot — even in the case of the great and fifth toes — so that the cicatrix may not be exposed to friction from the shoe. The knife is entered from half to three-quarters of an inch above the joint, and made to cut first in a longitudinal direction to the line of articulation, and then carried obliquely, first on one side and then on the other, to the edge of the inter- digital web, thus forming the branches of the oval, which are eventually joined by a transverse incision across the plantar surface. The tissues being dis- sected a little upwards from the bone, disarticulation is effected by forciby flexing the toe and cutting the extensor tendon transversely, and then severing the ligaments. The wound is closed so as to make an antero-posterior scar, protected from injury by the adjoining toes. In amputating the great toe, care must be taken to keep the incisions low, so as to provide ample cover- ing for the head of the metatarsal bone which is apt to project in a troublesome manner; it is sometimes recommended that it should be cut oft' with strong forceps, but its removal is undesirable as it furnishes a very important point of support for the arch of the foot. Amputation of toe by oval method. 650 AMPUTATIONS. Amputation of all the Toes Simultaneously may be effected by the ■plantar flap method of Lisfranc, or by the somewhat more complicated pro- cedure of Dubrueil. In the former, the surgeon applies the thumb and index finger of his left hand so as to mark the metatarso-phalangeal articulations of the fifth and great toes, and then with a narrow-bladed knife makes a curved incision, somewhat convex downwards, beginning (for the right foot) over the posterior part of the first phalanx of the fifth, and for the left foot over the corresponding part of the great toe. This flap being slightly dis- sected upwards, each toe is separately disarticulated, by dividing its extensor tendon and articular ligament, and the surgeon then, slipping the knife below the toes, which are raised for the purpose, cuts a plantar flap of sufficient size from within outwards. It is usually advised that the plantar flap should have been first marked out by a deep incision corresponding to the groove at the roots of the toes. Dubrueil's operation resembles Lisfranc's as regards the mode of obtaining a covering for the metatarsal bones of the four smaller toes, but he supple- ments the plantar flap by taking an internal lateral flap from the side of the great toe, thus insuring an ample covering for its metatarsal. For my own part, I would advise, as in the case of the fingers, that the surgeon should sacrifice brilliancy, and amputate each toe separately, by either the lateral flap or oval method as may seem best in each particular instance. Amputations of the Foot. Amputation of the Fifth Toe with part or all of its Metatarsal Bone is best effected by the oval (en raquette) method, the point of the oval being placed upon the dorsum of Fig. 183. the foot, but, in order to give more room for separa- tion of the bone, curved outwards as shown in Fig. 183. If part of the meta- tarsal only is to be re- moved, the bone may be divided with a narrow- bladed or chain saw, or with strong cutting pliers; if complete disarticulation is to be effected, the bone must be first separated from its attachment to the cu- boid, and then from that to the fourth metatarsal, and in doing this the direction of the articulation (oblique, inwards and backwards) must be remembered. This amputation may also be done by the external flap method, but the operation is not to be commended, as the flap is long, narrow, and ill-nourished, and is apt to slough. Amputation of the Great Toe, with part or all of its Metatarsal Bone, may also be performed by the oval (en raquette) method, the extremity of the oval being in this instance curved inwards, from the dorsum of the foot Amputation of fifth toe and metatarsal by oval method. AMPUTATIONS OF THE FOOT. 651 to the edge of the sole, as advised by A. Guerin and Dubrueil. The internal flap method may also be advantageously practised in this situation (Fig. 184), a fleshy flap being first raised from the inner side of the foot, and replaced after disarticula- tion. The surgeon introduces a strong and rather short knife on the dorsal surface, on a level with the tarso-metatarsal joint and between the first and second metatarsal bones, and cuts di- rectly forwards to the ball of the toe, then transversely out- wards and downwards in a line corresponding to the web, and finally backwards along the in- ner side of the sole. The flap thus marked out is dissected upwards, keeping close to the bone, and the knife is then re-entered between the metatarsals and made to cut forwards through the web. Disarticulation is then effected by attacking the joint from its inner and dorsal sides, and by then dividing the interosseous ligament and the tendons of the peroneus longus and tibialis anticus, taking care not to wound the dorsal artery of the foot. This operation is readily performed, and affords a good stump, but upon the whole I am disposed to give the preference to the oval operation as making a smaller wound, and one of which the cicatrix is better placed as regards the future usefulness of the foot. Amputation of great toe and metatarsal by internal flap method. Amputation of two or more Metatarsal Boxes is conveniently done by the oral {en raquette) method, the point of the oval being placed on the dorsum, and beginning about half an inch above the tarso-metatarsal joint, and its branches diverging sufficiently to include the toes which it is designed to remove. Beclard and Dubrueil advise that more room should be afforded for disarticulation by adding short transverse incisions on either side, at the upper end of the point of the oval. In all of these operations, it will be found advantageous to grasp the part to be removed with Fergusson's lion-jawed forceps, held firmly in the left hand, twisting the bone from side to side so as to render tense the parts which are to be divided. I feel bound to say that the various operations on the foot, hitherto described, are not often applicable in actual practice: the injuries in civil life which require amputation of the metatarsal bones, usually involve the whole anterior portion of the foot ; and the stumps which I have examined, result- ing from these partial amputations after gunshot wounds, have not been as a rule very satisfactory. Amputation through the Continuity of the Metatarsus. — This operation is not unfrequently required in cases of injury involving the base of the toes, or of gangrene following frost-bite. It may be done by either the circular or the flap method, the latter being, I think, preferable in this situation. Some operators employ a single dorsal flap, while others (as Pezerat, for instance) use three flaps — one from the dorsal, one from the plantar, and one from the inner side of the foot. I think that the best plan is to make a short dorsal and a long plantar flap, cutting both of them from without inwards, and, after sawing the bones on the same level, bringing up the plantar flap so as 652 AMPUTATIONS. to get a cicatrix which shall not be exposed to pressure from the shoe in walking. This operation gives an excellent stump, and one which seems to be more serviceable than those obtained by amputation at a point nearer the ankle. Amputation of the Entike Metatarsus. — This operation is said to have been formerly practised in a rude fashion by the North American Indians as a means of preventing their prisoners from escaping. It may be performed by either the elliptical or the flap method, the latter being that generally adopted. There are two principal varieties of this operation, known respect- ively by the names of Hey (of Leeds), and of Lisfranc. (1) Hcy's amputation is practised by cutting a long plantar flap from with- out inwards, the incision beginning on the outside at the tuberosity of the fifth metatarsal bone, passing downwards to the line of the metatarso-phalangeal articulations, then crossing the sole transversely in a curved line, and passing up again on the inner side of the foot to the prominence of the scaphoid bone. The upper ends of this wound are united by a curved incision, convex down- wards, across the dorsum of the foot, making a short anterior flap. The four outer metatarsals are then disarticulated from the cuboid and external and middle cuneiform bones, and the projecting internal cuneiform cut across with a small saw. This operation has been modified by sawing across the base of the second metatarsal bone, instead of the internal cuneiform, but the latter was the part divided in the operation as originally performed in 1799 by Mr. Hey. 1 A similar operation is known to French surgeons by the name of Beclard, while Cloquet has carried the use of the saAv still further, recom- mending its employment at any point at which disarticulation is found troublesome. (2) Lisfranc's amputation differs from Hey's in being a pure disarticula- tion. (Fig. 185.) The surgeon begins' his incision (for the right foot) at the tuberosity of the fifth metatar- Fig. 185. sal, carries it across the dorsum of the foot, in a curved line with its convexity downwards, and terminates it at the tubercle of the first metatarsal. This incis- ion divides all the tissues down to the bone, and, the skin being retracted by an assistant, a few light touches of the knife serve to expose the line of the tarso- metatarsal joints. Disarticula- tion is then begun at the outer side, the fifth, fourth, and third metatarsals being first separated, and then the first; the second, which projects backwards be- hind the line of the others, being left until the others have been freed. The point of the knife is then entered between the internal cuneiform and tlie base of the second metatarsal, and made to cut upwards so as to divide the interosseous ligament; the dorsal ligaments of the second metatarsal are next divided transversely; and finally disarticu- lation is completed by severing the fibrous bands on the outer side of the Arnpntation of entire metatarsus by Lbfrauc's method. 1 Practical Observations in Surgery, p. 331. Philadelphia, 1805. AMPUTATIONS OF THE FOOT. 653 same bone. The division of the interosseous ligament between the second metatarsal and internal cuneiform bones is the most difficult part of this manoeuvre, and is best effected by thrusting the point of the knife firmly into the posterior part of the first interosseous space, and then forcibly elevat- ing the handle — a motion which is described by French writers as the tour de maitre. Disarticulation, which may be greatly aided by pressing the an- terior part of the foot firmly downwards, having been completed, the knife is carried flatwise below the metatarsal bones, and made to cut a long plantar flap — rather larger on the inner than on the outer side — from within out- wards. In order to secure greater regularity of the plantar flap, it is a good plan to mark out its dimensions with the point of the knife before proceeding to cut it; or the surgeon may adopt Duval's plan, and begin by cutting the flap from without inwards, as in Hey's operation. Amputation at the Medio-tarsal Joint. — This operation (Fig. 186) bears the name of Chopart, although it is no longer performed in the way directed Fig. 186. Amputation at medio-tarsal joint. by that surgeon. 1 Chopart made a square anterior flap from the dorsum of the foot, and, after disarticulating, cut the posterior or plantar flap from with- in outwards; but most surgeons, at the present day, adopt Richerand's and Lisfranc's modification, making a curved anterior flap of which the extremi- ties reach to the position of the articulation, and many prefer to cut the plantar flap from without inwards, a plan which has the advantage of allow- ing the flap to be more regularly shaped than when it is cut in the opposite direction. The object of this operation is to remove all of- the tarsus except the os calcis and the astragalus, but it has often happened that the scaphoid has been left unintentionally, without interfering at all with the successful result of the procedure, and, indeed, M. Laborie and Mr. Hancock advise that it should always be retained if possible, the latter surgeon sawing across the cuboid on a corresponding line. 2 In performing Chopart's amputation, the surgeon grasps the anterior part of the foot in his left hand, and with a strong, short knife makes a transverse incision, convex forwards, over the dorsum, from a point half-way between the external malleolus and the tube- rosity of the fifth metatarsal on the outside, to a point about half an inch behind the prominence of the scaphoid, on the inner side of the foot. The plantar flap extends from the same points as far forward as the line of the metatarso-phalangeal joints. Disarticulation is rendered more easy by forci- 1 A similar operation appears to have been known to Fabriciua Hildanus. 2 A similar operation is practised by Prof. Agnew, of Philadelphia, and by Dr. S. F. Forbes, of Toledo, Ohio. 654 AMPUTATIONS. bly pressing the front of the foot downwards, so as to make the anterior liga- ments as tense as possible. Trouble is sometimes experienced during the after-treatment of patients who have submitted to Chopart's amputation, from contraction of the mus- cles of the calf drawing the heel upwards, thus, when the patient begins to walk, bringing the cicatrix against the sole of the shoe, and so causing irritation. This contraction can usually be prevented by bandaging the leg from above downwards, or by applying a broad strip of plaster connected with a weight and pulley, but division of the tendo Achillis may occasionally be required. Dubrueil recommends the use of a wedge-shaped pad in the shoe, the base of the wedge being directed forwards. Trouble from this source is less likely to be met with when the plantar flap is of ample dimensions, than when it is somewhat scanty. The statistics of Chopart's amputation were particularly investigated by the late Mr. Hancock, 1 who found that 152 terminated cases gave but 11 deaths, a mortality of only 7.2 per cent., while no less than 120 of the 126 patients who recovered had useful limbs. Larger's figures, 2 from French sources, are less favorable, 38 cases having given 14 deaths, or 36.8 per cent., though only half of these were properly attributable to the operation. Sub-astragaloid Amputation. — This operation appears to have been sug- gested by Lignerolles, 3 though it was, according to Hancock, 4 first performed by Textor in 1841. The peculiarity of the operation consists in the removal of the whole foot with the exception of the astragalus. Lignerolles and Vel- peau advised that the surgeon should make two lateral flaps, and turn them upwards towards the malleoli before disarticulating. Lisfranc employed a single dorsal flap, and Malgaigne a single flap from the inner portion of the sole. Verneuil's method, which seems to be the one generally adopted in France, is somewhat differently described by different writers ; it is essentially an application of the oval method, the point of the oval being placed on the outer side of the foot, below and be- hind the external malleolus, while the base of the oval crosses the inner side of the foot over the middle por- tion of the internal cuneiform bone. Nelaton modified this procedure by making another angle at the base of the oval, thus really making dorsal and plantar flaps, the junction of which was made further back upon the outer than upon the inner side. The plan recommended by modern English writers, and that which I have myself successfully followed in two cases (Fig. 187), is to make a flap from the heel, as in Syme's ope- ration at the ankle-joint, only some- what longer, with a short anterior flap from the dorsum. As soon as the heel-flap has been loosened as far back as the tubercles of the calcancum, the anterior part of the foot may be cut away, and the os calcis then grasped 1 Operative Surgery of the Foot and Ankle-joint, p. 386. London, 1873. 2 Bulletin do la Soeiete de < 'hirui'gie ; apud llayem, Revue des Sciences Medical es, Oct. 15, 1880. 3 Velpeau, Traitfi de Medecine OpSratoire, t. ii. p. 499. Paris, 1839. * Op. cit., p. 191. Sub-astrat,'alniil amputation of foot. AMPUTATIONS OF THE FOOT. 655 with the lion-jawed forceps, and twisted from side to side, while its separation is completed by disarticulat- ing it from the astragalus, and dividing the tendo Achillis and remaining attachments of the bone. If the flaps are not of ample dimensions, the head of the astragalus should be removed with a small saw, a step which Hancock recommends in all cases. This opera- tion affords a most admirable stump, which has the advantage over those produced by Syme's and PirogofFs methods that it retains the motions of the ankle-joint, and thus allows an elasticity of gait in walking, which would otherwise be absent. The appearance of the stump resulting from this operation is shown in Fig. 188, from a patient under my care, a year or two since, at the University Hospital. Mr. Hancock 1 refers to 22 cases of this operation (in- cluding one of his own), at least 20 of which terminated successfully. Larger 2 tabulates 21 cases, of which 5 proved fatal, only three of these, however, as the result of the operation. Both of my own cases resulted in recovery. Hancock's Amputation. — This, which may be re- garded as a combination of the sub-astragaloid with PirogofFs method (to be presently described), consists in sawing through the os calcis as in that operation, and bringing the sawn surface in contact with a trans- verse section of the astragalus. This is certainly a very ingenious procedure, and in the case in which Mr. Hancock employed it, the result was all that could be wished. I confess, however, that it does not seem to me to present any ad- vantage over the ordinary subastragaloid operation, which has the advantage of greater simplicity. Tripier's Amputation. — This operation, which has been suggested by M. Tripier, of Lyons, may also be looked upon as a modification of the sub- astragaloid method. The external incisions are made as in Chopart's medio- tarsal operation, and, the anterior part of the foot having been removed, the calcaneum is sawn through on a level with the sustentaculum tali, and on a plane at right angles to the axis of the leg. Other Amputatons of the Foot. — Mr. Hancock's suggestion that, instead of amputating at the medio-tarsal joint, the scaphoid should be left with the posterior portion of the cuboid, has already been referred to. The same sur- geon, reviving the teaching of Mayor, of Lausanne, advises that the foot should, for operative purposes, be looked upon as a whole, and that, after the formation of suitable flaps, the tarsus should be sawn through at whatever point may be found necessary, without regard to its articulations. Acting upon this suggestion, I, in one case, sawed through the scaphoid bone, the posterior part of which was healthy, and removed the anterior diseased sur- surface of the os calcis ; the patient made an excellent recoA T ery. The results of amputations of the toes and partial amputations of the foot are usually satisfactory. I have met with no fatal cases in my own experi- Stuinp from sub-astragaloid amputation. > Op. cit., p. 205. 2 Loc. cit. 656 AMPUTATIONS. ence, and the records of British surgery and of the late American war show a very low rate of mortality ; but the French statistics are much less favora- ble ; the figures are shown in the following Table : — Table showing Results of Amputations of the Toes and Partial Amputations of the Foot. Toes. Partial of Foot. Authority. Cases. Deaths. Mortality per cent. Cases. Deaths. Mortality per cent. Eeference. Otis . Hancock Legouest Larger 790 370 6 70 0.7 18.9 119 174 255 80 11 13 97 23 9.2 7.4 38.4- 28.7 Circular No. 6. S. G. O., 1865, p. 45. Op. Surgery of Foot and Ankle- joint, pp. 205, 386. Chirurgie d'Armee, pp. 726, 731. Revue des Sciences Medicales, Oct. 15, 1880. Aggregates 1160 76 6.5 628 144 22.9 Amputation at the Ankle. Removal of the entire foot at the ankle-joint was somewhat vaguely referred to by Hippocrates, and subsequently by Fabricius Hildanus, and appears to have been occasionally resorted to by various surgeons, among whom may be particularly mentioned Sedilier, of Laval, Rossi, and Baudens ; but the ope- ration did not obtain general acceptance as a recognized procedure until the late Prof. Syme, of Edinburgh, introduced a new mode of performing it in the year 1842. Rossi had employed two lateral flaps, and Baudens a single dorsal flap, while Velpeau advised semi-lunar incisions over the heel and in- step, the edges of the wound being brought together from before backwards, so that its angles should cover in the malleoli, which, in all of these methods, were allowed to remain. Various modifications of Syme's method have been suggested and practised, the most important being those of Roux, Pirogotf, Fergusson, and Le Fort. Syme's Amputation. — As I quite agree with Mr. Hancock and Mr. Syme himself, that, in estimating the value of any particular operation, we should take care that the operation itself is performed in the manner directed by its introducer, and not confuse it with the modifications, or so-called " improve- ments," of other surgeons, I shall quote Mr. Syme's own description of his mode of procedure : — l In performing the operation, the foot being held at a right angle to the leg, the point of a common straight bistoury should be introduced immediately below the fibula, at the centre of its malleolar projection, and then carried across the integuments of the sole in :t straight line to the same level on the opposite side. The operator having next placed the fingers of his left hand upon the heel, and inserted the point of his thumb into the incision, pushes in the knife with its blade parallel to the bone, and cuts down to the osseous surface, at the same time pressing the flap backwards until the tuberosity is fairly turned, when, joining the two extremities of the first incision by a transverse one across the instep, he opens the joint, and carrying his knife downwards on each side of the astragalus, divides the lateral ligaments, so as to complete the disarticula- tion. Lastly the knife is drawn round the extremities of the tibia and fibula, so as to 1 Observations on Clinical Surgery, p. 47. Edinburgh, 1861. AMPUTATIONS AT THE ANKLE. G<37 expose them sufficiently for being grasped in the hand and removed by the saw. After the vessels have been tied, and before the edges of the wound are stitched together, an opening should be made through the posterior part of the flap, where it is thinnest, to afford a dependent drain for the matter, as there must always be too much blood retained in the cavity to permit of union by the first intention. The dressings should be of the lightest description. As already indicated, this operation (Fig. 189) has heen modified or " im- proved" by various surgeons, some making the heel flap longer, and others shorter, than directed by Mr. Syme, and some only dissecting the flap back Fiz. 189. Amputation at ankle by Syme's method. to the point of the heel, and disarticulating before dividing the tendo Achillis and completing the separation of the os calcis. As regards the length of the flap, Dr. J. A. Wyeth, of Eew York, has proved by a large number of dis- sections that the main supply of blood to the heel flap is derived from the calcaneal branches of the external plantar artery, and that hence a Ions; flap is less likely to slough than a short one : hence if any deviation is to be ^made from Mr. Syme's lines of incision, it should be in the direction of lengthening the flap rather than of abbreviating it, Provided, however, that the knife be kept close to the bone, in separating the flap from the calcaneum, there is not much risk of impairing its vitality. Syme's amputation affords an excel- lent stump, covered with the natural tissues of the heel, and capable of sus- taining the entire weight of the patient. In some cases the tendo Aciiillis appears to acquire fresh attachments to the bones of the stump, and the patient is enabled not only to walk but to run. The same advantage is claimed for the stump made by Pirogoff's method, but the Syme stump is, according to Prof. Stephen Smith, of Xew York, better suited "than the other for the adaptation of an artificial limb. A modification of Syme's method which seems to me to be really an improvement, is that employed by Macleod, of Glasgow, and J. Bell, of Edinburgh, which consists in preserving', when- ever it is practicable to do so, the periosteal covering of the calcaneum. The following Table shows the statistical results of Syme's amputation, aa given by various authors : — vol. i. — 42 658 AMPUTATIONS. Table showing the Results of Syme's Amputation at the Ankle. Authority. Cases. Deaths. 17 8 8 Mortality per cent. Reference. Hancock . Spence . . Fayrer . . 219 107 12 7.7 7.4 6V.6 Operative Surgery of Foot and Ankle-joint, p. 152. Lectures on Surgery, vol. ii. ; Med. Times and Gaz., 1875 and 1876; Edin. Med. Journal, 1879. Hancock, op. cit., p. 155. Aggregates 338 33 9.7 Roux's Amputation. — In this operation, the flap is derived mainly from the inner side of the foot. The surgeon begins his incision at the posterior edge of the external face of the os calcis, carries it below the external mal- leolus, and then over the dorsum of the foot, in a curved line, convex forwards, half an inch below the articulation. This incision ends a little in front of the internal malleolus, and a second, starting from the termination of the first, crosses the sole somewhat obliquely backwards to the point whence the first took its origin. An irregularly oval wound is thus made with the point of the oval on'the outer side of the foot. The malleoli are removed in this as in Syme's operation. I have no personal experience with this particular form of operation, but should not suppose that the stump would be as serviceable as that obtained by Syme's method. Pirogoff's Amputation. — The peculiarity of this operation consists in the removal of all the foot except the posterior part of the calcaneum, which is brought forward and placed in apposition with the sawn ends of the tibia and "fibula, the articulating surfaces of the latter, with the malleoli, being removed as in the procedure of Syme and Roux. The operation is done as follows : The surgeon makes first a somewhat oblique incision, with an ante- rior convexity, across the plantar surface, from one malleolus to the other, coming a little further forward on the inner than on the outer side, so as to avoid the posterior tibial artery. The flap thus marked out is dissected back- wards for about a quarter of an inch, and the extremities of the wound are then united by a second incision, also with anterior convexity, over the dorsal surface, and crossing the Fig. 190. ankle in such a way as to expose the joint. This be- ing opened, disarticulation is effected, and the surgeon then, slipping a narrow- bladed saw, or the blade of a " Butcher's" saw behind the astragalus (Fig. 190) saws through the os calcis, obliquely downwards in the line of the first incision. The ends of the tibia and '' fibula 1 are next removed, and, hemorrhage having been checked, the wound is closed with sutures. If Amputation by pirogoff's method. Butcher's saw be used, the 1 It is somewhat uncertain whether Pirogoff himself removes more than the malleoli (see Han- cock, op. cit., p. 1(31), but it is customary in England and in this country to remove the whole articulating surface. AMPUTATIONS AT THE ANKLE. 659 leg bones may be divided from below upwards by reversing the blade of the instrument. Any tendency to tilting of the heel fragment by the action of the calf-muscles must be overcome in the manner directed in speaking of Clio- part's amputation. Various modifications of this operation have been sug- gested, as that the tibia and fibula should be sawn before the calcaneum ; that the latter should be sawn from below upwards, that it should be sawn obliquely, etc. Dr. J. S. Wight, of Brooklyn, saws through the os calr - ceps to facilitate its enucleation. The os calcis is" then depressed, and divided with a narrow-bladed saw from behind forwards, so as to remove all the upper part of the bone, beginning at the insertion of the tendo Achillis. The mal- leoli and articulating surface of the tibia are finally removed, and the sawn surfaces of bone placed in apposition. What is proposed to be accomplished by this particular form of operation, is to keep the os calcis in a compara- tively normal position, and to permit the patient, in walking, to receive pres- sure on the thick tissue of the heel, which is accustomed to support it, rather than on the thin tissue behind the heel, which is apt to be drawn forwards when the operation is done by the original method of Pirogoff. 1 Op. cit., p. 184. 660 AMPUTATIONS. The results of these various amputations at the ankle are quite satisfactory. The statistics of Syme's and PirogofFs methods have already been referred to, but a more compendious view of the subject can be obtained from the follow- ing Table : — Table showing the Results of Amputations at the Ankle. Nature of operation. | s. Deaths. Mortality per cent. Authority. Svrue's method . 338 Pirogoff's method! 273 Not specified . 358 33 28 101 9.7 10.2 28.2 Hancock, Spence, Fayrer. Pirogoff, Weber, Kestnor, Hancock, Gross, Pasquier. Legouest, Otis, Larger. Aggregates . 969 162 16.7 Amputation of the Leg. Amputation of the leg may be performed at any part of the limb, the best operation being, I think, the circular or modified circular, in the lower third, and Sedillot's or Lee's flap method in the middle and upper portions. As a rule, the stump should be made as long as the circumstances of the case will permit, but we still are occasionally requested by patients to amputate at what used to be called the " point of election" (two or three inches below the tuber- cle of the tibia), so as to allow the use of a " peg" or " box leg," without the annoyance of the stump projecting backwards. Amputation in the Lower Third of the Leg, or the supra-malleolar (sus-malleolaire) operation of French writers, is best performed by the circular method, the cuff of integument being slit upon its outer (fibular) side, 1 in order to obviate trouble in turning it up when the limb is a conical one; or by the modified circular method, in which case the skin flaps may be made either antero-posteriorly or transversely, according to the fancy of the operator. M. Guyon practises the elliptical method in this situation, taking the lower seg- ment of the ellipse from the tissues covering the heel. Amputation in the Middle or Upper Third of the Leg may be done by almost any of the operations which have been described, but the best, I think, are two varieties of the flap method, known respectively by the names of M. Sedillot and Mr. Henry Lee. Teale's method is less applicable in this situation than in the forearm, the long flap containing the anterior tibial artery, and being very thin where it overlies the tibia, and consequently liable to slough. The objections to the ordinary operation, in which a large flap is cut by transfixion from the calf, are that on the one hand, from its weight, it is apt to fall away from the anterior flap, and that on the other hand, the skin retracting more than the muscle, unless this is retrenched before the wound is closed, it is unduly compressed by the sutures which are employed, and great tension of the part, causing much discomfort, is almost sure to ensue. External Fiji /> Method, or that of Sidillot. — This is the operation which I pre- fer to all others for amputation in the upper part of the leg. It is performed as follows: the circulation having been controlled in the ordinary way, a preliminary longitudinal incision through the skin is made along the inner 1 The operation known as Lenoir's is simply a circular amputation with the cuff slit in front Instead <>t' at the outer si'li-, as 1 have advised. AMPUTATION OF THE LEG. 661 edge of the tibia ; the tissues being then drawn to the fibular side of the limb, the longitudinal incision gapes sufficiently to allow a slender catlin to be introduced close to the outer edge of the tibia, made to graze the fibula, and to be brought out posteriorly, transfixing the limb on the outer side of both bones. The knife is then carried downwards close to the bones, with a sawing motion, and then made to cut its way outwards, forming a broad, rounded flap. (Fig. 191.) The tissues on the inner side of the limb are next Fig. 191 Amputation of leg by external flap, or Sedillot's method. divided by an incision somewhat convex anteriorly, and the bones then cleared by a circular sweep of the knife. The interosseous membrane being divided, all the tissues are pushed upwards with the hand or the handle of the knife, so as to expose the bone about an inch higher up before the application of the saw. It is usually recommended that, in sawing the bones in any leg amputation, the instrument should be held vertically, and both bones cut through on the same level; but I am disposed to prefer the plan advised by Roux and Mal- gaigne, to wit, a separate division of the bones, and the removal of half an inch more from the fibula than from the tibia. Mr. Syme and other writers have directed that the sharp, anterior edge of the tibia should be removed by an oblique section either with saw or cutting pliers, to prevent its perforating the skin on the anterior face of the stump; but this precaution is hardly necessary if the flaps be sufficiently ample to prevent undue tension, while the oblique section of the bone rather increases, I think, the risk of necrosis and subsequent exfoliation. A better suggestion, in my judgment, is that of Oilier, of Lyons, who preserves a short flap of periosteum which is allowed to fall over the sawn end of the bone. Besides the anterior and posterior tibial and peroneal arteries, there are usually two or three muscular and cutaneous branches which require ligation, and, in cases of secondary amputation, sometimes a great many more. Diffi- culty is sometimes met with in securing the anterior tibial artery, on ac- count of its retracting above the point at which the interosseous membrane has been divided; under these circumstances the patient mav be simply turned over on his face, when the weight of the stump will bring the knee into an extended position, thus straightening the vessel and making it more accessible. In applying the tourniquet for a leg amputation, the pad should be placed on either the femoral or the popliteal artery; if on the latter, a some- 662 AMPUTATIONS. what broad compress should be used, and the screw of the instrument should be applied diametrically opposite, upon the front of the limb, just above the Lee's Method. — This operation, which may be considered a modification of Teale's method, was described by Air. Henry Lee, of St. George's Hospital, London, in a paper read before the Royal Medical and Chirurgical Society of that city in 1865. y The dimensions and shape of the flaps are the same as in Teale's method, but the longer is taken from the back of the leg, and embraces only the superficial muscles, the deeper muscles with the vessels being divided transversely by a circular incision on a level with the upper end of the flaps. The long flap made in this operation has less bulk and weight than that made by the ordinary transfixion method, but still seems to me, unless in very slender limbs, heavier than is desirable. I have, therefore, in muscular sub- jects, adopted a further modification, which consists in separating the gastro- cnemius from the soleus muscle, and including the former only in the flap, the latter being divided circularly with the deeper layer. (Fig. 192.) Fig. 192. Amputation of leg by Lee's method (modified). Amputation above the Point or Election may be done by the circular, or Larrey's method, the fibula being separated by disarticulation, and the tibia sawn through immediately below the attachment of the ligamentum patellae. The risks of amputation of the leg are not inconsiderable, the death-rate, for all cases taken together, being, as shown by the Table on page 630, no less than 34.3 per cent., or more than one in three. The danger increases with the proximity of the seat of operation to the trunk, the mortality of the supra-malleolar amputation being less than that of amputation at the point of election. At least, this has been my own impression, and it is confirmed by the statistics published by Dr. Gorman from the records of the Boston City Hospital, 2 which give the death-rates of amputations in the upper, middle, and lower thirds of the leg, as being respectively 42.8 per cent, ^>. ( .) pf the stump, and its removal renders the anterior flap so thin that sloughing AMPUTATIONS AT THE KNEE AND KNEE-JOINT. 665 Fig. 194. may follow. Mr. Eriehscn advises that, in order to prevent retraction, the flap should be turned upward and the attachment of the quadriceps femoris divided, but in my own cases I have not found this necessary. The semi- lunar cartilages should, I think, be removed, though A. Guerin recommends their retention. The articular cartilage of the femur need not be interfered with: it undergoes spontaneous separation, by a process of slow exfoliation, and comes away with the discharge in shreds or fragments of greater or less size during the second or third week ; some writers advise that it should be removed by sawing around the condyles with a Butcher's saw, but this seems to me an unnecessary complication. Amputation at the Knee. — Amputation at the knee, as distinguished from the knee-joint, may be done by any of the methods above described, the only difference between this operation and the disarticulation being that a portion more or less considerable of the end of the femur is removed by sawing through the condyles. The anterior flap method gives, I think, the best result, and, the patella being retained, furnishes an admirably firm and rounded stump. Several special forms of operation are practised in this situation, and may be here briefly referred to. Garden's Amputation. — This operation, which was introduced by Mr. Carclen, of Worcester, is done by taking a large rounded skin flap from the front of the knee; divid- ing the tissues on the back of the limb by a single transverse incision, made either by transfixion or from without inwards, on a level with the base of the flap ; reflecting the flap and dividing the deeper tissues straight down to the bone, above the patella which is drawn downwards by flexing the knee; and finally sawing through the base of the condyles. (Fig. 194.) This method of ope- rating is undoubtedly better than Syme's plan (which that surgeon abandoned in favor of Carden's) of taking a posterior flap to cover the sawn end of the condyles, but seems to me less desirable than that which I have described simply as amputation at the knee — a posterior being added to the anterior flap, and the patella being pre- served. It has, however, been very successful in the hands of its author, thirty cases recorded b}^ Mr. Carden himself having given but five deaths and twenty-five recoveries. 1 GinttVs Amputation. — This operation, introduced by Rocco Gritti, of Milan, in 1857, 2 may be regarded as an application of the osteo-plastic method of Pirogoft', to amputations at the knee. A rectangular flap is taken from the front of the leg and knee, and a shorter flap from the back of the limb ; the 1 British Medical Journal, 1864. Mr. Carden reports thirty-one cases, one of which, however, appears to have been a disarticulation. 2 Annali Universali di Medicina. Milano, 1857. Amputation at knee by Carden's method. 666 AMPUTATIONS. lower surface of the patella is removed with a small saw, 1 and the condyles similarly divided through their base, the two sawn surfaces being then brought into apposition. A very good stump results from this rather complicated procedure. Stokes's Modification of Gritti's Amputation is called by its author, Dr. W. Stokes, 2 of Dublin, a supra-cut ulyloid amputation of the thigh, whereas the line cf section in Gritti's method is trans-condyloid. This operation differs from that of the Italian surgeon simply in the fact that the anterior flap is oval instead of being rectangular; that the posterior flap is made somewhat larger (one third the length of the anterior) ; and that the femur is sawn through half an inch above the condyles, instead of through their base. The freshly sawn surfaces of the femur and patella are brought together as in the Italian opera- tion, and fixed by means of a catgut suture passed through the soft tissues immediately behind the bone, and with both ends cut short and left in the wound. The merits of these various forms of operation have been investigated by numerous surgeons, among whom I may particularly mention Profs. Stephen Smith 3 and Markoe, 4 and Dr. R. F. Weir, 5 of K"ew York ; Dr. J. H. Brinton, 6 of Philadelphia ; Mr. Pollock, 7 of London ; and Dr. Salzmann, 8 of Potsdam, who has particularly studied Gritti's method in regard to its applicability in military practice. Dr. Brinton, including in his Tables Prof. Markoe's and Dr. Otis's cases, refers in all to 494 examples of these different operations, death having followed in 207 ; Dr. Weir tabulates 76 cases (of Gritti's and Stokes's operations) with 22 deaths ; Mr. Pollock 48 cases of various kinds with 13 deaths ; while Dr. Salzmann collects, in all, 396 cases with 231 deaths. In the following Table I have included only terminated cases, and have taken care to avoid duplication in combining the statistics of the various authors quoted. Table showing the Results of Amputations at the Knee and Knee-joint. Authority. Cases. Deaths. Mortality per cent. Reference. Brinton (various sources) 233 76 32.6 Amer. Journ. of the Med. Sciences, April, 1868. Otis (American war) 202 106 52.4 Ibid. (Quoted by Brinton.) Garden (knee-amputation) . 30 5 16.6 British Med. Journal, April 16, 1864. Bryant (individual experience) 23 5 21.7 Manual for the Practice of Surgery, Third edition. Pollock (various sources) 42 13 30.9 Med.-Chir. Transactions, vol. liii. Legouest (Crimean war) 85 75 88.2 Traite de Chirurgie d'Armee, 18(i3. Salzmann, knee-amputations (va- 138 67 48.5 Archiv fur klin. Chirurgie, Bd. rious sources) xxv. H. 3. Id., knee-joint amputations (Mexi- can, Italian, Austrian, and Franco-German wars) 41 32 7S.+ Ibid. Aggregates 794 379 47.7 1 Mr. Pollock employs cutting forceps for this purpose; '■'■ Medioo-Chirurgical Transactions, vol. liii. p. 175. London, H 3 New York Journal of Medicine, November, 1852. 4 New York Medical Journal, March, 1868. s New York Medical Record, April 12, 1879. 8 American Journal of tbe Medical Sciences, April, 1868. i Medico-Chirurgioal Transactions, vol. liii. 1870. 8 Archiv fur klinische Chirurgie, Bd. xxv. H. 3, 1880. AMPUTATION OF THE THIGH. 667 The general death-rate, then, of these amputations at the knee-joint and knee, appears to be 47.7 per cent., or not quite one in two. Comparing this with the mortality of leg and with that of thigh amputations, as given in the Table on page 630, we find it almost midway between them, thus sustain- ing the general rule that the gravity of amputation increases as the opera- tion is done nearer the trunk. , Cases. Deaths. Mortality per cent. Amputation of the leg 5247 1804 34.3 " " knee 794 379 47.7 " " thigh 5606 3527 63.8 It is difficult to estimate the comparative mortality of the special forms of amputation which have been referred to, as authors do not distinguish clearly between them ; thus Dr. Brinton includes cases of Gritti's operation with ordinary amputations at the knee; Dr. Otis groups together all amputations whether of the knee or knee-joint ; and Dr. iSalzmann embraces in his Table of Gritti's operations, many cases in which the condyles were not touched. As a practical rule for treatment, I would advise that when there is ample tissue for the formation of flaps, and the joint itself is not involved, simple disarticulation should be preferred ; but that under other circumstances the condyles should be removed. The patella is, I think, best retained under all circumstances; if it is itself diseased, however, its articulating surface should be excised either with saw or cutting forceps. Amputation of the Thigh. The thio;h may be amputated by almost any of the methods which are employed in other parts of the body, but those which I am in the habit of employing, and to which I give the preference, are the anteroposterior flap operation, for amputations in the lower third of the thigh, and for those in the middle and upper thirds, the modified circular. Amputation in the Lower Third of the Thigh. — This operation is often required in cases of injury involving the knee-joint, such as compound frac- tures and dislocations, and in cases of disease of that articulation, in which the femur is too extensively implicated to permit of amputation through the condyles. The double flap method is the best in this situation, and I much prefer to take the flaps from the front and back of the thigh (Fig. 195), rather than from its sides, because the femur being placed very near the front of the limb, its sawn end is apt to protrude through the wound when the operation by lateral flaps is adopted. In amputating by anteroposterior flaps, the surgeon introduces his knife on the side of the "thigh, an inch or an inch and a half below the point at which he intends to divide the bone, and car- ries the blade longitudinally downwards for a space fully equal to half the diameter of the part, then crossing in front of the limb with a curved incision, convex downwards, and finally ascending to a point on the other side of the limb, opposite to that at which the incision was begun. There is thus marked out a rather square flap, with rounded corners, reaching usually to the upper borderof the patella. This flap is dissected up with rapid strokes of the knife, including all the tissues down to the bone, and is then intrusted to an assistant, while the operator forms the posterior flap by transfixing the limb behind the femur, and cutting first downwards, with a sawing motion, and then almost directly backwards. The posterior flap should be made nearly as long as the anterior, the greater retraction of the muscles at the back of the 668 AMPUTATIONS. thigh rendering it important that the lower flap should he of ample size. If the knife be kept close to the bone, in cutting the posterior flap, this, if the limb be a large one, will be found to be thick and unwieldy ; hence in ope- rating upon muscular subjects, it is better to follow Sedillot's plan, and, by keeping the knife away from the bone, include in the flap only the superficial Fig. 195. Amputation of thigh by antero-posterior flap method. muscles ; or the flap may be made of the proper dimensions by cutting it from without inwards. Both flaps having been formed, the bone is cleared by a circular sweep of the knife, and the tissues are then pushed upwards, so as to allow the application of the saw an inch or more above the point of junction. At least seven or eight ligatures will be required after amputation in the lower third of the thigh, and sometimes a much larger number. An admirable stump is afforded by this mode of operating, the bone being well covered by the anterior flap, and the cicatrix drawn out of the line of pres- sure. In applying the tourniquet for amputations in the lower part of the thigh, the compress should be placed over the femoral artery at the apex of Scarpa's triangle. Amputation in the Middle or Upper Third of the Thigh. — In either of these situations, the best operation is, I think, the modified circular. The skin flaps should be taken from the front and back of the limb (see Fig. 147, page 588), and care should be taken, after dividing the muscles, to push them well upwards, so that the bone may be sawn at a considerably higher point. The muscles on the back of the limb should be cut rather longer than those in front, on account of their greater tendency to retraction. In amputating at the upper part of the thigh, there may not be room for the application of the tourniquet, and the surgeon must then use an aortic compressor of some kind (as in amputating at Hie hip), or must rely upon manual pressure by an assist- ant. The best mode of controlling the circulation by manual compression, is, standing beside and behind the patient, to grasp the great trochanter of the limb to be removed with the fingers of the corresponding hand, and with the thumb make firm pressure on the artery just below Poupart's ligament; the AMPUTATION AT THE HIP-JOIXT. 669 thumb of the other hand is at the same time superimposed to regulate aud aid the compression, and to prevent any danger of slipping. Amputation through the Trochanters. — This operation, which is only less grave than amputation at the hip-joint, may be required in cases of injury, or in those of tumor involving the lower part of the femur. When practi- cable, it should be preferred to disarticulation, even in cases of malignant growth, as being a less dangerous operation in itself, and as no more likely to be followed by recurrence of the disease, which, when it does return, is at least as apt to attack the pelvis as the stump itself. Should it be found, moreover, after sawing through the trochanters, that the disease has extended higher up, it is very easy to convert the operation into a disarticulation by simply dissecting out the head and neck of the femur. The modified circular operation is well adapted for amputations in this situation. The above are the modes of operating to which I would advise a resort in cases of thigh amputation, in which the surgeon has the opportunity of selecting his method. It may well happen, however, that the structures on one side of the limb may be hopelessly diseased or injured, while those on the opposite side may be comparatively healthy ; under such circumstances the surgeon must try to utilize the sound parts wherever they are situated, and must secure a covering for the stump from whatever part is most available for the purpose. Single flaps, double flaps, triple flaps — any device may be resorted to — it being much more important in any given case to remove the limb at as low a point as possible, than to follow the details of any particular plan of procedure. Teales method affords a beautiful and useful stump in thigh amputations, but, for reasons already given (page 588), it seems to me an un- desirable operation in this particular locality. The death-rate of thigh amputations, taken all together, appears from the Table on page 630 to be 63.8 per cent., or more than Ave in eight. From the figures on the same page, it is seen that, in military practice, the mortality has varied from about one in two, for amputations in the lower third of the thigh, to the enormous proportion of seven in eight, for amputations in the upper part of the limb. Amputation at the Hip-joint. The removal of the lower limb at the coxo-femoral articulation may be properly regarded as the gravest operation which the surgeon is ever called upon to perform, 1 and it is only within a comparatively recent period that it has beeu accepted as a justifiable procedure. Ravaton wished to perform tlie operation in 1743, but the other surgeons called in consultation forbade the attempt. 2 The case usually referred to as the first amputation at the hip, oc- curred five years later (1748), 3 in the person of a lad of 13 or 14, who had been attacked with gangrene of both lower extremities as the result of eating spurred or smutty rye (ble ergote). On the right side a line of separation had formed at the hip, and when the limb was almost completely detached 1 " Obliged, as we are," says Hennen (Principles of Military Surgery, page 40. Third edition. London, 1829), " coolly to form our calculations in human blood, there is still something in the idea of removing the quarter of a man, at which the boldest mind naturally recoils." " Thes- is not one patient in a thousand that would not prefer instant death to the attempt." 2 Velpeau, op. cit., t. ii. p. 538. s Barbet, Prix de l'Academie Royale de Chirurgie, t. iv. p. 47. Paris, 1819. 670 AMPUTATIONS. by the efforts of nature, M. Lacroix, the attending surgeon, removed it by simply dividing with, scissors the ligamentum teres and the sciatic nerve. Four days afterwards, the left limb was painlessly and bloodlessly amputated on a level with the great trochanter, by sawing through the bone which was exposed by the separation of the gangrenous soft parts. The patient did well for a while, but finally succumbed, eleven days after the second, and fifteen days after the first operation. A quarter of a century later (1773 or 1774), Perault, a surgeon of Sainte-Maure, performed a similar operation upon a man named Francois Gois, whose thigh had been crushed between the pole of a carriage and a wall, and had subsequently become gangrenous. The limb was almost entirely separated by the processes of nature, and Perault merely completed its removal. The patient recovered, and twenty years afterwards was working as a cook in an inn of Sainte-Maure, was married, and had a healthy child. 1 The first amputation at the hip, through living parts, appears to have been performed by Mr. Henry Thomson, Surgeon to the London Hospital, some time before 1777 — that is, if his namesake, Dr. John Thomson, 2 is correct in supposing that it was this case the " horridness" of which provoked Mr. Per- cival Pott's denunciation of the procedure, in his Remarks on Amputation, written in that year. 3 In December, 1778, Mr. Kerr, of JSTorthampton, ampu- tated at the hip in the case of a girl of eleven years, who was suffering from advanced hip-disease and phthisis, and who survived the operation eighteen days. 4 The first hip-joint amputation in military practice occurred in 1793, the patient being a French soldier of the Army of the Rhine, and the ope- rator, the illustrious Baron Larrey. 5 The case terminated unfavorably owing to the patient's being obliged to accompany the troops in a forced march, which they were compelled to undertake a few hours after the operation. Three cases (two successful) are attributed to the elder Blandin (Larrey's as- sistant), in 1794, but, though Velpeau and Lisfranc both refer to them, they give no reference to their authority, and certain contemporary or nearly con- temporary writers, including Larrey and the younger Blandin, 6 do not men- tion their occurrence, so that their authenticity has been called in question. Brownrigg (in 1811) was the first British army surgeon to attempt the opera- tion, which he repeated successfully in the following year, the latter case being, if Blandin's claims are disregarded, the first instance of recovery from the operation known to military surgery. Amputation at the hip-joint may be performed in many ways — Farabeuf speaks of over forty-five methods — and writers on Operative Surgery describe more than one mode of procedure recommended by surgeons who, whatever their skill in operating upon the dead body, have never had occasion to amputate at the hip of a living person. I shall enumerate only the more important methods. Oval Method. — On a slender limb, this operation, which is known by the name of Cornuau and Scoutetten, gives ;i well-formed and serviceable stump, ] iarticularly if Malgaigne's modification (en rccquette)he adopted. The surgeon first makes a longitudinal incision of about three inches on the outer side of 1 Sabatier, quoted by Wlpeau, op. cit., t. ii. p. 539, and by Lisfranc, op. cit., t. ii. p. 381. 2 Report of Observations made in the British Military Hospitals in Belgium, etc., p. 2(j4. Edin- burgh, 1816. 3 Chirorgical Works of Peroival Pott, vol. iii. p. 218, and Life, l>y Sir James Earle, Ibid., vol. i. p. xxv, London, 18(is. 4 Medical and Philosophical Commentaries. By a Society in Edinburgh, vol. vi. Part iii. page 337. London, 1779. 5 Memoires de Chirurgie Militaire et Campagnes, t. ii. p. 180. Paris, 1812. 6 Dictionnaire do Me"decine et do Chirurgie Pratiques, t. ii. p. 280. Paris, 1829. AMPUTATION AT THE HIP-JOINT. 671 the limb, over the trochanter major, and then diverges in front and behind, carrying the lateral branches of the oval obliquely downwards and inwards, until they meet transversely on the inner side of the thigh. The first inci- sions divide the skin and fascia, and the next step is the severance of the muscles (except in the region of the main vessels), at the same level or a little higher. The joint is opened from the outer side, and, after disarticulation, the remaining tissues are cut through from within outwards as in Larrey's similar operation at the shoulder. However appropriate this operation may be in the case of a patient emaciated by disease, it is evident that, in a robust limb, the adductor muscles would form a bulky and cumbrous mass, which would interfere with the satisfactory adjustment of the wound, and would probably prevent primary union. Modified Circular Method. — This mode of operating is particularly indi- cated when amputation is required on account of a tumor which encroaches upon the upper part of the limb. Short antero-posterior skin flaps are cut from without inwards, and the muscles then divided by a circular incision at the level of the joint. This form of operation is convenient when the surgeon is not satisfied that the circulation is thoroughly controlled by pressure, as it exposes the femoral artery and vein, and affords an opportunity for securing them with ligatures before they are divided. The modified circular method has been rather a favorite with American surgeons, in this situation, and I may particularly mention, among those who have adopted it, the late Dr. J. Mason Warren, of Boston, and my colleague, Prof. Agnew, of Philadelphia. Single Flap Method. — This operation, which seems to be the favorite with most French surgeons, is performed by taking a large flap from the anterior or antero-internal surface of the limb, and dividing the remaining tissues by a circular incision, either before or after disarticulating. The Hap is usually made by transfixion, the operation then being known by the name of Manec. A long, double-edged knife is entered flatwise, midway between the anterior superior spinous process of the ilium and the great trochanter (the limb being slightly flexed so as to relax the muscles on its anterior sur- face), and directed "at first inwards and a little upwards, so as to graze the head of the femur and open the capsule of the joint. The handle of the knife is then raised so as to depress its point, and transfixion is next effected by pushing the instrument steadily onwards until it emerges at the middle of the line which separates the thigh from the scrotum. The flap is then formed by cutting downwards with a sawing movement, keeping the knife close to the bone, and taking care to make the inner part of the flap as long as the outer: the flap is terminated at the middle of the thigh. An assistant slips his fingers beneath the flap, and grasps the femoral artery before it is divided. The surgeon then opens the joint from the front, cuts the muscles on either side, the ligainentum teres, and the muscles attached to the great trochanter, and finally completes the separation of the limb by making a transverse inci- sion through the posterior tissues, from without inwards. Lenoir modified Manec's procedure by dividing the tissues on the back of the limb before dis- articulating. Other modes of performing the single flap operation are that of Lalouette, who began with a transverse, external incision, then disarticulated, and cut an internal flap as the last stage of his procedure; that of Plantade and Ash- mead (of Philadelphia), who made an anterior flap by cutting from without inwards ; and that of JDelpech, who first tied the femoral artery below Pou- part's ligament, then cut an internal flap by transfixion, and finally severed the external tissues, thus reversing the steps of Lalouette's method. G72 AMPUTATIONS. The single flap operation may be suitably resorted to when the destruction of the soft parts, by injury or disease, has extended much further on one side of the limb than on the other ; and it may even be proper, under such cir- cumstances, to employ a posterior flap ; but when the surgeon can choose his operation, he will, I think, do better to adopt either the oval or modified cir- cular, or the double-flap method after the manner of Guthrie, which will be presently referred to. Antero-posterior Flap Method. — We may recognize three varieties of this operation, which I shall designate respectively by the names of Liston, Bee- lard, and Guthrie. Liston's Method. — This form of the operation is very generally adopted in England and in this country, and is, perhaps, the best of the transfixion methods. The point of a long knife is introduced between the great tro- chanter and the anterior superior spinous process of the ilium ; made to graze the anterior surface of the neck of the femur ; and, finally, brought out just in front of the tuber ischii, \ery much as in Manec's procedure. An antero-internal flap, about five inches in length, is then cut from within out- wards, and, after disarticulation, a corresponding flap is cut from the buttock and tissues on the back of the thigh. Beclard's Method. — In this procedure the posterior flap is cut first. The point of the knife is introduced a little above the trochanter ; pushed across the limb, grazing the back of the femoral neck ; and made to emerge at the innermost part of the gluteal crease. A flap is then cut from the tissues of Fie. 196. Amputation at hip-joint by B6clard's method. the buttock, and the knife, being re-introduced at the same point as before, is made to traverse the limb, this time in front of the joint, and to cut the anterior i!;ip from the front of the thigh. Disarticulation is in this method the last step of the operation. (Fig. 196.) Guthrie's Method.- This is, T think, upon the whole, the best mode of am- putating at the hip-joint, and it is that which I have myself employed in the four fuses in which I have had occasion to perform this operation. The flaps are similar in shape and size to those made by Beclard's method, but they are AMPUTATION AT THE HIP-JOINT. 673 cut from without inwards, and can thus be formed more regularly. A com- paratively small knife is employed — a four-inch blade is quite sufficient — and the posterior flap should be made first that its line may not be obscured by bleeding from the anterior. The incision is begun a little above the tro- chanter, carried downwards and across the back of the limb in a curved line convex downwards, and terminated in front of the tuber ischii ; the anterior flap is marked out by a corresponding incision beginning and ending at the same points, and crossing the front of the thigh at least five inches below the joint. The skin having retracted, the muscles, first of the back and "afterwards of the front of the limb, are divided in an oblique manner from below upwards (Fig. 197) till the joint is reached, when disarticulation Fig. 197. Amputation at hip-joint by Guthrie's method. is affected in the ordinary manner. Fig. 198 shows the appearance of the wound after the amputation has been completed. This operation affords i. an Fig. 198. Wound resulting from hip-joint amputation by Guthrie's method. excellent stump, with a small and well-protected cicatrix, as seen in Fig. 199, from the photograph of a patient whose thigh I amputated at the hip- joint for a very large osteo-sarcoma, some years since at the Episcopal Hospital. vol. i.— 43 * F F 674 AMPUTATIONS. Result of hip-joint amputation by Guthrie's method. Fig. 199. Lateral Flap Method.— In tins form of operation, the flaps, as the name im- plies, are taken from the sides of the limb instead of from its front and back. Here, too, we may enumerate three varieties of the operation, viz., Larrey's, Lisfranc's, and Dupuytren's. Larrey's Method. — Larrey began by exposing and tying the femoral artery just below Poupart's ligament. The sur- geon introduces the point of his knife on the front of the limb, a few fingers' breadth to the inner side of and below the anterior iliac spine, pushes it back- wards till it strikes the anterior face of the bone, then inclines it towards the median line of the body, so as to graze the inner surface of the cervix femoris, and, finally, effects transfixion below the tuber ischii. An internal flap, four inches long, is next cut, as in Delpeeh's method, and, after disarticulation, a corresponding external flap is cut in the same manner. The elder Blandin's method differed from Larrey's simply in the formation of both flaps before attempting disarticulation. Lisfranc's Method. — In this operation, the surgeon employs a double- edged knife, transfixes on the outer side of the femur, and thus cuts the ex- ternal flap before the internal. As each flap is formed, he proceeds to tie the bleeding vessels, before proceeding to the other steps of the operation. Dupuytren's Method. — This differs from Larrey's method in that the inter- nal flap is cut from without inwards, the joint being then opened and the head of the femur turned out, when the external flap is made in the ordinary manner. These lateral flap operations give rather unwieldy stumps, and seem to me less desirable than the other methods which have been described in the pre- ceding pages. The most pressing risk, in any amputation at the hip-joint, is that of hemorrhage, for a very few jets from the femoral artery will reduce any patient to a state from which he is not likely to rally. Hence special pre- cautions should invariably be adopted against bleeding, in this operation. As already mentioned, Larrey directed that the main vessel should always be tied in the groin as a preliminary step to hip amputation, and if there be no efficient means at hand for restraining hemorrhage during the operation, such a course will be found advantageous. But under ordinary circumstances, it is, I think, better to dispense with preliminary ligation ; the separation of the vessel from the surrounding tissues, which is unavoidable when an artery is tied in its continuity, cannot but expose the patient to more danger of sec- ondary hemorrhage, following the operation, than when the cut end of the ves- sel is simply picked up with tenaculum or forceps as in other cases. Hence, when it is practicable, I advise that the surgeon should rely upon compression with an aortic tourniquet or other mechanical means of controlling the cir- AMPUTATION AT THE HIP-JOINT. 675 dilation, or, if these are wanting, that lie should trust to manual pressure exercised by intelligent assistants. The simplest and best form of aortic tourniquet is that of Prof. Lister (Fig. 112) ; the instrument employed by Prof. Joseph Pancoast (who was the first to use, in 1860, mechanical com- pression for restraining hemorrhage during this operation) is equally efficient, but more complicated and less readily adjusted. Prof. Spence prefers to compress the aorta by simply laying over it a thick pin-cushion, and keeping it in place by the pressure of an elastic bandage which is made to surround the body. Although there can be no question as to the advantage derived from the use of the aortic compressor in hip-joint amputations, yet, at the same time, the pressure which must necessarily be made upon the nervous structures of the abdomen, cannot but be undesirable, if not actually harmful ; hence no time should be lost in securing the vessels after the limb has been severed, so that the abdominal compression may be relaxed as soon as possible. The point at which the pad of the tourniquet is to be placed, is on a level with the navel, and usually somewhat to its left side ; but as the line of the aorta varies in different subjects, this must be determined by feeling for the pulsa- tion before adjusting the instrument. If the pad be properly placed, a moderate degree of pressure will be sufficient ; it is not necessary to screw the tourniquet " home," but merely to exercise enough force to completely arrest the pulsation in both iliac arteries. Before screwing down the pad, the patient should be gently rolled over upon his right side, so that his bowels (which should have been emptied by a cathartic and an enema) may fall away from the line of pressure. If manual compression is to be employed, this may be applied over the aorta (if the patient be thin), over the external iliac, or over the common femoral artery. The hands of an assistant, too, should follow the operator's knife, and should seize the artery in the anterior flap, before, or at least, as soon as, it is divided. Dr. Woodbury, of Philadelphia, and Prof. Van Buren, of New York, have suggested, quite independently of each other, that the circulation might be controlled, during this operation, by an assistant intro- ducing his hand into the patient's rectum, and exercising direct pressure upon the iliac artery. Following out the same idea, Mr. P. Davy, of London, has devised an ingenious " lever," to be introduced into the rectum for the same purpose, and a number of cases of hip amputation have now been reported in which Davy's lever has proved most efficient in preventing bleed- Not only is it essential that the circulation should be controlled on the cardiac side of the seat of operation, but it is very desirable that the patient should not lose the blood which is in the limb to be amputated. To meet this indication, Prof. Erskine Mason, of New York, advises that the part should be first rendered bloodless by the use of Esmarch's bandage and tube, and that the latter should be kept in place during the operation, so as to pre- vent the blood from re-entering the condemned limb ; all that is'lost will then be the blood between the elastic tube and the point of aortic compression. The practice thus suggested by Dr. Mason, I look upon as one of the greatest improvements which has ever been effected in the operation ; I have adopted it myself with entire satisfaction, and strongly urge its employment when- ever hip amputation is required. A broad, flat sponge should also be provided, as recommended by Mr. Butcher, of Dublin, for application to the whole posterior flap while the sur- geon is engaged in securing the principal vessels, which are in the anterior. After the operation, the stump should be closed in the customary manner, 676 AMPUTATIONS. suitable compresses being adjusted so as to keep the deep parts of the wound in apposition. The statistics of amputation at the hip-joint have been investigated by various surgeons, among whom I may particularly mention Prof. Stephen Smith, of New York; Mr. W. Sands Cox, of Birmingham ; the late Dr. G. A. Otis, of the United States Army; and Dr. A. Liming, of Zurich. Dr. F. C. Sheppard, of Philadelphia, has at my request made extensive researches into the literature of the subject, and has succeeded in collecting 633 cases of this operation, the details of which he has arranged for me in tabular form. These statistics are much more comprehensive than any which have hitherto been published, and show very conclusively the gravity of the operation, par- ticularly in traumatic cases. The following summaries show the results of the operation (1) in military practice; (2) in cases of injury treated in civil life; (3) in cases of disease; (4) in cases the nature of which is not certainly known ; and (5) in cases of all kinds taken together. I. Summary of Two Hundred and Thirty-eight Cases of Hip-joint Amputation in Military Practice. Nature of operation. Primary .... Intermediate Secondary .... Re-amputation of thigh stump Not stated .... Total number of cases Recov- Died. Undeter- Total. ered. mined. 7 89 96 4 59 63 10 17 27 4 3 7 5 39 1 45 30 207 1 238 Mortality per cent. 1 92.7 93.6 62.9 42.8 88.6 87.3 II. Summary of Seventy-one Cases of Hip-joint Amputation for Injury in Civil Practice. Nature of operation. Primary .... Intermediate Secondary .... Re-amputation of thigh stump Not stated Total number of cases Recov- ered. 24 25 7 6 1 47 31 12 11 5 12 71 Mortality per cent. 80.6 58.3 54.5 20.0 66 6 66.1 III. Summary of Two Hundred and Seventy-six Cases of Hip-joint Amputation for Disease. Natnre of operation. Amputation of'entire limb . Re-amputation of thigh stump Total number of cases Recov- ered. 136 20 156 Died. 95 10 105 Undeter- mined. 14 1 15 Total. 245 31 276 Mortality per cent. 1 41.1 33.3 40.2 Undetermined cases omitted in computing percentages. AMPUTATION AT THE HIP-JOINT. 677 IV. Summary of Forty-eight Cases op IIip-joint Amputation for Unknown Causes. Number of cases , Recov- ered. Died. Undeter- mined. Total. 10 34 4 48 Mortality per ceut. 1 77.2 V. General Summary of Sin Hundred and Thirty-three Cases of Hip-joint Amputation for all Causes. Nature of case. Recov- ered. Died. Undeter- mined. Total. Mortality per cent. 1 156 54 10 105 254 34 15 1 4 276 309 48 40.2 82.4 77.2 220 393 20 633 64.1 From the preceding statistics it will be seen that, in military practice, the death-rate of primary and of intermediate amputation has reached the appalling figure of 93 per cent,, or, in other words, that not one patient in fourteen recovers from the operation. In civil practice, the results of primary amputation are still very unfavorable, the mortality being over 80 per cent., or but one patient in five recovering. Hence the inference is irresistible that, except in very exceptional circumstances, as where the limb is entirely carried away by a round shot, or completely crushed at a point too high for amputation in its continuity, or where, besides the injury to the bone, the great vessels are severed — in other words w r here the patient is threatened with instant death as the result of his injury — primary amputation at the hip-joint should be avoided. Whenever there is the slightest chance of doing so, an effort should be made to tide the patient over the immediate risks of the injury by expectant and palliative measures, keeping amputation in reserve, if necessary, as a secondary operation. Secondary hip-joint ampu- tation, though very grave, is comparatively a successful procedure, the mor- tality, in civil and military cases taken together, being somewhat over 60 per cent., or two patients out of five recovering. In non-traumatic cases (opera- tions for necrosis, tumors, etc.), the results are still more favorable, the death- rate being less than 41 per cent., or three out of five patients recovering. Taking all cases together, the mortality is seen to be 64.1 per cent., as com- pared with a death-rate of 63.8 per cent, for all amputations through the continuity of the thigh, 2 thus confirming the general rule that the gravity of amputation increases as the site of operation is in closer proximity to the trunk. In every class of cases, but particularly in cases of injury, re-amputation after previous amputation through the thigh, is much less fatal than when the whole lower extremity is removed at once; this is easily understood when we reflect that the shock to the system of such a re-amputation is necessarily much less severe than when the patient, seeking to avoid imminent death, submits to what Hennen 3 calls the " tremendous alternative" of losing at one operation nearly a fourth of the whole body. 1 Undetermined cases omitted in computing percentages. 2 See Table, page 630. 8 Op. cit., p. 30. 678 AMPUTATIONS. W o O w w P5 a H o 53 w « 5=> w H-l o w P5 o pq r .j t> m i— co .X § ► 02 of - Q0 TJ1 co 13* O O to CO £ O r- 1 o .2 ft t3 co o> i-h i - on V "1© r i. 47. a. State M 2, ii. 209. d. Journ., i—i as - u G «» c4 • -i to 6 ^ gioia io • ft ft° -a ft ft R. - >. t- be CO s 7J B o a 3 o • 1-5 CO CO o /. c I 53 B t~-" 13 <3 O to c . «J 00 T— 1 a) o s, No. 17 d., No. 1 d., No. 1 c. 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I— co 3 « CO CO § co "- 1 » ft H (f . rt 3" N £ 3 "E 3 43 -^ CD CD — cS ft t> S fi INDEX. YOL. I. ABSCESS, 117 Accidents of anaesthesia, 412, 415 Acetic ether, 432 Acid, carbolic, 430 Actual cautery, 504 Acupuncture, 502 Administration of anaesthetics, 412 of chloroform, 446 of ether, 443 Age, effect of, in amputation, 618 in anaesthesia, 414 in operations, 459 in shock, 359 in surgical diagnosis, 339 Agnew, surgical diagnosis, 337 Air in veins after operations, 476 dressing of stump, 594 passages, effect of anaesthetics on, 406 erysipelas of, 201 Alcohol in erysipelas, 198 Alcoholism, 322 Alcohols, 430 Aldehydes, 432 Allen's method of transfusion, 512 Ammonia in shock, 373 Amputation or amputations, 551 advantages of different methods, 589 at ankle, 656 of arm, 642 for avulsion of limb, 559 Carden's, 665 cases of, 612 Chopart's, 653 circular operation, 579 history of, 556 for compound fractures and luxations, 560 conditions calling for, 559 et seq. for deformities, 564 for disease of bones and joints, 564 for dry gangrene, 563 effect of age in, 618 of constitutional condition, 622 Amputation — for effects of heat and cold, 562 effect of hygienic surroundings on, 623 of nature of lesion on, 625 of part involved on, 629 of period of, 627 of sex on, 622 at elbow, 640 elliptical operation, 583 erysipelas in, 624 of fingers, 631 et seq. • flap operation in, 558 double, 585 single, 584 of foot, 650 of forearm, 639 Gritti's, 665 for gunshot injuries, 561 Hancock's, 655 of hand, 634 Hey's, 652 at hip-joint, 669 history of, 552 et seq. for hospital gangrene, 563 instruments for, 565 at knee, 663, 665 at knee-joint, 663 for lacerated and contused wounds, 560 Langenbeck's method, 587 Lee's, 662 Le Fort's, 659 of leg, 660 for lesion of arteries, 562 ligature in, 554 Lisfranc's, 652 Lister's method, 5S8 Malgaigne's method, 584 at medio-tarsal joint, 653 at metacarpus, 635, 636 at metatarsus, 650 et seq. modified circular operation, 582 for morbid growths, 564 (703) 704 INDEX. Amputation — mortality and causes of death after, 610 for mortification, 562 operative methods employed in, 579 et seq. oval operation, 584 Pirogoff's, 658 pyaemia in, 624 Ravaton's method, 585 Roux's, 658 Scoutetten's method, 584 Sedillot's method, 586, 661 above shoulder, 647 at shoulder, 643 simultaneous, 590 special, of lower extremity, 649 et seq. of upper extremity, 631 el seq. Stokes's, 666 subastragaloid, 654 Syme's 656 synchronous, 590, 592 Teale's method, 587 for tetanus, 564 of thigh, 667 of thumb, 634 of toes, 649 tourniquet in, 553 Tripier's, 655 Vermale's method, 585 at wrist, 637 Aniyl chloride, 429 iodide, 429 nitrite, 429 Amylene, 425 Amyloid degeneration, 62 Anaeinia, 3 Anaesthesia, 403. See also Anaesthetics, accidents of, 412, 415 after-treatment of, 445 artificial, mortality from, 422 asphyxia during, 412 from compression, 422 in dentistry, 417 by electricity, 419 history of, 403 influence of age, sex, and temperament on, 414 of cerebral and spinal diseases on, 414 of excitement or terror on, 415 of intra-thoracic diseases on, 415 of rate of inhalation on, 414 from intravenous injections, 419 local, 418, 447 meaning of, 4<>3 in obstetrics, 416 In operations, 441 phenomena of, 406 physiology of, 409 Anaesthesia — post-mortem appearances after death from, 423 by rapid respiration, 419 in surgery, 416 syncope during, 412 by various methods, 419, 448 Anaesthetic mixtures, 420 substances, 424 Anaesthetics, 403 administration of, 412 effect of, on action of heart, 408 on air passages, 406 on brain, 407 on eyes, 406 on general sensibility, 406 on muscular movements, 407 on nervous centres, 414 on power of volition, 407 on reflex action, 408 on respiration, 408 on secretions, 408 on temperature, 408 employment of, 416 in shock, 374 Aneurism of aorta, 329 of stumps, 604 Ankle, amputation of, 656 et seq. Anodynes in inflammation, 156 Antecedent history in surgical diagnosis, 341 Antiseptic dressing of stumps, 597 Antiseptics in inflammation, 159 Aorta, aneurism of, 329 Aran's ether, 428 Arm, amputation of, 642 Arteries, amputation for lesion of, 562 influence of, on operation, 463 Arterial atheroma, 329 transfusion, 513 Arteriotomy, 509 Artery forceps, 574 Arthritism, 311 Artificial limbs, adaptation of, 606 respiration, 514 et seq. in shock, 372 Ashhurst, amputations, 551 Asphyxia during anaesthesia, 412 Aspiration, 519 pneumatic, 595 Assistants during operations, 449 Astringents in erysipelas, 194 in inflammation, 157 Atheroma, arterial, 329 Aural symptoms in scurvy, 300 Auto-transfusion, 513 Aveling's method of transfusion, 510 Azoturia, 331 INDEX. 705 BANDAGE or bandages, 483 circular, 485 crossed or oblique of angle of jaw, 494 figure-of-eight, 491 of chest, anterior, 491 posterior, 491 of elbow, 491 of head and jaw, 493 handkerchief, 497 hardening, 498 for head, 493 many tailed, of Scultetus, 497 oblique, 485 plaster of Paris, 498 recurrent, of head, 494 of stumps, 495 roller, 483 sling or four tailed, 496 special, 485 spica, 488 of foot, 490 of groin, 489 of both groins, 490 of shoulder, 489 of thumb, 489 spiral, 485, 486 of chest, 488 of fingers, 4S6 of hand, or demi-gauntlet, 486 of penis, 488 reversed, 485 of lower extremity, 487 of upper extremity, 486. despensory and compressor, of breast, 492 of both breasts, 493 T double, 496 T single, 496 use of, 483 V of head, 495 Velpeau's, 493 Bandaging, general rules for, 484 Basis-substance, vital processes in, 34 Beclard's amputation at hip-joint, 672 Belladonna in shock, 373 Benzene, 425 Bert on skin-grafting, 546 Bilious erysipelas, 186 Bisulphide of carbon, 433 Bites of serpents, delirium from, 3S4 and stings of insects, delirium from, 385 Bladder, care of, after operations, 454 Bleeding. See Venesection and Blood-letting, from external jugular, 509 from internal saphena, 509 Blood, clot of, causing inflammation, 79 defect in quality of, causing inflamma- tion, 70 VOL. I. 45 Blood- examination of, in pysemia, 205 poison in, causing inflammation, 71 transfusion of, 509 direct, 510 Blood-letting, 505 in erysipelas, 193 in inflammation, 149 Blood-poisoning, 106 Bloodvessels, contractile elements of, 4 Bloody cupping, 506 Blunt knives in operations, 451 Bone forceps, 573 hypertrophy of, in stumps, 606 nippers, 573 suppurative inflammation in, 38 Bones, amputation for disease of, 564 of head, changes in, in rachitis, 260, 264 of lower extremity, changes in, in rachi- tis, 267 of trunk, changes in, in rachitis, 264, 265, 267 of upper extremity, changes in, in rachi- tis, 266 Bordeaux dressing of stumps, 598 Bowel affections, influence of, on operations, 467 Bowels, care of, after operations, 454 in scurvy, 292 Brain, effect of anaesthetics on, 407 Brinton, operative surgery in general, 435 Bromide of ethyl, 428 Bryant on skin-grafting, 543 Burns, delirium from, 3S9 Bursae in stumps, 606 Butlin, scrofula and tubercle, 231 Butylchloral hydrate, 430 CACHECTIC conditions causing erysipelas, 163 Cachexia, influence of, on operations, 468 scorbutic, 295 Calcareous degeneration, 62 Cancer, 313 Capillaries, contractility of, 5 Carbolic acid, 430 in erysipelas, 197 Carbon bisulphide, 433 Carbonic acid, 433 oxide, 433 tetrachloride, 426 Carden's amputation, 665 Cardism, 329 Caries in stumps, 605 Cartilage, suppurative inflammation in, 38 Cartilaginous changes in rachitis, 257 706 INDEX. Catalepsy, delirium from, 392 Catarrhal inflammation, 132 Cathartics in inflammation, 157 Cautery, 504 galvanic, 523 Paquelin's, 505 Cell-nucleus, 42 Cells, apparent migration of, 34 fixed, new observations on, 51 of glands, contractility of, 9 Cellulitis, diffuse, of stumps, 602 Cerebral disease, effect of, in anaesthesia, 414 symptoms in scurvy, 299 Charpie, 479 Chemical irritants causing inflammation, 80 theory of pyaemia, 204 Chloral hydrate, 430 Chloride of amyl, 429 Chloroform, 426 administration of, 446 compared with ether, 442 first insensibility from, 431 history of, 405 mortality from, 422. 433 Chopart's amputation, 653 Chorea, delirium from, 385 Circular amputation, 579 Circulation, investigation of, in surgical diag- nosis, 347 Climate causing inflammation, 73 Clinical thermometer, 348, 527 Clot of blood causing inflammation, 79 Coagulable lymph, 110 Cohnheim's theory of inflammation, 25 Cold, amputation for effects of, 562 a cause of erysipelas, 163 of inflammation, 74 in erysipelas, 194 in inflammation, 144 Colloid degeneration, 62 Color in surgical diagnosis, 345 Compresses, 480 Compression causing anaesthesia, 422 in inflammation, 147 Connective substance, comparison of, with sup- posed fibrillar substances, 43 Constitutional conditions, classification of, 307 effect of, in amputation, 622 in operations, 463 and injuries, reciprocal effects of, 307 influence of, 308 Contagion of erysipelas, 165 Contractile elements of bloodvessels, 4 Contractility <>{ capillaries, 5, !> <'(,ntusc3 proof paper, 482 Waxed paper, 482 Weather, influence of, on operations, 401 Weight in surgical diagnosis, 345 Wet or bloody cupping, 506 Wood spirit, 430 Wounds causing inflammation, 75, 70 lacerated, delirium from, 387 Wrist, amputation at, 0'37 END OF VOL. I.