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NATIONAL LIBRARY OF MEDI C I NE NATIONAL IIIUIV OF MEDICINE N A T I O N A L L I B R A R Y 0 F M E D I C I N E N A T I 0 N A I I I B R A R Y O F M E D I C I N E N A T I 0 N A L I I B R A R Y O F M I D I C I N E N A T I O N A I I I B R A R Y 0 F M E D I C I N E N A T I O N A I I I B R A R Y O NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY ',=££ jNiDiaaw jo Aavaan ivnouvn j n i 3 i o 3 w jo a»v »a n i vnouvn 3n i 3 io j w jo Aav»a n tvno ii v n 3 n i 3 i a jw jo a«v aa ii i vnoi i v n 3 n i 3 i a 3 w jo a«v »a m i vnou v n jn i 3 iqj w jo Aivaa n ivno 11 v n 3n 1 31 ajw jo a»v»a ^ 1 Imhy i NAl LIBRARY OF MEDICINE N A T I O N A I I I B R A R Y O F M E D I C I N I N A T I O N A I I I B R A R Y O F M E D I C I N E N A T I O N A I L I B R A R Y O F M E D I C I N E N A T I O N A I L I B R A R Y O F M E D I C I N E * A T I O N A I I I B R A R Y O F M E D I C I N E N A T I O N A I L I fi R A R Y CONTRIBUTIONS TO OPERATIVE SURGERY AND SURGICAL PATHOLOGY. ''<^ ^ •M. < ■\ CONTRIBUTIONS TO OPERATIVE SURGERY AND SURGICAL PATHOLOGY. BY J. M. CARNOCHAN, M.D., FORMERLY PROFESSOR OF SURGERY IN THE NEW YORK MEDICAL COLLEGE, SURGEON-IN-CHIEF TO THE STATE EMIGRANTS' HOSPITAL, 1850-71, &a WITH ILLUSTRATIONS DRAWN FROM NATURE. iMu ^*. ' • > '» » » •- \ • NEW YORK: HARPER & BROTHERS, PUBLISHERS, FRANKLIN SQUAEE. 18 77. WO qCz9lc Entered according to Act of Congress, in the year 1877, by J. M. CARNOCHAN, M.D., In the Office of the Librarian of Congress, at Washington. DEDICATION. TO SAMUEL D. GROSS, M.D., D.C.L. (Oxon.), PROFESSOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, WHOSE INTELLECT, DURING A LONG AND ILLUSTRIOUS CAREER, HAS BEEN DEVOTED TO THE SUCCESSFUL CULTIVATION AND ELUCIDATION OF THE SCIENCE AND ART OF SURGERY, AS SURGEON AND AUTHOR, THIS WORK IS RESPECTFULLY DEDICATED, AS A TRIBUTE TO HIS HIGH PROFESSIONAL ATTAINMENTS AND EMINENT PRIVATE VIRTUES, BY THE AUTHOR. EPISTLE. TO VALENTINE MOTT, M.D., LL.D.: My dear Sir,— A witness, from early youth, of your efforts for the advancement of our Art, I naturally attach a high value to your opinion upon surgical subjects. Permit me, therefore, to ask your perusal of these contributions, and, at the same time, to express my acknowledgment that whatever merit they may display is to be attributed, in a measure, to your example. Richly endowed by nature, your genius acquired its fine proportions under the tuition of Astley Cooper, the disciple of Hunter, whose methods and principles you were thus enabled to inaugurate successfully in the schools of your native land. With this signal service to science, as weU as with several great and original improvements in Operative Surgery, your name will ever remain associated; and, for my part, I regard it with the veneration which becomes a pupil who is sensible of the beneficial influence you have exercised over his surgical career. Animated by this sentiment, I beg leave to subscribe myself, Your most obedient servant, J. M. Carnochan. PEEFAOE. Since the time that Laennec applied the stethoscope to the exploration of dis- eases of the chest, as an important addition to the physical means of diagnosticating pathological conditions of the lungs, other organs have been subjected to direct exam- ination, upon a similar principle, and through the medium of the senses, by the use of various instruments invented for the purpose. Percussion has been brought into use to reveal the measure of dulness or clearness of sound. The deepest part of the globe of the eye is made plain to the observer, and the intricate mechanism and con- ditions of the ear are more perfectly explored. The nares, pharynx, larynx, rectum, urethra and bladder, vagina and uterus, can now be minutely inspected. Where the sight, the touch, or the sound cannot reach, physiological discoveries have shown the way to localize in such organs as the brain and spinal marrow the seat of morbid phenomena and changes which were previously occult and not comprehended. The temperature of the body and the oscillations of the pulse have been measured by ingenious instruments, but these will scarcely ever supersede the information acquired by the trained touch and the mental record impressed upon the senses by observa- tion-and experience. In 1801 Bichat gave a fresh impulse to the study of medicine by publishing his great work on general anatomy, supplying a more correct knowledge of the tissues of which the human body is composed. In this important work he was followed by Beclard, who contributed to the labors of his famous contemporary. Their efforts were the basis of farther improvements. Analytical chemistry and the microscope were applied to make known the more minute structure and composition of the healthy and morbid conditions of the solids and fluids. Thus the knowledge of medicine has been extended, the sources and nature of disease are more readily and 9 11 PREFACE. precisely determined, and the removal of obscurity has been followed by accuracy of diagnosis and a more rational system of therapeutics. Following the example of my early master, Professor Syme, of Edinburgh, I pub- lish these contributions in the hope that they will be found useful by those who recognize that it is from the study of particular facts operative surgery frequently derives its most valuable suggestions. Operative surgery embraces not only a knowledge of the pathological condition indicating the necessity for an operation, but the management of the patient immediately previous to its performance, a com- prehension of the contingencies that may arise during the operation, and the proper treatment of the case afterward. The life of man is too short to allow him, even with the greatest industry, to witness all the varieties of accident or disease; and as there is no limit to the multi- plicity of pathological differences, the most experienced practitioner may find himself in the presence of unknown and unforeseen conditions. Hence it is incumbent on the surgeon to read much, as well as to see much, and to extend his knowledge as far as possible beyond the sphere of his own immediate observation. This is especially the duty of country practitioners and of practitioners in small towns and villages; and even in the case of surgeons dwelling in the midst of large centres of population, with corresponding hospital facilities, it will not do to neglect the experience of other men, under the penalty of abdicating progress in both the science and art of surgery. The practitioner may be deficient, without blame, in some of the natural endowments which go to make the complete surgeon: he may be wanting in tact, in presence of mind, in clearness of vision, in manual dexterity or bodily strength; but a conscien- tious man will never be able to justify to himself an incapacity which proceeds from ignorance of the recorded triumphs of operative surgery in difficult cases. These are not always described at length in the text-books, and, in fact, can only be known through the current surgical literature of the day. The science of operative surgery exhibits results in a harmonious and systematic shape; but these results are precise- ]y the particular facts by whose assistance science is advanced, the elements without which science could not exist at all. The methodical treatise, or corpus sciential, is indispensable to the professor, the practitioner, and the student; but, after all, it must be recollected that the progress of operative surgery is chiefly effected by the discov- erios of great surgeons in particular cases, and by new methods which effect cures PREFACE. iii that were once deemed beyond the reach of art. Thus the treatment of aneurism by the method of Hunter was a progress in operative surgery, for it enabled the sur- geon to effect the cure of aneurism in cases which had always before been regarded as hopeless. In some of the cases contained in these contributions the methods are essentially curative—as in the exsection of the entire ulna and in the exsection of the entire radius, where the amputation of the entire member is avoided; in others the meth- ods are purely operative; but whether curative or operative, I flatter myself that they are entitled to consideration, in many instances, on the ground of originality of conception. And I may add here that while respect for life will dictate to the surgeon the greatest prudence—will counsel him to attempt no operation which he would not be willing to perform on his own child—it will also teach him that if the extremes of boldness are to be shunned, pusillanimity is not the necessary alter- native. The surgeon who has not sufficient courage to propose a useful operation, and sufficient skill to perform it, is as open to censure as the reckless practitioner who is swayed by the unworthy lure of notoriety. While recognizing the value of the recent improvements and innovations in med- icine and surgery, it is not necessary to parcel out and subdivide a great art to an unlimited extent. The invention of an instrument or any improvement, with the view of detecting with greater precision the characteristics of a particular class of diseases, does not form a sufficient basis for magnifying the pathological phenomena of every organ into a distinct department of science. Such a custom, too prevalent at present, tends to give undue importance to manual and instrumental efforts, to the neglect of therapeutic and conservative measures, thus leading to errors of judgment, and to a course of practice often useless and injurious. The principles and doctrines incul- cated by the great masters—by Harvey, Hunter, Boyer, Desault, Larrey, Dupuytren, Lisfranc, Roux, Dieffenbach, Astley Cooper, Charles Bell, Brodie, M'Dowell, Physick, Valentine Mott, and other illustrious men of preceding times—must be taken as the foundation upon which has been erected the superstructure of modern surgery. This work was commenced some years since, and had reached the fourth number, but was interrupted by the destruction by fire of the establishment of the printer, thereby losing plates, drawings, lithographs, etc. The epistle addressed to Valentine Mott, following the title-page and dedication, was printed while he was living, and is IV PREFACE. now inserted unchanged, from sentiments of great regard for his memory. Some of the matter has been previously published in various medical journals, but has been thought of sufficient importance to be reproduced, as presenting special types of disease, and the character of the work enables me to add whatever fresh material I have since collected or may collect. I have placed as introductory to the following pages an address on the study of science, given before my class when Professor of Surgery in the New York Medical College, which, although it was delivered some time since, may not be out of place as touching on the inductive method of research now so much in vogue among the scientists of the present day. J. M. Carnochan. New York, 11 East Sixteenth Street, November, 1876. INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. " What gave Marcellus the greatest concern," relates Plutarch, in his account of the storming of Syracuse, " was the unhappy fate of Archimedes, who was at that time in his museum, with his mind as well as his eyes so fixed and intent upon some geometrical figures, that he neither heard the noise of the Romans, nor perceived the city to be taken. In this depth of study and contemplation, a soldier came suddenly upon him, and commanded him to follow him to Marcellus; which he refusing to do until he had finished his problem, the soldier in a rage drew his sword and ran him through." The studies, gentlemen, which enrapt the soul of Archimedes in the midst of war's alarms must have been a source of pleasure, pure and high, not less valued than existence itself. With such men, the appetite for finding out laws from facts, causes from effects, necessary truths from the floating occurrences of the day, puts in its claim to gratification, which is as legitimate as that of the animal nature for food and sleep. If the question, " What fruit does science bring ?" be understood, as it certainly ought not, to refer to the material wants of humanity, it is a base and sordid question, against which every better mind indignantly protests. Science was never brought to its present height by hopes of wealth, plenty, and comfort alone, but chiefly by those "admirable loves" with which she can inspire her followers. But whilst the coldest utilitarians admit that the value of science must not be estimated by what she can practically perform, no doubt it must be granted that even the highest sciences do condescend to help our lowest wants. Astronomy, Chemistry, Geology, and Mechanics, not only furnish delightful contemplations to the student, but they put food into the mouths of the million : they clothe them, and fill their purses: they put houses over their heads, and adorn them with objects of beauty and convenience. The acquisition of knowledge is, indeed, in itself a positive good: the man who has his mind open to the perception of surrounding objects, and is led to reflect upon their nature and properties, has much greater capabilities of happiness—has much greater capacity for understanding and fulfilling the duties of his station, than if vi INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. brought up in gross ignorance, without ever having exercised his intellectual powers. T.rsides attaining .the self denying, upright, benevolently co-operating, and industrious habits which live" in the very atmosphere of science, an enlightened intellect looks after and before, observes relations, calculates consequences, and, according to the nature of things, avoids evil and secures good. There is no situation in life that must not, after all, owe its highest enjoyments to feelings with which the mind is connect- ed : there is none which may not be cheered and refined from the same source. In- dependently of all worldly considerations, scientific pursuits always bestow rich rewards on their votary, in the delights attendant upon their cultivation, and the temporary oblivion, at least, of all care, in the abstraction they require. Finally, it may be said that while we have long experienced that knowledge is profitable, we are now beginning to find out that it is moral, and shall at last discover it to be religious. Aristotle declared the highest and truest science to be that which was most disinterested. Bacon, treating science as separate from religion, asserted knowl- edge to be power, and held that truth must be tested by its fruits, that is, its instru- mentality in promoting the right and useful. Both assertions may be justified and reeonciled by the fact that, while no real knowledge is powerless and fruitless, the fruits differ in refinement and value; the highest being, unquestionably, those disin- terested gratifications which minister to the highest wants and the highest faculties, and which earned for Philosophy the title of a " divine love," realizing the mysterious longing of the soul, and promoting the accomplishment of its destiny: " To rise in science as in bliss." But science confers these advantages only on condition that those who cultivate it shall be absolutely devoted to truth, and that far from seeking to maintain the error they may have mistaken for it, they shall be the first to renounce it, and incline their heads to those who set them back in the right path. But is the acquisition of truth as easy as is commonly supposed? This question must be answered unhesita- tingly in the negative. It will not suffice to declare that we are seekers after truth ■ we must be also able to say that we know how to distinguish it from error and that being able to demonstrate its reality, we are likewise able to develop its conse- quences The hostility which well-intentioned men sometimes bear to the propaga- tion of truth proceeds in part, from a secret dread that one day all things may be explained-thus eyeing the profoundest of all infidelity, the fear lest the" truth b wlwi ' ^^ i thG bellGf that ^ " ^^ the cause of those disturbance ,hich threaten he existence of the social state. But truth should not b held responsible for the results of error. It is demonstrable that the evil effe ts w so frequency witness proceed from erroneous opinions propagated as truths and which would have been nipped in the bud had they been submitted to , I /i 'Ji* nation fitted to estaMisfi their falseLood; L^^^^^Z INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. vii pretension to understand and explain that which it is impossible for any human being to understand and explain. Thus the ability of discriminating between what is true and what is false lies at the very threshold of the pursuit of science; and we acquire this ability by familiarizing the mind with the rules which constitute method. There exists a general method, and there also exist particular methods, adapted to the different branches of human science. The rules of the general method are found in all the particular methods; but every particular method has special rules, which constitute the philosophy of the science to which they belong. To these special rules we are indebted, from Galileo down to the present time, for the immense progress we have made in the natural sciences. In Astronomy, for instance, we take for our point of departure the observation of phenomena, and seek for their causes conformably to inductive rules which are appropriate to that science. The advan- tages of this direction of the human mind are no longer contested. We proceed from acquired truths to truths that are still latent, or, in other words, from the known to the unknown, and thus the progress of knowledge is definitively assured. But truth, the magnum opus of science—its possible achievement—the aim and object of the labors in which you are about to engage in these academic halls—where and how is it to be found ? This inquiry leads us directly to the consideration of the distinction of truths a priori and truths a posteriori, and of the methods which derive from them. If there are any truths wThich the mind originally possesses, whether consciously or unconsciously, they may be called a priori truths, as belonging to it prior to all that it acquires from the world around. On the other hand, truths which are acquired from observation and experience are called a posteriori truths; because they come to the mind after it has become acquainted with external facts. How far a priori truths are possible, is the great battle-field of mental philosophy; but no one at present main- tains that the mind can know any thing at a point of time before its observation of external things began. However independent of experience any process may appear to be now, as, for instance, that by which geometrical truths are proved, we may be sure that we made much use of observation before we educed the very laws which place it in our minds far above all need of confirmatory evidence from observation. A mind which never observed would not be mind. But the question is, whether even the facts which we observe do not furnish evidence that something was in the mind before it was directed to the facts; just as we know by looking at something that we have eyes, and must have had them before we looked; although, without putting them to their common use, we could never have known that we had them at all. Now, without going into the dispute how much of our knowledge is a priori, we may be able to show that at least the conditions of all our knowledge are so— that the mind does not simply reflect the images of things without, but impresses Vlll INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. characters of her own upon them-that our knowledge of things is not the exact ^nCrt «f the things but of the things and mind operating together When we ero uin age in a minor we know that our shape is the cause of it on the one hand, id the power of reflection in the mirror on the other: if we were to see it multiplied increased, or diminished, or changed in hue, we should infer tha the mirror had several angular faces, or was convex, or was concave, or made of tinted glass. Each of these properties would be inherent in the mirror prior to our presenting our- selves before it; they are its a priori laws, although we could only know them a posteriori by a trial. When an image is received upon the mirror of the mind, we see that the latter, also, has its laws and properties. The mind does not simply re- ceive the impressions of the senses; it groups them, judges about them, separates their qualities from each other, and draws inferences about the qualities which like objects, hitherto unknown, may be expected to have. But qualities, classes, inferences, are not objects of sense, however completely they may reside in or be drawn from these objects. They have no separate existence out of the mind; whilst, within it, they are perfectly distinct. This transmutation of objects of sense into their elements must, therefore, be the work of the mind alone. It is a law of the intellect itself, and never was or could have been in the sensuous impressions we have received. The acts of the mind are so quick, so numerous, so complex, that they are not easy to note and describe, although we daily perform them, and that without serious mis- takes. As the act of standing erect, so simple apparently, calls into operation a nu- merous array of muscles by means of which the body perpetually sways and adjusts itself without conscious effort, so we may believe that the mind goes through acts which, from long practice, scarcely awaken her own attention, much less the sense of pain and effort, yet which involve a great number of subordinate acts, depending on distinct principles. When the English traveller, Sir Francis Bond Head, was journey- iug across the pampas of South America, his guide, one day, suddenly stopped him, and pointing high into the air, cried out: " A lion !" Surprised at such an exclama- tion, accompanied with such an act, the traveller turned up his eyes, and with difficul- ty perceived, at an immeasurable height, a flight of condors soaring in circles in a par- ticular spot. Beneath that spot, far out of sight of himself or guide, lay the carcass of a horse, and over that carcass, as the guide well knew, stood a lion, which the con- dors were eying with envy from their airy height. The signal of the birds, was to the guide what the sight of the lion, alone, would have been to the traveller—a full assurance of its existence. Here was an act of thought which cost the thinker no trouble, which was as easy to him as to cast his eyes upward. The sight of the condors convinced him that there was some carcass or other; but as°they kept wheeling far above it, instead of swooping down to their feast, he guessed that some beast had anticipated them. Was it a dog or some other inferior animal? No. INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. ix The condors would not fear to drive such away, or share with it. It must be some large beast, and as lions abounded in the neighborhood, he concluded that one was there. These steps, at least, of thought, and probably many more, rushed through his mind, and were summed up in the words: "A lion!" From the primary conditions of thought—a priori and a posteriori truths, or, in other words, mental action and experience—science is derived. In its most compre- hensive sense, it is defined to be a system of principles and deductions to explain some object-matter. To fulfil its intention, every science must have attained to true statements concerning its object-matter, so far as the nature of the case aiid the present means of examination allow: it must be able to define the object-matter and its sev- eral subordinate parts with clearness and precision: it must be able to indicate the extent of the domain the object-matter covers; and, lastly, it must exhibit these re- sults in a systematic and harmonious shape. For the first, it must employ Induction and Deudction: the second is the province of Definition: the third is provided for by Division; and the fourth may be referred to Plan. The search after truth cannot long dispense with any one of these instruments; and even with the free use of them, the history of science shows how slow has been the advance, how largely the sand and mud of error have been mixed with the gold grains of truth. All of them, in their degree, have to do with evidence—with the proof of propositions: Induction and Deduction, chiefly with the discovery and appre- ciation of evidence; Definition, Division, and Plan, chiefly with the statement and arrangement of its results. Hence, if we have to answer the question whether a criterion of truth, that is to say, a standard for judging of the truth of propositions, is possible, the answer is, that evidence is the sole means of establishing, and therefore the sole standard for testing, the truth of any proposition, and that all the operations connected with evidence contribute their share to the criterion. In fact, no shorter rule, no more portable touchstone, can be indicated than the whole science and rules of evidence. And in the special cases where other criteria appear to be applied—as in the discussion whether religious truth is to be tried by external testimony or internal conviction, whether historical evidence or the religious sentiment is the best criterion—the dispute is only as to the kind of evidence that shall take precedence. Induction is usually defined to be the process of drawing a general law from a sufficient number of particular cases: Deduction is the converse process of proving that some property belongs to a particular case, from the consideration that it comes under a general law. More concisely, Induction is the process of discovering laws from facts, and causes from effects; and Deduction that of deriving facts from laws, and effects from their causes. For instance, that all bodies tend to fall toward the earth is a truth which has been reached inductively, by considering a number of bodies where that tendency has been displayed: if from this general principle we 3 X INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. argue . that the stone we throw from our hand will show the same tendency we deduce. If it were always possible duly to examine the whole of the cases to which a law applies, and to see by intuition the significance of each, the process of Induction would be simple enough. But a complete inspection of all the cases is very seldom possible. Even the laws on whose invariable operation the strongest reliance is placed must have been laid down upon the evidence of a number of cases very lim- ited, when compared with the whole: that men must all die, and that heavy bodies tend to fall toward the earth, are statements which no one can boast of having veri- fied by enumeration. The perfect certainty with which they are believed rests upon far less than the millionth part of the cases that might be brought to bear witness about them. Nor, again, are the significant and essential circumstances easy to observe in the few cases that lie within the reach. Either they escape notice alto- irether, as did the fact of the earth's revolution in the early days of Astronomy, or they are so entangled or overlaid with a mass of other facts that their import does not at first appear; like the action of cold in the production of dew, or the influ- ence of an open drain in producing and sustaining fever. It appears, then, that the argument by which a law is laid down as the exact sum of all the single cases will not suffice for scientific research. The statement, for instance, that all metals combine with oxygen could not be formed until people discovered, what at first no one sus- pected, that oxygen "was the cause of the rusting and tarnishing of metals: but this is still open to dispute as an invariable truth; for a metal which refuses to combine with oxygen may hereafter be discovered. Science, therefore, must employ other instruments beside this argument, so very limited in its application, so very liable to question. In the first place it may be asked: How are the causes of facts to be distin- guished among a multitude of other causes, all open to observation ? To this the answer is: By the principle of generalization. All men are apt to notice likenesses in the facts that come before them, and to group similar facts together. The similar- ities are sometimes so obvious that the most careless observer is arrested by them. The rise of the tide to-day and yesterday, the tendency to fall which a stone from the hand, an acorn from an oak, and a hailstone from a cloud, alike exhibit, and the power of growth exhibited by a grain of corn, afford groups of cases which seem so to clas- sify themselves as to leave the mind little room for inquiry. The faculty by which such similarities are apprehended is called Observation: the act of oroupino- them together under a general statement, as when we say, "all seeds grow" "all\odies fall/'is Generalization; and from this principle follow some practical rules for ascer- taming causes; such as: Tlie cause of a given effect may he the same as we know to produce a similar effect in another case better known to us. INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. xi For example, Berzelius records that a small bubble of the gas called seleniuretted hydrogen, inspired by accident through the nose, deprived him for some time of the sense of smell, and left a severe catarrh which lasted for fifteen days. An English etiologist suggests that the corresponding effects of influenza may be traceable to the same cause as undoubtedly produced them here—to the admixture, namely, of this or some similar substance with the air we breathe; and as a suggestion, this is per- fectly legitimate, and may prove highly valuable. Another rule is: If we can either find produced by nature, or produce designedly for ourselves, two instances which agree exactly in all but one particular, and differ in that one, its influence in producing the phenomenon, if it have an}T, must thereby be rendered sensible. If that particular be present in one instance and wanting altogether in the other, the production or non-production of the phenomenon will decide whether it be or be not the only cause; still more evidently, if it be present contrariwise in the two cases, and the effect be thereby reversed. But if its total presence or absence only pro- duces a change in the degree or intensity of the phenomenon, we can then only con- clude that it acts as a concurrent cause or condition, with some other, to be sought elsewhere. In nature, it is comparatively rare to find instances pointedly differing in one circumstance, and agreeing in every other; but whenever we call experiment to our aid, it is easy to produce them; and this is, in fact, the grand application of exper- iments of inquiry in physical researches. They become more valuable and their results clearer in proportion as they possess this quality of agreeing in all their cir- cumstances but one; since the question put to nature becomes thereby more pointed, and its action more decisive. A third rule is: Complicated phenomena, in which several causes, concurring, opposing, or quite independent of each other, operate at once, so as to produce a com- pound effect, may be simplified by subducting all the known causes, as well as the nature of the case permits, and thus leaving, as it were, a residual phenomenon to be explained. It is by this process, in fact, that science, in its present advanced state, is chiefly promoted. A very elegant example may be cited from the explanation of the phe- nomena of sound. The inquiry into the cause of sound had led to conclusions respect- in^ its mode of propagation, from which its velocity in the air could be precisely calculated. The calculations were performed; but when compared with the fact, though the agreement was sufficient to show the general correctness of the cause and mode of propagation assigned, the whole velocity could not be shown to arise from this theory. There was still a residual velocity to be accounted for. At length Laplace struck on the happy idea that this might arise from the heat developed in the act of that condensation which necessarily takes place at every vibration by xii INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. which sound is conveyed. The matter was submitted to exact calculation, and the result was at once the complete explanation of the residual phenomenon. This is a specimen of the method according to which researches into causes are conducted. I add another example, exhibiting proportionality of cause and effect, experiment and residual phenomena, in one and the same set of inquiries. In Sir Humphry Davy's experiments upon the decomposition of water by gal- vanism, it was found that, besides the two components of water, oxygen and hydro- gen, an acid and an alkali were developed at the opposite poles of the battery. As the'theory of the analysis of water did not give reason to expect these products, they were a residual phenomenon, the cause of which was still to be found. Some chemists thought that electricity had the power of producing these substances of itself; and if their erroneous conjecture had been adopted, succeeding researches would have gone upon the false scent of considering galvanic electricity as a producing rather than a decomposing force. The.happier insight of Davy conjectured that there might be some hidden cause of this portion of the effect; the glass vessel containing the water might suffer partial decomposition, or some foreign matter might be mingled with the water, and the acid and alkali disengaged from it, so that the water would have no share in their production. Assuming this, he proceeded to try whether the total removal of the cause would destroy the effect, or at least the diminution of it bring a corresponding change in the amount of effect produced. By the substitution of gold vessels for the glass, without any change in the effect, he at once determined that the glass was not the cause. Employing distilled water, he found a marked diminution of the quantity of acid and alkali evolved: still, there was enough to show that the cause, whatever it wap, was still in operation. Impurity of the water was not the sole, but a concurrent cause. He now conceived that the perspiration from the hands touching the instruments might affect the case, as it would contain common salt and an acid and an alkali would result from its decomposition under the agency of elec- tricity. By carefully avoiding such contact, he reduced the quantity of the products still further, until no more than slight traces of them were perceptible. What remained of the effect might be traceable to impurities of the atmosphere, decomposed by contact with the electrical apparatus. An experiment determined this: the bat- tery was placed under an exhausted receiver, and when thus secured from atmos- pheric influence, it no longer evolved the acid and alkali. ^ An example like this brings into strong light many of the characteristics of inductive reasoning. The later steps tend to confirm the earlier, on which however they themselves depend; so that a mutual confirmation is obtained from settin- them together. When the chemist substituted gold vessels for the glass, and inferred, from the continuance of the effect under this change, that the glass could have nothing to do with its production, it was possible, in the existing state of knowledge that°the INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. X1U glass might be the cause, in one experiment, and the decomposition of the gold, in the other. But the later steps, which showed that the effect varied with the variations, in a circumstance wholly distinct from the decomposition of glass or gold, reduced the possibility of maintaining such a view to the lowest possible amount. It may next be asked: How are causes discovered which are not obvious even after repeated inspection of the facts in which they lie hid ? The answer is: By a power, or combination of powers, granted only to a few, which has been called Anticipation; that is, the power of penetrating into the secrets of nature before the evidence is unfolded. It is enjoyed, as one might expect, by those only who have long and deeply studied the laws already laid open, but not even by all of these. It is no mere power of guessing, but the power of an active imagination, supplied with materials by a clear understanding, carefully disciplined. The system of Anatomy, which immortalized the name of Oken, is the consequence of a flash of anticipation, which glanced through his mind when he picked up, in a chance walk, the skull of a deer, bleached by the weather, and exclaimed, " It is a vertebral column!" When Newton saw the apple fall, the anticipatory question flashed into his mind, "Why do not the heavenly bodies fall like this apple?" In neither case had accident any important share: Newton and Oken were both pre- pared by the deepest previous study to seize upon the facts offered to them, and to show how important they might become; and if the apple and the deer's skull had been wanting, some other foiling body or some other skull would have touched the string so ready to vibrate. But in each case there was a great step of anticipation: Oken thought he saw the type of the whole skeleton in the single vertebra and its modifications, whilst Newton conceived at once that the whole universe was full of bodies tending to fall—two truths that can scarcely be said to be contained in the little occurrences in connection with which they were first suggested. The discovery of Goethe—-which did for the vegetable kingdom what Oken's did for the animal—that the parts of a plant are to be regarded as metamorphosed leaves, is an apparent exception to the necessity of discipline for invention, since it was the discovery of a poet in a region to which, it was supposed, he had paid no special or laborious attention. But Goethe was himself most anxious to rest the basis of this discovery upon his patient observation, and doubtless with good reason. As with other great discoveries, hints had been given already, though not pur- sued, both of Goethe's and Oken's principles. Goethe left his to be followed up by others, and but for his great fame, perhaps, his name would never have been con- nected with it. Oken had amassed all the material necessary for the establishment of his theory: he was able at once to discover and conquer the new country. A mistaken notion prevails that this rapid anticipation does not belong to the philosophic cast of mind; that it is precisely what Bacon condemns as the method xiv INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. which hurries rapidly from the particulars supplied by the senses to the most general axioms, and from them, as principles of indisputable truth, derives the intermediate axioms. It is thought that caution, and a deliberate examination of every particular we can find, before we allow ourselves to form any conclusion whatever, are the condi- tions of all sound physical inquiry. There is here a confusion of two distinct things: scrupulous caution should be exercised before a hypothesis is considered to be proved; and the law we believe to be true should be applied to every fact where it can be supposed to operate, and to every other law with which it might interfere, in order to verify exactly what was at first only a happy conjecture. This manner of proceeding is well exemplified in the discovery, made by Professor Horace Green, of the use of the sponge-probang in the topical treatment of diseases of the respiratory passages; that is to say, there was first a genesis of the anticipation, which was then tested in every case where it could be supposed to operate. Bacon meant to complain that this sober process did not always follow the bright thought and brilliant sugges- tion ; and perhaps, also, that the bright thought itself was not always suggested in the region of facts, but only of words. When the ancient astronomy, rushing to the general axiom that " the circular motion is the most perfect," deduced from it the intermediate axiom that the motion of the heavenly bodies must be circular, it might be reasonably charged with an abuse of anticipation; because the highest axiom, having no precise and definable meaning, cannot have really sprung from the con- templation of facts, nor do it and the axiom drawn from it square with the facts they pretend to embrace. But, on the other hand, when these conditions are obeyed, An- ticipation is, as it has been called, the mother of scientific discovery. " To try wrono- guesses," says an eminent physicist, "is with most persons the only way to hit upon right ones." The character of the true philosopher is not that he never conjectures hazardously, but that his conjectures are clearly conceived, and brought into rigid contact with facts. He sees and compares distinctly the ideas and the things, the relations of his notions to each other and to phenomena. Under these conditions it is not only excusable, but necessary, for him to snatch at every semblance of general rule, to try all promising forms of simplicity and symmetry. Anticipation, then is the power whereby the mind presages a truth before it is fairly proved—before she proceeds to establish it by exact and cautious methods. Science works upon a sys tern of credit: if she never advanced beyond her tangible capital, her wealth would no be so enormous as it is. She works with a principle as true before she knows it to be so, because, in watching how it operates upon facts, consist the best means of establishing its truth; but she must be prepared, at the 'same time, to abandon aid Sri: ver it is proved to be in direct and i~iiabie C* -*^£ Granting, on the one hand, that the theory or conception which anticipation fur- INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. XV nislies to explain facts will be worthless unless it shall prove itself to be a fact, we must admit, on the other, that great steps of inductive discovery are made with the help of a preconception, and not by merely throwing observations together. That the fact of the elliptical motion of the planet Mars was not merely the sum of the different observations, is plain from this: that other persons, and Kepler himself before his discovery, did not find it by adding together the observations. The fact of the elliptical orbit was not the sum of the observations merely: it was the sum of the observations seen under a new point of view, which point of view Kepler's mind supplied. Such a conception effects the colligation, or binding together, of the facts to be explained. But, in order to connect itself with the facts, the conception itself must be capable of definition; not, indeed, of adequate definition—since we shall have to alter our description of it, from time to time, with the advance of knowledge—but still capable of a precise and clear explanation. For example, a large class of facts is bound together by the notion of chemical affinity, and could not be understood with- out the thread of the conception to run through them. No rules can be given for the discovery of the appropriate conception that explains our facts; such achievements appear to result from a peculiar sagacity and felicity of mind—never without labor—never without preparation; yet with no con- stant dependence upon preparation, upon labor, or even entirely upon personal endowment. The suggestion of the conception may be due almost entirely to acci- dent ; the explanation of it, often by far the most difficult step, cannot be accidental, but will proceed from a natural sagacity, highly disciplined by scientific pursuits. The variableness with w7hich the power of conception manifests itself is exempli- fied by what Goethe relates in his own case. " The quiet friend of nature," says that great man, "is not always in possession of himself; and from day to day the subject is clear or obscure before his eyes, in proportion to the greater or lesser activity of his intellectual powers. I shall make my subject more intelligible by a statement. Some time ago I was occupied in reading manuscripts of the fifteenth century, which are full of abbreviations. Although I had never applied myself to the deciphering of manuscripts, I set to work with great energy, and to my astonishment read off, without hesitation, unknown characters which ought to have been riddles to me. My success wras not lasting. Some time afterward, when I wished to resume the same occupation, I found that I sought in vain to finish by labor and attention a task I had bero ceeding constitutes the experimental method, because, definitively, experiment is the test or criterion of the correctness of our ratiocination. The experimental method INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. xix thus defined, is applicable to the group of sciences called sciences of observation and ratiocination. In some, the application has not been made; such as the sciences of geology, botany, and zoology, which are not now, whatever they may become here- after, sciences of experiment, as well as of observation and ratiocination. It follows that a branch of human knowledge to which the experimental method has not been applied has not as yet a complete scientific character. It may acquire it one day, but in the mean time it cannot be taught with that degree of gravity and luminous exposition which pertains to the sciences of higher development, such as chemistry and physiology. Medicine, also, including surgery, fulfils the three conditions of an advanced science; for it observes, ratiocinates, and experiments: observation being applied to the phenomena of disease; the ratiocination being for the most part inductive; and the experiment, the therapeutic treatment. Such, at least, is Rational Medicine. When the therapeutic treatment is not the experimental test of a ratioc- ination, but is, nevertheless, sanctioned by a certain amount of experience, medicine is empirical; but when the treatment is wholly isolated both from ratiocination and experience, medicine becomes quackery; of which immoral and opprobrious prac- tice this is a strict and adequate definition. Scientific truth being the result of investigations made by the experimental method, there can be no sound instruction conveyed which does not rest upon this method as a basis. For the advantages a'nd uses of true science are, that it consists not only in preventing error in regard to those things that are already known, but also in enabling the mind to distinguish w'hat is true or probab.le from what must be erroneous in respect of those things which are still involved in obscurity. In this latter case, patient and deep investigation becomes indispensable, and the habit of experiment, acquired in early life, will be efficient in putting the student upon the track which leads to the discovery of the unknown truth. Of course conjecture and hypothesis have their use; but it the conclusion which is derived from them be given as the expression of positive truth, it will produce all the bad effects of ascertained error, especially if it meet a certain direction of public sentiment or expectancy at a certain epoch; for, then, opinions without any real foundation will receive from the theories which are invoked in their support a sort of consecration. We have only to cast our eyes abroad on the surface of society to recognize the truth of this proposition. The doctrine of progress, for instance, as defined and understood by many, is de- rived from theories which have not been tested by experiment; consequently it has conferred no advantage on society. Its influence is exercised in disparaging the past, and making light of the undeniable good which exists in the present—when its apos- tles do not claim to be the authors of that good. But a doctrine of progress ought to be an exposition of the causes which have ameliorated society in its moral, mate- XX INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. rial and intellectual development, and such an exposition will be wanting m meaning if, among other things, it has not for its object to make men feel how much they owe to the authors of that development, It embraces, therefore, a historical part, and, also, a moral part, the tendency of which should be to present the benefactors of hu- manity to our moral approbation. I need scarcely remind you that a prevalent idea of progress is directly the other way, and that its tendency is to extol the future, to the exclusion of the past and present. This tendency originates in ignorance or dis- honesty. In either case it leads to error and injustice. We are not within the limits of truth in dating progress from the epoch in which we live. It begins with the origin of every community, and is so much the necessary consequence of the organ- ization of man and of his specific nature, that we find it in every association that attaches itself to a particular soil and expands by successive generations. Art is the nature of man. Let us examine for a moment what progress really is, and seek its causes by ascending to the past; that is to say, by following the inductive method as our safest guide. The cause of the most direct, as well as the most lasting, influence of the nations of antiquity upon the civilized nations of the actual world, was exercised by intellectual labors, with each of which the name of an individual is associated. Thus, religion had Moses for its exponent: poetry, Homer: history, Herodotus: philosophy, Plato: science, Archimedes. As regards religion, no influence is comparable to that of the people of Israel; wrhile as regards letters and the fine arts, none is comparable to that of the Greeks. But what part had the ancients in the cultivation of sciences ? In pure mathematics, and even in mathematics applied to astronomy and mechanics, in cases where instruments are not required, ratiocination discovered a great number of truths. The discoveries of Euclid in elementary geometry, and of Archimedes in geometry and mechanics, place their authors in the first rank of intellectual power. The genius of antiquity reached, also, the highest point of elevation in the treatment of those capital questions which are outside of pure mathematics, and of the sciences of observation, ratiocination, and experiment. Whatever system of philosophy we may profess, Plato and Aristotle will always be men of the first order. In a word an- tiquity showed immense power in the development of the method of deduction when applied to speculative philosophy, and to the proof of propositions resulting from definitions made in conformity with the laws of thought. Lastly, antiquity attained the extreme limits of the sublime and beautiful in poetry, architecture sculpture, and, perhaps, in painting. But the aspect under which the ancients present themselves in the cultivation of the sciences of observation, ratiocination, and experiment is not equally brilliant Here their inferiority to the moderns is clearly manifest; but while recognizing this inferiority, we must not imagine that it proceeded from inaptitude; for the history INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. Xxi of animals by Aristotle testifies to the superior manner in which he was capable of handling questions accessible to simple observation, and to what he might have accomplished had he possessed instruments of the same precision as are employed at the present day. We might also refer to real experiments in physico-mechanics performed by Pythagoras, when he showed the relation existing between the sounds rendered by chords and the weights w^hich distend them. The inferiority of the ancients in the sciences of observation, ratiocination, and experiment is to be attributed to many causes; but the principal one was the almost exclusive use they made of the a priori method. To this may be added the influence of the master upon the disciple; so great, for instance, in the school of Pythagoras, that it was only after many years of trial the pupil was judged to be in a fit state to receive the first teachings of his master. Another cause of this inferiority was the tendency of the ancient mind to absolute opinions. For instance, so long as the mag- net continued to be regarded in merely an absolute point of view, it was defined to be a body which had the property of attracting iron; but magnetism did not assume a scientific character until the magnet came to be considered in a correlative point of view—that is to say, when it was seen that the bodies which act upon iron have two magnetic states; so that if iron be attracted by the pole of a magnet, that part of the iron which is attracted has a different magnetic state from that of the pole of the magnet toward which it is drawu. It then became possible to define the magnetic property, by asserting that the bodies which manifest it are in two states. When they react, with their parts in the same state, there is repulsion; whilst there is attrac- tion when they react with their parts in different states. The magnetic property, con- sidered in an absolute point of view, belongs to the infancy of science—an infancy which lasted for ages—whilst the definition of the two magnetic states, in the correla- tive point of view, is the conclusion of progressive science. The electrical properties of bodies, and chemical properties of the greatest generality, occupy precisely the same position as magnetic properties. The middle ages accepted submissively the teaching of antiquity, and under the sanction of the Roman theocracy the authority of Aristotle was absolute in the schools. But, by degrees, out of the admixture of the nations which occupied the soil of Europe arose a new civilization, and out of the multiplied relations of men holding a common faith arose the sciences of observation, ratiocination, and experiment, to which we are indebted for a control and use of the forces of nature which neither antiquity nor the middle ages conceived to be possible. These sciences came into existence as soon as men became aware of the insufficiency of the a priori method to explain the most ordinary phenomena pertaining to natural philosophy. It is the glory of Bacon that he proclaimed the incompetence of the old method, and recom- mended experiment as the means of unfolding scientific truths. xxii INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. Thus the history of the human mind embraces two principal epochs: that which preceded the era of the experimental method; and that which, commencing with it, will endure so long as man shall desire to know the world in which he lives. But we cannot afford to sacrifice one of these epochs to the other, for we are equally their debtor: to the first, for its models of the sublime and beautiful in poetry, eloquence, historical narrative, architecture, sculpture, and philosophy; to the second, for its immense development of the natural sciences. Such is progress, viewed in its greatest generality, and studied in its details by the light of the inductive method—that is to say, by ascending from effects to their causes, and thus reaching, in a measure, the cradle of human intelligence. This man- ner of proceeding will enable us to perceive the slowness of progress, its prolonged struggles, and how little it owes to any one individual. For however great may have been the performance of the discoverer, he in every case received vastly more from his precursors and contemporaries than he has left to posterity. Is public opinion always conformable to this view of progress? Assuredly it is not. For instance, the major- ity of men are filled with extravagant wonder at such results as steam locomotion and the electric telegraph, because they are ignorant of their antecedents; but the wise mau, who is not ignorant of them, is moderate in his approbation, and declines joining in the acclamation of the multitude. Besides, men do not sufficiently consider the immense superiority of discoveries of laws of nature over mechanical invention, how- ever ingenious. But Archimedes, himself one of the greatest inventors the world has ever seen, esteemed mechanical inventions greatly inferior in value to those specula- tions which carry irresistible conviction to the mind. Hans Christian Oersted used to call the year 1820 the happiest year of his life, because in that year he discovered electro-magnetism, or the law of reciprocity between electrified bodies and the magnet. " It was in the deep recesses, as it were, of a cell," says Sir John Herschel, " that in the midst of his study a far idea first struck upon the mind of Oersted." He waited long and calmly for the dawn which at length opened upon him, altering the whole rela- tions of science, and, indeed, of life. The electric telegraph, and other mechanical inventions of recent date, are but mere effervescences from the surface of this deep, recondite discovery which Oersted liberated, and which was yet to burst with all its mighty force upon the world. If men possessed science enough to be able to foresee, to some extent at least, the consequences of a capital discovery, made by abstract science, they would never ask Of what use is it? and still less would they prostrate themselves before mechanical inventions the merit of which is exaggerated by friends or interested judges. Better prepared to see consequences in the one case, they would, in the other, be more capa- ble of enlightened appreciation. While, also, they would be less astonished than they are by the practical results of great discoveries made in the domain of nature INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. Xxiii they would be enabled to see, in regard to those discoveries themselves, how small is the part of chance, how great the part of pure science. And in regard to utility, is it not because the Chinese despise abstract science that their arts ceased in their devel- opment some centuries ago, and have not the progressive character which the same arts exhibit among the nations of Christendom, owing to the marvelous influence exercised by the mathematics, physics, and chemistry ? Thus, even in a purely moral point of view, it is evident that the more we are taught in our study of the law of progress to ascend from effects to their causes, the greater will be our respect for pure science, because we shall be more capable of aj^preciating its influence upon the condition of humanity. An enlightened public will not believe in a complete man. It will never ask who is the greatest poet, the greatest historian, the greatest painter. By this we do not mean that the public, by becoming enlightened, will lose its admiration for men of talent—for those who occupy the first rank in letters, art, and science. On the contrary, being less absolute in its judgments, it will count many eminent men in the same department of human knowledge; and thus furnished with numerous objects for comparison, it will find new enjoyments of a highly rational kind in observing the diversity of means employed by men of great gifts, in addressing the reason, the imagination, and the heart, and, I may add, in observing the diversity of merit pos- sessed by men whose profession it is to alleviate the ills to which humanity is heir. Comparisons made in this spirit, without abasing the merit of one in proportion as we exalt the merit of another, have the advantage of satisfying the conscience that we are within the limits of truth; whilst when the opinion we entertain is absolutely opposed to another, the result is to establish two categories of judges, one only of which has common-sense—that, of course, to which we ourselves belong. If a moderate amount of self-esteem be a beneficent provision of nature, it is equally true that the exaggeration of it is pernicious to the individual and to the society of which he is a member. The overestimation of one's own merit leads man to isolation. When he does not become hostile to the past he despises it, or sees nothing in it deserving his respect; and as for his contemporaries, he does not like them, unless, indeed, they belong to the same sect as himself. Isolation fills him with unmeasured ambition for his own elevation at the expense of his fellow-men, for whom he has no care. It engenders an opposition to law and authority, an opposition which is based upon a false interpretation of the doctrine of progress. In fact, we find that numerous classes—in one conspicuous case having an almost independent political status—denounce the actual condition of society, because, impressed with the successful applications of abstract science to the mechanical arts, they believe that society can be ameliorated with the sa'me facility that matter is modified when it obeys the commands of man, delivered from the sanctuary of science! These decep XXiv INTRODUCTORY ADDRESS ON THE STUDY OF SCIENCE. tive analogies between things really heterogeneous explain the sympathy felt for sys- terns which, although in contradiction with human nature, flatter our illusions by promising what man cannot give, and which, therefore, it is unreasonable to hope for. Now is it not mauifest that whatever shows the weakness of the individual in the work of humanity is a testimony to the power of association, a protest against the abuse of self-esteem, and a motive for uniting ourselves more closely than ever to our fellow-men ? But it is precisely by means of the inductive method applied to the study of progress that the weakness of individual reason is demonstrated. It points out the benefits of association, by showing that the greatest work of the greatest individual man could not have been performed at a given epoch without the assist- ance of his precursors and contemporaries. In this relation the history of the human mind, inductively considered, concurs with the Christian pulpit in attesting the weak- ness of man even in his greatest triumphs. I would therefore say to you: Admire the grand intellects that have existed in the past, and honor their memories for the advantages you have derived from them. And if you survey your contemporaries, you will see many who are entitled to your admiration for their genius, and to your respect for their character. But recollect that this genial view of your fellow-men will chiefly depend upon the degree of cul- tivation you yourselves possess. When a man's own mind is polished, it reflects the brilliancy of other minds; but common people see no difference between man and man. ELEPHANTIASIS ABABUM OF THE RIGHT INFERIOR EXTREMITY: SUCCESSFULLY TREATED BY LIGATURE OF THE FEMORAL ARTERY. The treatment of Elephantiasis Arabum by cutting off the supply of blood to the diseased parts by ligature of the main arterial trunk, the branches of which are distributed to the hypertrophied tissues, is a proceed- ing now so well established by frequent repetition that the efficacy of such a curative method can no longer be doubted. Since the publication of the first case treated upon this principle by myself, in 1851, different surgeons have put the same mode of treatment to the test, and almost invariably with favorable results. If in some instances the disease has not been entirely cured, it has been diminished in size, and kept at bay so that farther hypertrophic growth has ceased; the complete restoration of the parts to their normal dimensions having been impeded or prevented by an anomalous arterial distribution or by the ligature of the main artery being placed among the diseased tissues instead of entirely beyond them on the cardiac side, thereby insufficiently intercepting the supply of blood. At the converging or terminal limit at which the progressive metamor- phosis of the materials carried into the system for the purposes of restoration and repair ends, and the retrogressive metamorphosis begins, which, by secre- tion and excretion, eliminates the effete elements no longer of use in the sys- tem, a physiological balance of synthesis and of disintegration of elements must exist, or, in default of this condition, morbid phenomena in some form 5 26 or other will begin to be manifested. By progressive metamorphosis I mean to express the different changes by which the materials of the blood are con- verted into the elements destined for the repair of the tissues, wdiile retro- gressive metamorphosis is understood to embrace those changes which take place at or upon the return, through the channels of circulation, of those effete elements contained in the blood which have not been utilized for the reparation of the tissues, and which ultimately are eliminated from the body. The controlling influence which presides over this normal equilib- rium is supplied directly from the nervous system to the parts or tissues undergoing the physiological or healthy change. If, however, from the inter- current action of some abnormal perturbating cause, the fundamental source of nervous supply shall become abnormal, and the function of the nutritive capillaries shall become disturbed, some pathological phenomena are sure to present themselves by functional or organic irregularity. Thus we may have as a result homological growths composed simply of the normal tissues, more or less hypertrophied, or an atrophy may take place, or heterologous forma- tions may be developed, composed of structures foreign to the original histological characters, revealing the malignant traits of scirrhus, fungus nematodes, or other cancerous or destructive formations in their various modifications. It is by a train of reasoning in this direction that we may account for such a hypertrophied condition of the tissues as is met with in Elephantiasis Arabum, and it is upon a theory so founded that the therapeu- tic indication is deduced of modifying the nutrition of the parts by lessening the amomit of the arterial supply. Below is recorded the first case of Elephantiasis treated in this manner, as originally published, the entire success of which is, from its extended character, to be attributed probably to the application of the ligature to the external iliac artery, on account of secondary hemorrhage from the femoral. [From the New York Journal of Medicine, Sept., 1852.] Elephantiasis Arabum, so called in contradistinction to Elephantiasis Grseconun, because its history was first described by Arabian authors, is a malady the etiology and pathology of which are not definitively understood 27 at the present day. The treatment also remains uncertain; and when the disease has existed for any length of time, it is generally looked upon as irre- mediable by any other means than amputation of the tissues or of the mem- ber involved. This malady is not confined in its attacks to any particular part of the body; the vulva, the scrotum, and the inferior extremities are, however, the principal seats of the disease. When affecting the lowTer extremity, its peculiar form, which is somewhat like the clumsy appearance of the elephant's leg, suggested the name of Elephantiasis. Elephantiasis of the Arabs is said to be uncommon in Europe, and as respects this country, I am not aware of its occurrence endemically in any part of it. Insulated cases, however, certainly do present themselves. Within the last three years five marked cases have come under my observation; of these, in two instances, the malady showed itself in the scrotum, and in the other three, the seat of the disease was in the inferior extremity. Four of these cases became developed in persons residing in different parts of the United States: one in New York, one in Florida, one in Virginia, and one in the State of Pennsylvania; the other case occurred in a patient who was a native of Ireland, and who imported the disease with him. These patients were all adult males, and the circumstances preceding the development of the disease in each case were generally dissimilar; thus, in the cases where the inferior extremity was affected, the disease in one became manifested after an attack of paludal fever; in another, also after a febrile attack; and in the third, after the individual had been working for some time at an occupation requiring him to stand for hours with his legs immersed in water. In one of the two cases where the scrotum and integuments of the penis were affected, the elephantiasis was preceded by a scrotal hernia, and by an attack of syphilis, while the other was associated with, and preceded by, a large hydro- cele of the tunica vaginalis testis. Climate cannot be said to have exerted any influence, as the cases oc- curred in different localities. The accounts, however, related of this malady will not allow us to doubt that it is met within certain latitudes and localities more frequently than in others. In the West Indies, some parts of Asia, and among the Arabs, it is found to exist endemically; but although this fact is 28 established, and points to the influence of climate, what that influence is, and how it operates, remain unaccounted for with any degree of certainty. The enlargement of the thyroid gland, which occurs in certain parts of Europe and North America, is ascribed to the drinking of snow-water and of water impregnated with calcareous or earthy particles; while in the equatorial or tropical regions the prevalence of elephantiasis is attributed to the alterna- tions of heat and cold. But these speculations, resting as they do upon no positive data, are extremely vague, and thus, both as regards the more fre- quent occurrence in certain localities and as regards the difficulty of account- ing for the influence of climate, elephantiasis and bronchocele, both hyper- trophic conditions of the tissues, appear to have some analogy to each other. The production of the disease has also been attributed to the oblitera- tion of the veins of the members affected, and likewise to chronic inflamma- tion, commencing at the dermoid structure, and extending, by contiguity of tissue, to the subcutaneous layers; but again it must be remarked that no fixed invariableness of antecedence has been observed. One fact which may have some bearing upon the etiology of the elephantiasis, and to which I shall again presently allude, has been generally overlooked. I refer to the morbid condition and dilatation of the principal arterial trunk of the member affected. The disease has also been supposed to arise from frequent attacks of erysipelas ; and, as another cause, from subinflammation of the absorbent vessels and lymphatic glands. Elephantiasis, as in two of the cases which came under my observation, is sometimes rapid in its accession or invasion, and when occupying an exten- sive surface, the constitution participates in the local affection. The skin assumes no erysipelatous hue; but the subcutaneous tissues become engorged, tumefied, and tense; while the course of the lymphatics, if the seat of the malady be on a limb, is marked by nodulated cords; and the glands of the groin or of the axilla may also become affected and enlarged; these various symptoms being ushered in by a deep-seated and violent pain in the region of the disease. If the disease, after the acute stage, does not recede, the intumescence remains, although the other symptoms may subside for a time. Exacerba- 29 tions recur at intervals, varying in duration, and the enlargement of the tissues increases, until the structures invaded remain, as it were, stationary in their abnormal condition, imparting to the hand when examined a harsh, dense, pachydermatous sensation, and presenting to the eye, in the most characteristic form of the disease, a rough, scaly, dusky - looking mass of deformity, well represented in the accompanying illustration. If the disease progresses no farther than has just been described, the enlargement of a limb or of the scrotum remains an insufferable encum- brance ; while, in the uninterrupted progress of the disease, fetid and incur- able ulcerations may occur, abscesses may take place among the morbid tissues, and the internal organs may become disordered. The prognosis, consequently, must be iinfavorable when the disease has existed for some time, and assumed its characteristic, chronic, and intractable form. In the early stages of the disease it is possible that it may be con- founded, especially in females, in whom the subcutaneous strata are usually thicker than in males, with diffuse and deep-seated inflammation of the cel- lular tissue, or with oedema or anasarca. The history and progress of the disease, the sensation imparted, upon examination, by the tumor, and the peculiar local traits, generally suffice to enable the practitioner to discrim- inate without much difficulty between elephantiasis and the other diseases just named. It would appear, from the different accounts given of this disease, that the whole of the tissues of a member may become ultimately implicated. Some are primarily affected, wThile others, such as the bones, are probably not involved in the morbid degeneration until the disease has been of long standing. The tissues primarily affected would seem to be the vascular; and the pain, redness, and hardness met with in the first stage of the disease, in the course of the lymphatic vessels, together with the appearances of the veins upon autopsy, as mentioned by Bouillaud and others, evince with suf- ficient certainty a pathologic condition of the vessels. The arteries also par- ticipate in the disease, and very probably at an early stage of its invasion. The skin generally shows early participation in the malady; most com- monly the development of the initiatory stage is accompanied by some form 30 of cutaneous affection, such as eczema, erysipelas, lichen, or ulceration. These affections occur, however, so frequently without any of the hard and bulky intumescence characteristic of elephantiasis being manifested as a sequent, that it is reasonable to suppose they are accompaniments merely of disease of the deeper-seated tissues, especially of the vascular tissues, upon which, in reality, the elephantiasis depends. The different strata of the skin are hypertrophied to a considerable degree, the epidermis presenting a series of dusky, hard, superimposed scales. This condition of the epidermis, how- ever, is not always present, especially when the scrotum is the seat of the disease. The subcutaneous adipo-cellular layer is blended with the der- moid tissue, so as to form a hard, dense, and lardaceous mass of irregular thickness; the subaponeurotic and intermuscular cellular tissue becomes changed and hypertrophied; the muscles also are in the progress of the dis- ease perverted, becoming softened and less deeply colored than in their nor- mal condition—sometimes being converted into fatty tissue, at others into an indurated formation, and even, at times, exhibiting deposits of bony material. The nerves are sometimes found to be increased in size; the bones are some- times found unaltered, and sometimes are found increased in size; and, lastly, the interosseous ligament is at times found ossified. Lesions of the internal organs are not so frequently found to accompany Elephantiasis Arabum as the other form, known as Elephantiasis Grsecorum; still, diseases of the internal viscera are seen as complications of the former, when the malady has existed for a long period. In its initiatory stage, the treatment of elephantiasis, regarded as a phleg- masia, should be conducted upon antiphlogistic principles; thus, bleeding, emollient applications, tepid baths, and the vapor douche, are recommended and resorted to. In the more chronic stages of the malady, compression, combined with scarifications and local bleeding, is said to be useful. Iodine frictions and the vapor douche appear to merit most attention, having, upon good authority, been used advantageously in cases of genuine elephantiasis. When the disease has resisted every rational curative method, and when the part attacked has attained a size which, by reason of the weight of the mass, renders it an unmanageable encumbrance, as happens in elephantiasis 31 of the scrotum and of the inferior extremities, amputation is advised and practised as the only alternative. But this extreme resort is not usually attended with success, the disease generally returning upon some other mem- ber with all its original inveteracy and obstinacy. In the following case, which came under my management, I resorted to a method of treatment which, as far as I know, is entirely novel, and which, both for this reason and because it terminated in the perfect restoration of the diseased and cumbrous limb to its normal condition and functions, I have thought deserving of publicity. The accompanying drawing of the limb of the patient, taken from nature (vide Plate No. 1), gives an accurate representation of the disease. Case.—Charles Roller—of lymphatic temperament and short stature, get. 27, born in Aix-la-Chapelle, occupation, merchant—left his home in December, 1819, landed in New York in February, 1850, went thence to Connecticut, where for some months he worked in a factory, standing dining his hours of labor; thence went to Virginia, where he worked on a farm for about six months, at the expiration of which period he was taken with fever of an intermittent character. Up to that time he had always been in good health. During the fever the inguinal glands on the right side became swollen and painful, the swelling and pain extending in the course of the femoral vessels as far as the knee. The pain was followed by swelling and redness of the thigh down to the knee. From the knee the pain and swelling * continued to extend downward as far as the toes, being at this time confined chiefly to the portions of the limb along the course of the saphena vein, and also of the posterior tibial vessels. The redness and tumefaction here, as in the thigh, were preceded by deep-seated pain. The tumefaction of the limb continued to increase, while at the same time febrile exacerbations occurred at intervals, varying from two to six days. After a period of about six weeks from the commencement of the disease, the fever entirely disappeared, and by that time also the pain and redness had entirely ceased; the limb, however, remaining hard, swollen, and rough, and presenting in a marked degree the peculiar characteristics of Elephantiasis Arabum in the chronic 32 period of the disease. From that time forward the hardness and intumes- cence gradually increased, and the limb became so cumbersome that the patient was obliged to give up all business, and confine himself chiefly to a recumbent posture. In this condition the patient left Virginia for the pur- pose of seeking medical relief at the New York Emigrants' Hospital, into which he was admitted the 15th of January, 1851. The appearance of the patient upon entering the hospital was somewhat emaciated. He had no febrile symptoms, and the chief difficulty under which he labored arose from the enlarged and hypertrophied condition of the right inferior extremity. The limb was enlarged from the toes to within a short distance below Poupart's ligament. The thigh, although enlarged, was not much indurated; while from a short distance above the patella downward the limb presented a dense, hypertrophied, hard, scaly, shapeless mass, the appearance of which will be best apprehended by referring to the accompanying plate. The morbid condition of the tissues pervaded the foot and toes, there presenting groups of tuberculated growths. The circumference of the limb around the ankle was nearly as large as that of the calf, measuring fifteen and one-half inches; while the circumference of the calf measured nineteen and one-half inches. The patient was put under treatment upon entering the hospital. The recumbent posture was enjoined, and for some time various discutient lotions were used. Bandaging was resorted to, with frictions of ung. Potass. Iodid.; the Iodide of Potassium being also prescribed internally. At times, also, the limb was painted with strong tincture of Iodine; local. and general baths were used; regular bandaging of the limb, from the toes upward, being the while carefully observed. This plan of treatment was perseveringly adhered to from the 15th of January to the 22d of March, a period of a little over two months, without any amelioration. Having thus tried, without success, the method of treatment most approved of, I proposed to place a ligature upon the femoral artery, with the view of changing the morbid condition of the structures supplied by the branches of this arterial trunk. A consultation was held, and my proposition was acceded to as preferable to amputation, the usual alternative 33 resorted to in this stage and extent of the disease. Accordingly, on the 22d of March, 1851,1 seemed the femoral artery, a short distance below the origin of the arteria profunda. Upon exposing the femoral artery, this arterial tube was found to be changed, so as to present an appearance somewhat like the color of the aorta of the ox, and to be larger than the common iliac of the human subject. In consequence of this appearance of the artery, after some hesitation I applied the ligature, preferring to do this rather than to expose the external iliac, of the soundness of which I could not be certain. The ligature came away from the femoral artery on the eleventh day, accompanied by secondary hemorrhage, the occurrence of which I had expected as probable. For the purpose of arresting the hemorrhage, the external iliac artery, which was found to be smaller than usual, about the size of the brachial artery, was secured by ligature. This, for a time, apparently had some influence upon the hemorrhage; but on the following day bleeding was again renewed from the orifice in the femoral artery, with as much profusion as ever. The hemorrhage was now restrained by the prompt application of a tourniquet on the cardiac side of the bleeding orifice, by the house surgeons, Drs. Thompson and A. K. Smith. This even failed to stop permanently the hemorrhage, and the blood recommenced oozing copiously at intervals. The patient was now sinking fast, and the ligature of the common iliac, or amputation at the hip joint, appeared to be the only resources left. But the hemorrhage now being evidently reflux, it was suggested to apply the tourniquet, so as to produce compression on the distal side of the bleeding orifice: this was done, and was followed by a complete cessation of the bleeding. From that time (April 4th, 1851) the house surgeon kept an instructive record of the case, which I have now before me. For several days the pulse ranged from 115 to 108: the dressings were carefully attended to, and light diet prescribed. On the twelfth, the leg was found to be considerably reduced in size, and the ligature of the external iliac came away. On the seventeenth, brandy and quinine, with good nourishment, were ordered. On May the first, finding the leg still more reduced and the lower wound healed, I ordered 6 34 tincture of iodine to be painted on the leg, and the bandage to be continued; I also ordered a solution of chloride of soda to be used as a wash on the upper wound, which continued to discharge freely. The patient now went on gradually improving in strength and appear- ance, and left the hospital, in the latter part of June, completely cured of his malady. At this date, sixteen months after the ligature of the femoral artery, the patient is in robust health, and presents no indications that the disease will return.* [From t7ie New York Medical Gazette, Jan., 1858.] In September, 1852,1 recorded a case of Elephantiasis Arabum success- fully treated by ligature of the femoral artery. Since then I have received a letter from Professor Erichsen, of the London University, in which he mentions a case of elephantiasis treated, with a successful result, upon the same principle. The portion of his letter referring to this subject runs as follows: "I have perused the details of your cases with great interest, and have been especially struck by the account of the successful ligature of the femoral artery for that otherwise intractable disease, Elephantiasis Arabum. The operation was certainly a bold step, but one that the result shows to have been the proper one to take; and it certainly does infinite credit to your judgment and skill to have devised a successful treatment for this complaint. I have at present under my care a man with extensive elephantiasis of the foot, in whom, about two months ago, the assistant surgeon, during my absence, tied the anterior tibial, in the middle third of the leg. This case has done well, and the limb is fast recovering its usual dimensions. The operation was performed on hearing of the success of your case." * Afterward, I may add, at this date, December, 1876, that he acted as my valet for over a year of equal size purchased ready-made, without reference to his former diseased limb. When he left m to bis own country. 35 The following case is another example of the beneficial results of this practice, in a disease hitherto deemed incurable by other means: Francisco Podesta, a native of Italy, 39 years of age, peasant by occu- pation, was admitted into the State Emigrants' Hospital on the 17 th of April, 1857. About six years previous to his admission, after prolonged exposure to cold and dampness, he was attacked with severe pains in the left leg, extending upward along the thigh. The pain was followed by general tumefaction of the leg from the toes upward to the knee joint. The local disease was attended by constitutional disturbance, which, however, gradually subsided, the limb remaining much disfigured and considerably larger than that of the opposite4 side. The foot was thickened, and appeared stunted, from the increased circumference around the ankle; the calf of the leg was also considerably enlarged; the skin and subcutaneous tissues were dense, hard, and hypertrophied; the surface of the limb below the knee was scaly, and in general presented the unseemly appearance from which the term elephantiasis has been derived. Around the ankle the hypertrophied tissues were thrown into large and prominent folds, hanging, as it were, over the ankle joint; between two of these folds an extensive ulceration existed, as large as a dollar piece. The patient, in this condition, was unable to follow any vocation; in fact, was unable to walk, and entered the hospital more as an asylum than with the hope of obtaining relief. His general condition was feeble, and he presented a cachectic appearance. The following were the measurements of the limb: the thighs at the middle were of equal meas- urement, 19 inches; around the calves—on the sound side, 10 inches; on the diseased side, 13 inches; above the ankles—on the sound side, 8i inches; on the diseased side, 12 inches; around the ankles—on the sound side, 9£ inches; on the opposite side, 15i inches; while the measurement from the heel around the instep on the sound side was 12 inches, and 19 inches on the diseased side. Deeming it unnecessary to repeat in this patient's case the numerous remedies which had been unavailingly tried, I proposed to apply a ligature upon the femoral artery for the purpose of modifying the morbid nutrition of the limb. Allowing him some time to improve his general health and to 3G become accustomed to the air of the hospital, on the 23d of May a ligature was applied on the femoral artery in Scarpa's space. The artery was found to be healthy and of normal size. May 27th: Every thing had progressed favorably up to this time, and the limb was beginning to show evidence of diminution. July 1st, the ligature came away; at this time the calf of the diseased side had diminished 1 inch above the ankle; around the ankle, If inches; and in the measurement in the heel around the instep, 3h inches; the skin of the leg and foot was also soft. July 10th, the patient was allowed to move about; the ankle joint, which previously was almost immovable, now admitted of flexion and extension. The ulceration had now healed, and from that time forward until the 24th of August (the time of his discharge from the hospital) the dense and hardened tissues were gradually becoming more natural and soft. He left the hospital with his limb almost of natural size, and able to walk with but slight lameness. Since the publication of the last case I have repeated the operation of tying the femoral artery in three instances for the cure of elephantiasis. These cases occurred in two young women, one of whom had the disease on one inferior extremity; the other had both of the lower limbs affected. The following is a brief history of these cases: Ami O'Brien, native of Ireland, domestic, aged 25 years, apparently in robust health, had had one child, was admitted into the hospital on the 27th November, 1857. She stated that she had suffered considerable pain in the right leg during the last five years. About twelve months ago the leg began to enlarge, and continued to do so until the time of her admission. At that time the foot, especially on the dorsum, was considerably enlarged. Above the ankle the leg was much increased in size, the skin there presenting thick pachydermatous folds hanging over the ankle joint, so as to prevent the motion at the articulation. The enlargement of the limb extended upward above the knee as far as the middle of the thigh, and she was totally unable to perform her duty as a domestic. 37 The following measurements of the diseased and sound limbs were taken previous to the operation, which was performed on the 12th December, 1857, by applying the ligature around the artery in the Scarpa's space: The diseased side measured, around the middle of the thigh, 201 inches; the sound side, 19i inches; above the knee of diseased side the measurement was 15i inches; on sound side, 14f; immediately under the knee, 13f inches on diseased side; on the other side, 13 inches; at middle of calf, 14 inches on diseased side; on sound side, 13 inches; below the calf, on diseased side, 13f inches; on the other side, 10i inches; around the ankle of diseased limb, 111 inches; on the other side, 8£ inches; around instep on the diseased foot, 11 inches; around the other, dh inches; around the toes of diseased foot, 9f; around the other, 81. The femoral artery at the seat of the ligature was healthy; every thing progressed favorably, and the ligature dropped off on the twenty-eighth day after the operation. Soon after the application of the ligature the dense character of the tissues of the leg became much abated; the spine of the tibia could be traced by the finger, which could not be done previously; the folds of dense tissues around and above the ankle became soft and dimin- ished ; the flexion and extension of the joint could be accomplished. The following measurements were taken on the 26th December, fourteen days after the operation, showing, by reference to the first measurements, that the limb had considerably diminished: Right side, diseased, around the middle of the thigh, 19h inches; around, above the knee, 15£ inches; under the knee, 12f inches; around the middle of the calf, 12i inches; around the ankle, 101 inches; around the instep, 10i inches; around the toes, 9 inches. This patient now walks about with facility. After walking for a length of time without a bandage, the limb becomes somewhat enlarged; but the tissues are now soft and compressible, and the limb is gradually regaining its natural condition. 38 The next case which came under my observation is of interest, as both of the lower limbs were affected, and both femoral arteries were tied. Catherine Punch, native of Ireland, aged 26 years, unmarried, entered the hospital on the 29th of October, 1857, for elephantiasis of both legs. For several years past she had suffered from pain in the legs, especially in the right one. About three years since, her legs began to enlarge, and they have slowly increased up to the present time. The right limb being most diseased, the femoral artery was tied on the 30th January, 1858: the artery was healthy, and the ligature came away on the twenty-third day after the operation. After the application of the ligature the tissues of the limb soon became softer and more natural, and the size also gradually diminished. The patient was so much satisfied with the result of the first operation that she insisted upon having the artery tied upon the left side. On the 17th April, two months and a half after the first ligature had been applied, the left femoral artery was tied. Only eleven days have elapsed since the operation, yet there is a decided amelioration in the condition of the limb, both as regards the diminished size and the induration of the tissues. fcw.' Erom Phc ■ Kelly, NY ELEPHANTIASIS ARABUM Fie. I. TREATED BY LIGATURE OF BOTH COMMON Fig-.n CAROTID ARTERIES IU/irr.sr//ts t/io p< //. Air. XVI. 51 Behandlung zum Trotze fiihrt die Krankheit, ihrem natiirlichen Verlaufe nach, unaus- bleiblich zu chronischem Siechthume und nach jahrelangem, oft entsetzlichen Leiden zum Tode. Was friiher von chirurgischen Hiilfsmitteln versucht worden war, die Druckbinde, die horizontale Lage, Scarificationen, etc., hat mehr nur die Folgezustaude, als die Krankheit selbst in ihren wesentlichen Ursachen getroffen und blieb meistens ohne dauernden Erfolg. Die von Dieffenbach angeregten Versuche, durch wiederholte Excisionen langer Hautstreifen und der Narben derselben, pachydermische Schwel- lungen zuruckzubilden, haben in den Handen Anderer nicht den Erfolg gehabt, welchen Lebert (Abhandlungen aus dem Gebiete der praktischen Chirurgie) von ihnen riihmt, und die Methode ist tiberhaupt, ausser von Dieffenbach, nur wenig versucht worden. "---So blieb denn nichts iibrig, als den Kranken mit einigen palliativen Mitteln gegen Nebenzufalle zu versehen, oder, wenn die Beschwerden unertraglich wurden, sich zu Exstirpationen und Amputationen zu entschliessen. " Bei dieser wenig befriedigenden Lage der Sache wurde der erste Erfolg, welchen Carnochan im Jahre 1852 durch Unterbindung der Hauptarterie des geschwollenen Gliedes erhalten hatte, freudig begriisst. Der Gedanke, auf diese Weise Hiilfe zu schaffen, glich den gliicklichen Inspirationen, durch welche so oft schon eine in Dunkel gehiillte, aber fast selbstverstandliche Wahrheit, wie durch einen Lichtblitz mit einem Male aufgehellt, und Allen, die wie mit Blindheit geschlagen an ihr voriibergegangen waren, offen vor Augen gelegt wurde. War auch die Voranssetzung,* von welcher Carnochan ausgegangen, namlich dass die Arterie erweitert sei, irrig, oder doch nur in wenigen Fallen zutreffend (Chelius, Heidelberger Annalen, glaubte ebenfalls schon die Cruralarterie erweitert gefunden zu haben), und ohne Bedeutung fur die Erklarung der Krankheitsgenese, so schien doch der Erfolg unzweifelhaft und auf dem gliick- lichen rationellen Gedanken zu beruhen, das gestorte Gleichgewicht zwischen der Zufuhr, der Anhaufung und Verwendung der Ernahrungssafte durch Verminderung der Zufuhr auszugleichen." * The enlargement of the artery is mentioned in the text as a fact merely, not as a source of the disease. Note 1.—Bauer's case as reported in the table (No. 17) is reckoned as one which had a relapse. I had an opportunity to see this person in 1874, five years after the ligation of the femoral artery below the art. profunda. At that time the leg and thigh were enlarged, but after reaching a certain point the size of the limb remained stationary, and continued smaller and softer than it had been prior to the operation. This man could walk about quite well. This case was one of great extent, involving the entire limb as high up as Poupart's ligament. Professor Syme, of Edinburgh, had removed the scrotum for elephantiasis. The ligature of the external iliac artery was indicated in a case of such magnitude. Note 2.—I am informed that this patient (No. 2 in the table) entered the Pennsylvania Hospital mainly for the breaking out again of the extensive ulcerations of the leg. 52 STATISTICAL TABLE OF CASES OF ELEPHANTIASIS ARABUM, TREATED BY LIGATURE OF THE MAIN ARTERY, AS PRESENTED BY PROFESSOR WERNHER IN THE "DEUTSCHE ZEITSCHRIFT FUR CHIRURGIE," JUNE, 1875. No. Author. Year. Sex. A^o. Side of the Body. General State of Health before the Operation. Symptoms. Duration of the Disease. Treatment. Accidents after Ligation. Immediate Success. Later Results. Carnochan. New York Jrn. of Med., 1852. Contri- butions, etc., 1852. Canioehan. Contriluit., etc., 1858. M. 2 7 years. Aachen. r. General state of health good. Repoatod at- tacks of inter- mittent fever precede the oedema, Carnochan. Ibid., 1858. Carnochan. IbiiL, ISiS. M. ">S years. Italian. L F. 25 years. Ireland. r. Feeble, ea- chectic consti- tution. F. 28 years. Ireland. Both extremi- ties. Pains precede the swelling for several years. The whole leg is swollen for 6 months previously. Rest, horizontal position, and wrapping the limb up, tried with- out success for 3 months. Extends over the leg for 6 years; nu- merous ulcers. In- ability to walk. Exists for C years. Grown up to the middle of the thigh. Difference of cir- cumference on the calf of the leg, 3£". Thick tumors of the skin; immovable an- kle-joint. Both extremities are swollen, the right more than the left, up to the thigh. Li- of a. femoralis close under the profun- da. The art. has the cal- ibre of the iliaca. Ligation of the arter. fern. March 23,1857. Lig. of a. fem. in trigon. Scar- pse. Lig. be- comes sepa- rated on the 28th dav. Lig. of art. fem. dext. Sepa- ration of ligature on the2Sdday; that of the left later. The liga- ture falls off on the 11th day. The il. ext. gets ligated on account of second- ary hemor- rhage. Hem- orrhage con- tinues. Tour- niq. applied to the cen- tral end of the artery does not suffice; a second, ap- plied to the periph., stops the hemorrhage. The art. appears nor- mal. The lig- ature comes off on the 34th day. Cure after 3 months. The swelling of the leg di- minishes rapid- ly, the ulcers heal. At the time of dis- missal, after 3 months, nearly natural circum- ference ; some lameness. After 1 month the circumfer- ence has dimin- ished by 1 inch, the skin has be- come soft. Skin becomes soft rapidly and diminishes. Pa- tient insists on lig. of second art. The contin- uation of the success is con- firmed 17 months later. Relapse aft- er 14 months. Admitted to Pennsyl. Hos- pital, and dis- charged not cured. [See Note 2, page 51.] Discharged after 1£ mo. The patient can walk with ease. But the leg be- comes cedema- tous when no bandage is worn. Published on the 11th day after the sec- ond liga- ture. Infor- mation of a later date is wanting. 53 No. Author. Year. Sex. Age. Side of the Body. Statham. Letter to Erichsen. M. Middle age. Ogier. Amer. Journ. of Med. Sc., 1S60. M. Negro. 26 years. Butcher. Operative and Conservative Surgery, 1865. Dublin Quar-terly Journal, 1863. F. 44 years. Ireland. r. Richard. Gaz. des ho-pit., 1864. A F. 28 years. French. summary of surgical op-erations per-formed in the Bristol Roy-al Infirmary. British Med. Journ., 1869. June. 1. Fayrer. Edinb. Medic. Journ., 1865. M. 30 years. Hindu. r. Same. Wil-son Journal of Cutaneous Diseases. General State of Health before the Operation. Symptoms. Duration of the Disease. Treatment Accidents after Ligation. Immediate Success. Later Results. Menstruated since the 16th year. Good health, without previous dis- ease. Hard oedema of the leg. Existing for 5 years ; enormous swelling of leg and foot. Existing for 18 years. The differ- ence of the circum- ference amounts to 8". The sufferings cause the patient to desire an amputa- tion. Pains by day and night. Increas- ing weight, repeated painful attacks with increased swelling. Only short intervals of rest. The color of the skin is dark, the calves are spe- cially swollen, the toes are ulcerated. Painless, gradual swelling, extends rapidly to the thigh. Walking very diffi- cult. Periodic swell- ings preceded in- flammatory attacks of the lymphatics. Cups draw a milky fluid mixed with blood; sensation of cold alternatingwith burning heat. Skin indurated, cannot be folded, color not changed; beginning swelling of nates and skin of the ab- domen. Leg for 7 years. Periodic attacks of fever characterize the progress of the disease. 10 Lig. of art. tib. antic, at the middle third. Lig. of art. femor. Lig. of a. fem. 1£" be- low lig. Pou- part. Sep- aration of ligature on the 31st day. Compres- sion band- age ; salve containing iodine. Lig. of art. femor. be- neath the de- scent of the profunda. Lig. of art. fem.; sepa- rated on the 17th day. Lig. of art. fem. Circumference of leg gets al- most normal. Already on the following day the swell- ing is consider- ably less. Cure. Cure. Swelling and tension dimin- ish from the 1st day. Diminu- tion of circum- ference about 5 cen. Me- thodical com- pression band- age, with flannel and gutta-per- cha roller, can be tolerated only for 5 to 8 hours in the The swelling decreased rap- idly. Later in- formation is wanting. Affirmed aft- er 3 months. Affirmed aft- er 18 months and after 4 years. 1^ years aft- er the oper- ation incom- plete cure. The lower leg has diminish- ed the most. On the knee the parts re- assume nor- mal flaccidity. The leg is hardly thick- er than the sound one. The pulse can- not be felt on the malleol., although col- lateral circu- lation is re- stored. Death thro' pyaemia on the 18th day, sequence of hospital influ- ences. Death. 11 Vi 13 14 15 Author. Yeur. Hrvant. A case of Klr|ill.'llltiuM: Arabum. London Mr.] Thin:. Trans.. V. XI.IX., i> IT.r>. Lancet, 1866. Alcock. Lancet, I860 p. :t 10-314. 16 Buchanan. Mel. Times and Gazette. Clinical Lect- ures, Glas- gow. Medic. Jour., 1866. Quiivl. Li.cat. de la fem. dans un eas d'Kleph. Gaz. hebd. de M., 1862. Sympson. St." Bart hoi. Hosp. Rep., V. IV., 1866. Pondt5n. Upsal. Lakc- foren.Jahres- bericht von Virch.-Hirsc, IV. Jahrg., Bd. 2. Sex. Ape. si,i,• of I lie liody. General State of Health before the Operation. V. '.'< years. Wals. M. 33 years. F. 17 vcars M. r. F. 41 years. L Good health. Ten years ago light scarla- tina. During the convales- cence the \v. Banu of die jaw. c. Booh' id'die jawin a Shite of necrosis and seen as separated iturinj the o/ieration AMPUTATION OF THE ENTIRE LOWEE JAW. The chief utility of recording severe surgical operations may be said to consist in proving that life may be preserved and sustained after they are performed with judgment and care. In the two operations which follow, where the entire lower jaw was removed in each instance, the patients had a perfect recovery, and lived in comparative comfort after cicatrization was completed. In one case the operation was performed for necrosis and caries of the jaw; in the other, the lower jaw was removed by operations at two different times—a deux temps—for osteo-fibroid tumors of considerable size. Previous to the date of the first operation, so far as I know, the entire lower jaw had never been removed successfully at one sitting. [From the Xew York Journal of Medicine, 1852.] Notwithstanding the repeated instances on record of large portions of the lower jaw having been lost by accident or disease, surgeons appear to have been slow in admitting the possibility of practising amputation, either partial or total, of this bone. To Dupuytren was reserved the glory of hav- ing, in 1812, first removed, by a methodical operation, a portion of the body of the inferior maxilla; but since the innovation of the celebrated French surgeon, the operation for the partial exsection of this bone has been repeat- edly performed. In the annals of surgery there is an allusion made to the amputation of the entire lower jaw, by Walther, of Bonn; but I have not been able to trace the truth of it to an official source. 10 66 The following ease will prove that this operation can be performed with kuccc- and that' the patient, although deprived of the chief instrument of mastication, mav survive, and enjoy the usual condition of health. Nicholas Done-an, aged 43, a farmer by occupation, was admitted into the \ew York Emigrants' Hospital, March 7th, 1851. He was treated for some weeks, in the Medical Division, for typhus fever, and was afterward transferred to the Surgical Department, under my charge. Upon examina- tion of the patient, his face presented much tumefaction, and he complained of great pain, seated chiefly in the region occupied by the inferior maxilla. rpon carrying the examination further, the lower jaw was found to be ex- tensively affected with ostitis and necrosis. All the external appearances denoting a cachectic condition of the constitution, with extreme debility and general prostration of the vital functions, were present. The patient stated that, during his recent voyage to this country, he had received a severe blow upon the lower jaw and side of the face. This circumstance, coupled with the cachectic condition following the attack of fever, appears, as far as can be learned, to have been the origin of the disease of the bone. A tonic course of treatment was prescribed for him, and various local applications and lotions were resorted to, in order to allay the irritation in the mouth and abate the fetor emanating from the disease. In a short time the teeth became loose, and had to be extracted; the alveolar ridge became partially denuded; the swelling increased toward and over the rami and condyles; and the patient complained of excruciating suffering and depres- sion. Nutritious diet and the various therapeutic agents proper to improve and renovate his system were persevered in, and soothing and astringent lotions and applications were unremittingly used. This plan of treatment was pursued for about three months, at the expiration of which time it became evident that the disease of the osseous tissue was too deeply rooted to be affected by mere remedial agents. In fact, they were found to be entirely unavailing. The disease had now apparently seized upon the entire jaw; pus was abundantly secreted into the cavity of the mouth; the saliva was also thrown out in great quantity; and the fetor became almost intol- erable to the patient himself and to those around him in the ward. Consti- 67 tutional irritation and hectic of a grave character had also set in; diarrhoea made its appearance ; and the patient was gradually sinking under the complications of his disease and the terrific pain by which he was unceas- ingly tortured. It was apparent to me that the speedy death of the patient could only be avoided by removing the source of such intense suffering and constitutional derangement. The integuments over the diseased bone, although much tumefied, cedematous, tense, and red, remained free from ulceration, the vitiated secretions taking their exit by the cavity of the mouth. On the 13th of July a consultation was held, and an operation for the removal of the bone decided upon. The formidable nature of the operation proposed, together with the debilitated and cachectic condition of the patient, induced me to enter into full explanations, and to inform him of the great risk that would attend it. The matter was then left to himself, and, at his urgent request, I proceeded to use my efforts for his relief. It was not thought expedient to administer either chloroform or ether, on account of the liability to asphyxia from the passage of the blood into the windpipe. The patient being seated on a chair, and the assistants properly arranged, an incision was first made, commencing opposite the left condyle, passing downward toward the angle of the jaw, ranging at about two lines in front of the posterior border of the ramus, extending thence along the base of the jaw7, and terminating by a slight curve on the mesial line, half an inch below the free margin of the lower lip. The bone was now partially laid bare, by dissecting upward the tissues of the cheek, and by reflecting downward, for a short distance, the lower edge of the incision. The tissues forming the floor of the mouth, and situated upon the inner surface of the body of the bone, were separated from their attachments, from a point near the mesial line, as far back as the angle of the jaw. The attachments of the buccinator were next divided. The facial artery, the submental and the sublingual, already cut, were then secured by ligature. It was now seen that the bone was partially separated at the symphysis, and that the necrosis was complete from that point to the anterior portion of the ramus. The ramus itself w^as found diseased; the periosteum externally was inflamed, H6 and in some parts easily detached. The tongue was now grasped and held forward, while tl.e attachments of the genio-hyo-glossi muscles were divided. A double ligature was passed through the anterior part of the root of the tongue, and intrusted to an assistant, in order to prevent its retraction upon the superior orifice of the larynx. A fatal case, from the falling backward of the tongue, occurred a few years ago in the practice of an eminent surgeon of this city, and a similar misfortune should always be guarded against when the muscular attachments of the tongue to the posterior part of the bone behind the symphysis are divided. A slight force exercised upon the left half of the body of the jaw broke the connection at the symphysis and at the angle, and this part was easily removed. The next step consisted in the removal of the left ramus. The external surface of the branch of the jaw and of the temporo-maxillary articulation was exposed, by dissecting the masse- tcr upward as far as the zygomatic arch. Seizing the ramus in order to pull the coronoid process downward below the zygoma, it was found that the temporal muscle was rigidly and permanently retracted. This circumstance presented an unexpected difficulty, which was increased by the unusual development of this apophysis, and by the retraction also of the pterygoid muscles. Passing the forefinger along the inner aspect of the ramus, the situation of the internal and external carotids was sought for and recognized. The insertion of the pterygoideus internus was then felt and cut, grazing the bone in doing so, the lingual nerve, here in close proximity, being carefully avoided. Passing still higher up, the orifice of the dental canal, indicated by an osseous projection, could be felt; and the instrument, still guided by the finger, divided the dental artery and nerve. The knife was thus made to separate the tissues attached to the inner face of the bone as high up as a point situated about a line below the sigmoid • notch, between the condyle and the coronoid process. On a level with this point, at the posterior margin of the ramus, the transverse facial, internal maxillary, and temporal arteries form a kind of tripod, the two last-named branches of which should not be divided, if possible. It now became necessary to detach the tendon of the temporal muscle. As the coronoid process could not be depressed I proceeded cautiously, by dividing the lower attachments of the tendon by 69 means of blunt curved scissors; and by using them and a probe-pointed bistoury alternately—keeping close to the bone—a considerable portion of the tendon was divided. Deeming it not prudent to use freely a sharp cutting instrument deep in the temporal fossa, where the coronoid process was situated, I made use of a pair of bone-scissors, curved flatwise; and by passing the blades of this instrument over the process, as far as its position would permit, the temporal muscle was detached, a small portion of the apex of the coronoid process being cut through. The ramus, now movable, could be made use of as a lever to aid in the disarticulation of the bone. In order to effect safely the disarticulation of the condyle, I began by penetrating into the joint, cutting the ligaments from before backward, and from without inward. The articulation was thus opened sufficiently to allow the condyle to be completely luxated. Blunt-pointed scissors were now used to cut carefully the internal part of the capsule and the maxillary insertion of the external pterygoid muscle, and, by a slow movement of rotation of the ramus upon its axis, the condyle was detached, and the operation was completed on this side. By proceeding to disarticulate, in the manner here described, injury to the temporal artery, as well as to the internal maxillary, was avoided. To effect the removal of the other half of the lower jaw, a similar incision was made on the opposite side, so as to meet the first on the mesial line. The dissection was also similar; and by disarticulating the second condyle in the same manner as had been observed for the first, I was successful again in avoiding lesion of the temporal and internal maxillary arteries. The annexed plate, No. III., Fig. II, is a correct delineation of the inferior maxilla, after maceration, and exhibits the portions of the bone as they became separated during the operation. The object I had in view, in shaping the external incisions in such a way that an inverted Y should be formed in front of the insertion of the genio-hyo-glossi muscles, was to leave a portion of integument so fashioned that the suture pins could be passed through the integument, and, at the same time, through the root of the tongue, at the point where its muscles 70 had been detached from the inner surface of the jaw. The several tissues becoming thus incorporated in the resulting cicatrix, served to form a new bridle, somewhat analogous to the natural muscular attachments of the tongue to the genial processes. The amount of blood lost was inconsiderable; the arteries divided, besides those mentioned, were the transverse facial, the anterior masseteric, the anterior parotidean, etc., and these were seemed as soon as divided. The bone being disarticulated, the flaps wTere adjusted, and the lips of the incision united by eighteen points of twisted suture. The tongue was retained forward, after the dressing, by attaching the ends of the ligature already passed through its base, on each side, to a bandage passed vertically around the head. Forty-eight hours after the operation the first dressing was removed: union by first intention had taken place, and eight of the suture pins were taken out. In ninety-six hours the wound was again examined : union was foimd to be entirely completed, and the remaining pins were removed. On the seventh day it was thought safe to remove the ligature from the tongue. On the tenth day the arterial ligatures came away; and on the fourteenth day the patient was pronounced cured, not having had an untoward symptom since the performance of the operation. The operation occupied fifty-five minutes, the patient having been allowed intervals of repose to recruit. It was performed in the presence of a number of professional gentlemen; and I was ably assisted by my colleague, Dr. A. Y. Williams, Drs. Dewees and Dixon, of New York, and by Drs. Thompson, Whitehead, Smith, and Bailey, resident assistants attached to the surgical staff of the hospital. The present appearance of the patient, upon reference to the accom- panying plate, No. III., will be seen to present much less deformity than might be expected from the severe mutilation which he has undergone. His general condition and health are good, and he is now able to perform any ordinary vocation. The ducts of Steno on both sides were necessarily divided in the superficial incisions; but there is no salivary fistula, the saliva taking its course into the mouth. The division of the branches of the facial nerve has not been followed by permanent paralysis of the face, although, for a 71 time after the reunion of the incision, the orbicularis palpebrarum of the right side appeared to have lost its action to some extent. In grasping the chin, a thin cartilaginous deposit can now be felt, extending, crescent-shaped, for about three inches, and occupying the position at which the bone wras most diseased. Higher up, toward the glenoid cavity, no deposition of bone or cartilage has taken place. Injury to the bag of the pharynx, during the detachment of the soft tissues from the angle of the jaw, was carefully avoided, and fluids could be swallowed, in small quantities, immediately after the operation. Deglutition is now effected without difficulty. Articulation is sufficiently distinct to render his words intelligible, and although unable to masticate, he does not complain of difficulty in eating, breaking up, as he says he does, his food between the tongue and the palatal vault of the superior maxillae. Disarticulation of the lower jaw, by external incision, at the temporo- maxillary articulation, can be accomplished without wounding the duct of Steno, or the trunk of the portio dura, as the following case will illustrate: A gentleman about 45 years of age, from the State of Yermont, consulted me for a cancerous growth springing from the body of the lower jaw, upon the right side. The enlargement encroached upon the cavity of the mouth, and also formed a considerable tumor externally. The disease of the bone was supposed, before the operation, to extend from the angle of the jaw as far as the second small incisor tooth of the right side. The operation for removal was commenced by an incision of the soft parts, beginning at a point below the duct of Steno, near the posterior margin of the ramus of the jaw. This was prolonged downward as far as the angle of the jaw, and then carried forward, along the lower border of the ramus, as far as a point opposite the first incisor tooth, with a slight cmve, the border of the lower lip not being divided. Upon laying bare the diseased bone, I was induced to believe that the disease extended farther upward upon the ramus than had been antici- pated. The remaining portion of the ramus was exposed by dissecting, and by pushing upward with the handle of the scalpel the tissues resting upon 72 it. The jaw was now divided by the chain-saw opposite the second incisor tooth. This allowed the diseased portion to be depressed so as to place within reach the insertion of the temporal muscle. A pair of bone-scissors, blunt on the point, and curved flatwise, was made to separate the temporal muscle at its insertion into the coronoid process. The tissues over the articulation were then drawn upward, and the joint being entered at its external and anterior part, disarticulation was easily accomplished. NOTE.—I have in the text, as originally written, given the credit of priority to Dupuytren for the removal of a part of the lower jaw. Professor Eve, in his recent work, Collection of Eemarkable Cases in Surgery, has brought forward very strong evidence in favor of Dr. Deaderick, of Tennessee, as the originator of this operation. The question stands thus : Dupuytren's case was recorded in 1813, and published to the scientific world; Dr. Deaderick's case is said to have occurred in 1810, but was not published until 1823; in other words, it was a claim made after thirteen years of silence on the subject, The name of my celebrated and esteemed preceptor, Professor Mott, is also identified with the early operations for partial removal of the lower jaw. In fact, Professor Mott's first operation for the removal of a portion of the lower jaw, for osteo-sarcoma, was published in 1822, or one year prior to the publication of Dr. Deaderick's case. REMARKS ON AMPUTATION OF THE ENTIRE LOWER JAW. [From the New York Medical Journal, Mai/, 1852.] Since the publication of my case of amputation of the entire lower jaw in the January number of the Journal, I have been led to investigations which justify me in presenting it as the first successful operation of the kind reported in the annals of surgery. The operation attributed to Walther, of Bonn, cannot be admitted as authentic; not because it presented formidable surgical difficulties, although such must always exist, but because no such operation is recorded either by himself or by an eye-witness. I am not alone in this opinion. Yelpeau, the great compiler of surgical literature, alludes to it in a brief note [Xouveaux Elemens de Medecine Operatoire. Paris, 1839. Yol. ii., p. 610] as a mere rumor, unsustained by proof. Nelaton [Elemens de Pathologic Chirurgicale. Paris, 1849. P. 749] also alludes to the opera- tion as a mere rumor. The most eminent German authority, Dieffenbach, in his Operative Surgery [Die Operative Chirurgie. Leipzig, 1848. Zweiter Band. P. 56], under the caption of " Exarticulation of the Entire Lower Jaw," describes a cadaveric operative procedure, but makes no allusion to Walther in this relation. Chelius, another eminent German professor [System of Surgery. By J. M. Chelius. Translated from the German, with notes, by John F. South. Yol. iii. Philadelphia, 1847. P. 745], under the caption of " Excision of the Lower Jaw," says that " even the total extirpation of the lower jaw may be indicated by various kinds of disease," but does not pro- ceed to mention Walther, or any other surgeon, as ever having performed 11 74 that operation. From this silence it may be inferred that he assumes that the operation was thitherto wholly imknown in the records of surgery. The latest French authority, M. Yidal (de Cassis) [Twite de Pathologic Exteme de Midline Operatoire Paris, 1851. Vol. iii., p. 509], holds this language m re-ard to Walther's operation: -Success (in an amputation of the entire lower jaw) is attributed to Walther, of Bonn;" and further on, "the success spoken of is unique; it has not even an irreproachable authenticity."* There is an operation transcribed from the Italian into the Gazette Midfoalc for November, 1854, p. 758, under the head of "Extirpation of the Entire Lower Jaw by subcutaneous incision, by M. Signoroni," but it is very far from coining within the category of successful amputations or resections. The record is in many respects vague and unsatisfactory; No details are given of the disease requiring the operation. The operation itself, according to the author, was not an amputation properly so called, but an extraction of the bones, by means of forceps, and the use of the bone-scissors. There were no incisions made, except of the buccal mucous membrane, where it is attached to the surfaces of the jaw. Moreover, the extraction was not effected by a single operation, but required a second, after the lapse of eight days. And still farther, the patient was not cured; for, according to M. Signoroni, " at the end of nine months he succumbed to a reproduction of the disease." . Professor Syme [Contributions to the Pathology and Practice of Surgery. Edinburgh, 1848. P. 21], in the article on "Excision of the Lower Jaw," states that he disarticulated the jaw; but no details are given of the case or of the operation. Moreover, the patient referred to is stated by him to have died on the following day. Mr. Perry's case, related in the Medico-chirurgical Transactions [London, second series, vol. iii., 1838, p. 290], like that of M. Signoroni, was an extrac- * Beaucoup d'auteurs francais attribuent la premiere extirpation du maxillaire infiMeur h Walther et a Graefe: uiais c'ost uue affirmation sans foudement. [Traitddes Resections par le Docteur O. Heyfelder, traduit de I'AUemand par le Docteur Eugene Bcekel. Strasbourg—Paris, 1863.] In the New York Medical Journal, vol. x., new series, 1ST>3, the editor states he is promised the details of a case of amputation of the lower jaw, but I have not been able to rind a record of it. 75 tion of the bone, piecemeal, at intervals, extending over a period of three weeks. It would be easy to multiply negative facts of this kind; that is to say, to adduce cases where the operation of amputation of the entire lower jaw was not performed; but those I have noticed and commented upon will suffice for my purpose. In reality, my claim to priority, which I now feel entitled to make, is based upon the positive fact that there exists no record, antecedent to my own, of an operative procedure of amputation of the entire lower jaw, performed with success upon the living body. In regard to that operation, it was performed upon a principle analogous to that which would govern the amputation, in contiguity, of any other member similarly affected by disease. For example, the removal of the upper extremity at the scapulo-humeral articulation would be preferred to an operation with section of the bone, where the disease was likely to return if any portion of the shaft or head of the humerus were allowed to remain. As mentioned in the published report of my case, the body, only, of the bone was in a state of necrosis. To be more definite, the necrosis extended to the anterior edge of the masseter muscle of the left side, and some lines farther upon the right side. But, although the necrosis did not extend beyond the body of the bone, the condition of the rami, on both sides, was such as to demand their removal. They were already inflamed, and if they had not been removed, they would have remained liable to caries or necrosis in the progression of the disease; the maxillary muscles having become rigidly and permanently retracted, from the irritation of the disease, would have drawn, by the action of the pterygoid muscles, the ramus of each side upon the bag of the pharynx, and so impeded deglutition; while the immovable posi- tion of the rami, occasioned by the permanent contraction of the temporal muscles, attached to the coronoid processes, would, upon the deposition of new bone, have led to increased irritation and danger. Lastly, the dilapi- dated condition of the patient, and the danger of purulent infection to which he was exposed from the quantity of pus secreted by the diseased parts, to- gether with his inability to endure much longer the torture under which he was laboring, from the irritation propagated to the ramifications of the third 76 I .ranch of the fifth pair of nerves, lodged in the dental canals, furnished an additional reason for total disarticulation. In conclusion, I may remark that the patient now, ten months after the operation, is pursuing his vocation as a dairy-man, in a state of perfect health. The morbid specimen is deposited in the museum of the New York Medical College. The foregoing "Remarks on Amputation of the Entire LowTer Jaw," taken from the Xeiv York Medical Journal for May, 1852, were written in answer to some observations made in one of the medical journals of the day in relation to my case operated on in July, 1851. I see no reason, at the present time, to modify the statement I then made, and leave the article as formerly published. Before, and particularly since 1851, military surgery has afforded numerous cases of injuries of the inferior maxilla, in many of which the bone was so shattered as to require at the time or at a future period the extraction of nearly the whole of the jaw, piecemeal. [Yide Larrev, Me moires de Chirurgie Militaire. Paris, 1812. Also Medical and Surgical History of the War, First Surgical Yolume, p. 345,1870.] The first formiilized operation on record, however, where the whole jaw was removed with success at one sitting, for disease that required a methodical dissection, appears to have been performed on the patient upon whom I operated. Even at the present time there are but few instances where the inferior max- illa has been removed successfully by formal operation. In addition to the references of eases previously made, I may mention those of J. F. Heyfelder, the first of which occurred in 1843, the operation having been performed on a young girl, a deux temps, with an interval of fifteen months between the first and second operations. Two operations of a similar character are recorded by the same surgeon, one in 1852, and one in 1858. All of these operations appear to have been required for phosphoric periostitis and ne- crosis. [Yide Traite des Resections, par le Docteur 0. Heyfelder. Traduit. Paris, 1663.] Maisonneuve reports two cases, one of operation for cancer of the bone, wherein the operation was performed a deux temps, the first i i operation having been done on the left portion of the jaw, July 17th, 1851. Fifteen months after this operation, the disease having returned on the other side, the remaining half of the jaw was removed. [Bull. Acad, ale Sciences, 3 Mai, 1853.] The same surgeon records another case, in which he removed the entire lower jaw, at one sitting, for a fibrous tumor as large as the fist, This case is recorded at length in the Bulletin of the Academy of Sciences, 12th May, 1856 ; 10th August, 1857. The patient, set. 33, entered the Hopi- tal de la Pi tie April 11th, 1856, and was operated on a few days after. This is probably the first authentic record of any case of the kind performed in Europe. The periosteum in Maisonneuve's case was preserved to a great extent, which should be avoided where a cancerous predisposition is appar- ent. As will be seen by reference to the dates, I have to place my case as the first on record, having been performed July, 1851.* The following case is one where the entire lower jaw was success- fully amputated for osteo-fibroid tumor. * Cases are often quoted and copied from book to book by successive authors, and mistakes are transmitted unintentionally, from neglect to consult the original publications. Thus we have Butts, of Virginia, credited in almost all the works on operative surgery issued during the last twenty-five years with the first removal of the entire radius, when, in the case as originally published, it is found that his operation was upon the ulna, and not upon the radius at all, and that two-thirds only of the lower or carpal portion of the ulna were resected, the elbow joint not being implicated in the operation. The case is fully detailed, and a plate given representing the portion of bone removed. [Vide Philadelphia Journal of Medical and Physical Sciences, vol. i., new series, p. 115, Art. ix.] V. Mott is credited with having removed the entire clavicle, when the description of the operation as published states that the bone was sawed through with a chain-saw near the coracoid process, thus preserving some attach- ments, to the portion of the clavicle remaining, of the trapezius and deltoid muscles, making an important differ- ence in regard to the functions of the humero-scapular joint. [Vide American Journal of Medical Sciences. Phila- delphia, 1828. Vol. iii., p. 100. Also Mott's Yelpeau, edited by Blackman.] Other instances of a similar character might be alluded to. I have failed to find any case, reported by the author, of an operation where the whole jaw was removed by a regular operative procedure at one time prior to my case, and have left unnoticed cases mentioned by miscellaneous authorities, concluding that an operation of such importance as the removal of the entire lower jaw was not likely to have escaped so far the attention of the operator as to induce him to forego recording the operation himself in accustomed form and detail. AMPUTATION OF THE ENTIRE LOWER JAW FOR OSTEO-FIBROID TUMOR A DEUX TEMPS. In May, 1864, I was consulted by M----J----, a lady about 40 years of age, married, of nervous temperament. She had been operated on, three years before, for an osteo-tibroid tumor on the left side of the lower jaw, the growth commencing at the site of the second large molar tooth, and extending gradually, during a period of eighteen months, up the ramus of the same side, and passing forward as far as the second small molar. This operation was performed in 1861, the bone having been sawed through opposite the first small molar, and disarticulated at the left condyle. The patient had a good recovery, the wound healing in about four weeks. In six months after this operation the end of the stump of the portion of the jaw that re- mained began to take on a diseased action, similar in character to that of the tumor already removed. This continued to enlarge and to extend upward, at first occupying the centre of the body of the bone, and then the rest of the body as far as the angle of the jaw. At the time that she visited me for advice, May, 1864, she presented an appearance of great suffering and of broken-down health. On the left side of the face the cicatrix of the former operation was visible, and opposite the spheno-maxillary fossa a hard lump, as large as a walnut, was seen, which had sprung up some months after the first operation. The entire middle of the body of the bone and the horizontal portion were diseased, and presented a spherical tumor AMPUTATION OF THE ENTIRE LOWER JAW, A DEUX TEMPS. Ki.i. 1. t Ki<> II 7/ie /ndierif he/ore t//e o/ierotion, re/ireseiidi/j the turuor at the /ieprcseiits die three fourths of the jaw last removed'.the other ■ /aw with die fine of incision uulicafed. portion, on the left side, /aiviiu/ been resected some time previous A portion of the coronoid /iroeess was cut off'hv die hone force/is and dissected out to fardihde die openitiou .iiVJ\ llth 79 as large as the two fists, extending from above downward, toward the malar bone, and below as far as the os hyoides, and transversely from the alveolar ridge of the left canine tooth along the mental and horizontal portion of the body of the bone, a little beyond the place of junction of the body with the ascending ramus of the right side. The morbid mass thus springing from and making part of the inferior maxilla encroached upon the floor of the mouth, pushing the tongue upward and to one side, pressing upon the salivary glands, ducts, and nerves toward the pharynx. The carotid artery could be felt on the side of the neck upon a level with the cornu of the os hyoides. The buccal cavity presented several teeth irregularly projecting from the surface of the tumor, and from the left extremity of the mass unhealthy granulations were springing up and pouring out a viscid and offensive secretion. The temporo- maxillary articulation was perfectly free, but the angle of junction made by the body and ramus of the jaw, on account of the growth of the tumor, had become much more obtuse, giving the tumor an inclination downward and forward. The skin covering the morbid growth was rough, and showed large blue varicose veins ramifying over the surface, while the tumor itself gave to the touch a hard, unyielding, and somewhat nodulated sensation. The collected important scientific facts connected with operations for partial amputations of the inferior maxilla, and the successes which have followed them, have been sufficiently numerous to render almost unnecessary any additional detailed accounts of such achievements. In cases, however, where removal of the entire lower jaw has been undertaken, the data are not so abundant, and farther observations may prove useful and interesting. The position in which the patient should be placed during the opera- tion, the extent to which anaesthetics can be prudently administered, the propriety or necessity of ligating the carotid artery as a preliminary step to the operation, the precautions required to prevent the falling back of the tongue upon the upper part of the larynx, and the safest manner of effecting disarticulation of the condyles, are points which admit of deliberation and study. In severe operations on the jaw, the sitting or semi-recumbent posi- tion is best, and the anaesthetic influence should never be carried to the point of insensibility. By adopting this precaution the patient will run less SO risk of being killed by apneea, or of succumbing in case of fainting from loss of blood. The more precise knowledge of the surgical anatomy of the blood- vessels concerned in these operations has rendered the ligation of the com- mon carotid artery, as a preliminary step, an exceptional measure, as well as taught that the best mode of proceeding in the disarticulation of the maxillary condyle from the glenoid cavity is to attack the articulation in front, and to continue the section of the capsule from before backward. Where large portions of the lower jaw have to be amputated, operators who have had most experience in this class of cases have taken pains to lay down rules in relation to the shape and direction of the line of external incision, having in view the prevention of deformity from the resulting cicatrix, and the promotion of the egress of saliva and pus from the cavity of the mouth. These incisions have been in general semi-lunar in form, with the convexity directed downward, or downward and backward. This shape is preferable among the various plans which have been adopted for laying bare the disease and lessening disfiguration; and, to the general semi- lunar form, when three-quarters or the whole of the jaw has to be removed, I have practised the prolongation of the incision so as to ascend in a curved direction to a point on the mesial line within half an inch of the free border of the lower lip. From this point the incision for the opposite side is com- menced, and carried in the direction corresponding with the incision on the other side, and terminating at a given point, or at the temporo-maxillary articulation, according to the extent of the diseased portion. From the direction of the line of incision in front, we have thus a point flappui, or piece de resistance, for incorporating the detached base of the tongue with the more solid tissues of the external flap, and by not carrying the incision through the free border of the lip, the labial arteries are not divided, and hemorrhage from these vessels is, therefore, avoided during the first steps of the operation. I may here mention that, although the general line of incision should be determined upon before commencing an operation, where the external incision has to be so extensive it is prudent to make it by degrees, and not all at once. The blood-vessels of the neck are near the centre of circulation, and bleed actively, and by subdividing the general in- 81 cision into several, and securing the vessels as they are cut, the loss of blood may be considerably abated. In the following operation the patient was seated on a chair facing the light, and chloroform administered so as to produce only partial anaesthesia. An incision was commenced on the mesial line, half an inch below the surface of the free border of the lip, and carried backward and downward over the tumor to a point opposite the middle of the right side of the body of the jaw, in a semicircular sweep, slightly below the lower border of the face. From this point the incision was prolonged, still coursing from before backward, and a little below the lower margin of the body of the bone, as far as within a few lines of the angle of the jaw, thence extending upward within a line of the posterior border of the ramus as far as a point imme- diately above the superior and middle part of the condyle, in front of the temporal artery. This incision divided the integuments, the platysma my- oides, and subcutaneous layer of cellular tissue. The dissection now was confined to that part of the tumor between the commencing point of the incision at the chin and the place of transit of the facial artery over the side of the jaw, and the surface of the tumor reached for three-quarters of its extent. The dissection was also carried deeper along the side of the neck, as far as the angle of the jaw, dividing the facial artery and vein, the former of which was immediately secured, and laying bare the bone. The bone at and above the angle was found to be thickened and diseased, and, with the presence, besides, of an apparently cancerous diathesis, there was no longer any doubt as to the necessity of disarticulating the condyle, so as to get rid of the entire bone. The dissection was now carried deeper, in order to reach the bone along the posterior border of the ramus as high as the con- dyle, thus dividing the superficial tissues, branches of the portio dura, small masseteric branches, and a portion of the parotid gland. The tumor and ramus being thus laid bare on the external aspect, and the bleeding vessels secured, the dissection was continued, so as to detach still farther the sound tissues from the tumor in this direction. This accomplished, an external incision, similar to the first, was begun on the other side of the tumor at the same point, and carried outward so as to sweep over the left external aspect 12 82 of the diseased mass and beyond its posterior margin. The tumor in this direction was promptly laid bare without much bleeding, and the healthy and soft tissues separated from the diseased by carrying the knife down- ward, backward, and forward, so as to open the cavity of the mouth. The left lateral and anterior aspects of the tumor being now exposed, the upper flap was farther detached, from below upward, so as to divide the cheek completely as far as the anterior border of the ramus. The lower flap was now dissected downward toward the os hyoides, and upon the neck as far as the angle of the jaw. By this the anterior and inferior parts of the tumor were exposed, as well as the whole length of the inferior margin of the body of the jaw. It remained now to detach the tumor from its attachments to the os hyoides, the root of the tongue, and the floor of the mouth, and to effect the disarticulation of the condyle after freeing the attachments of the masseter, temporal, and pterygoid muscles. Before dividing the genio-hyo-glossi muscles attached to the middle of the posterior part of the tumor, a double ligature was passed through the substance of the tongue, and the ends confided to an assistant, a double hook was also inserted in the tongue, and directions given to carry this organ up- ward and to one side, so that it would not interfere with the incisions. The lip and upper flap pulled up, and supported by another aid, the knife was carried closely along the posterior aspect of the tumor from left to right, and the genio-hyo-glossi, the genio-hyoidei, the mylo-hyoidei2 and anterior bellies of the digastrics divided, cutting from left to right, and from above downward. The main part of the tumor was now detached, so as to be seized by the hand, and moved in different directions to facilitate the dissection. The masseter muscle was now dissected from the outer surface of the ramus as for as its attachments to the zygoma. The tumor was then carried forward and downward, hi order to stretch the temporal muscle and bring it within reach; but the coronoid process ascended unusually high, and it became necessary to use the bone-forceps to cut through its superior portion, in order to liberate the attachment of the temporal muscle. By depressing and rotating the bone outward, the pterygoid muscles and dental nerve and 83 artery were put upon the stretch, and rendered more easy of division. The forefinger of the left hand was now made to pass along the inner and inferior surface of the ramus of the jaw, the two carotid arteries were felt and then- position ascertained, as well as the insertion of the internal pterygoid upon the jaw. This muscle was divided by passing the knife close upon the bone from below upward, taking care to avoid the lingual nerve. The forefinger, carried still further upward, along the inner surface of the bone, reached the superior orifice of the dental canal, indicated by a bony projection, and the artery and nerve were now divided as they entered the canal. The superior portion of the external carotid courses along at the dis- tance of a quarter of an inch from the posterior border of the ramus, and at a point about a line below the notch which divides the coronoid process from the condyloid, and close to the bone forms the tripod of vessels—the transverse facial, the temporal, and the internal maxillary—previously alluded to. The transverse facial passes from its origin over the masseter, the tem- poral ascends over the root of the zygoma, as the continuation of the trunk, while the internal maxillary is applied immediately upon the inner surface of the bone, crosses its direction, and creeps along the inferior border of the external pterygoid muscle, indicating, from its position, that the temporo- maxillary articulation should be attacked from before backward and from without inward as the first step in the disarticulation. The articulation being opened and divided in this manner, two-thirds of the tendinous insertion of the external pterygoid muscle were divided from above downward and from without inward, grazing the bone, and using principally the curved scissors. The operation was finished by a few cautious cuts with the scissors, and by rotating the bone so as to detach the mass by laceration of the remaining fibres around the joint. The inter- nal maxillary artery, by this manoeuvre, escaped cutting altogether, and thus a considerable source of inconvenience from hemorrhage was avoided. The edges of the wound were now adjusted and maintained in place, along the line of incision, by interrupted sutures of silver wire. On the mesial line, where the incision made an angle in form of an inverted V, a suture was inserted on each side of the triangle, near the apex, incorporating 84 the tissues on the lower surface of the tongue with the integuments on the line of the incision. The tongue was in this manner held forward in the natural position, and prevented from falling back on the upper opening of the larynx. A few strips of isinglass adhesive plaster were placed between the points of suture ; some charpie, a compress, and a light retentive band- ago completed the dressing. The sutures were removed daily, beginning their removal forty-eight hours after the operation, and by the eighth day the whole line of the external incision was healed without any salivary fistula. The ligatures were all away by the fourteenth day. The side of the wound, within the mouth, healed more gradually, and a slightly astringent injection was daily used for cleansing and promoting the healing process. The tumor, after removal, presented a globe-shaped mass, of which the portion of the bone most involved seemed to form part, as if the disease had originated from the centre of the osseous tissue. From one side of the tumor, across the greatest diameter, a part of the body of the jaw and the ramus were to be seen extending from the tumor to the condyle, the perios- teum and ramus thickened, the condyle remaining healthy at the end of the mass; the part of bone where the first operation had terminated was found partly enveloped with the tissu inodulaire of the old cicatrix, and covered with some unhealthy granulations. The coronoid process was seen deprived of the part cut off by the bone-forceps during the operation. [Vide Plate IV., Fig. II.] The greatest diameter of the tumor extended from the side where the section of the bone had been made in the first operation to the last molar tooth of the right side, as seen in the plate. The anterior surface presented the triangular portion of integument resulting from the formation of the lower flap at this point. The lateral surface showed the external side of the body of the jaw expanded, and, like the inferior aspect, was rough and irregular from the dissection of the muscular attachments. The buccal or alveolar aspect of the tumor—the surface seen upon opening the mouth —presented a dense, compact mass, which filled the mouth, covered by the mucous membrane of the gums, thickened, and of pale maroon-color, firmly adherent to the morbid tissue below, and confounded with it. The alveolar edge was quite effaced, and along the original line of the teeth three large 85 molars and one small one were seen jutting out from the surface of the dis- eased mass. In cutting into the tumor from this surface a creaking sound was made by the knife, and a resistance was felt like that produced by incis- ing into a scirrhous growth through the substance of which thin plates of bone are disseminated. The intimate structure presented, on the cut sur- faces, a grayish-white fibrous mass, traversed by osseo-fibrous intersections filled up with striated cartilaginous material, from which, in some parts, an unhealthy granular liquid could be pressed. There was very little vascular- ity and scarcely any traces of vessels to be seen. The lingual nerve and the hypoglossal remained uninjured, and the sublingual and submaxillary glands were left intact, healthy, and in their natural place. To the unaided eye, as well as to the microscope, this tumor revealed traits of a cancerous or malignant character. The patient, however, had a good recovery, and was able to leave her room for out-door exercise three weeks after the operation. As was mentioned previously, the patient, when presented to me, besides the main tumor on the lower jaw, had on the side originally operated on a small growth, about the size of a walnut, apparently springing from the region of the spheno-maxillary fossa toward the origin of the external ptery- goid muscle. Two months after the operation just detailed, by a careful dissection I removed this tumor, which partook of the same pathological character as the larger growth just described. This wound also healed kindly, and the patient, with the entire lower jaw thus removed, presented the same physiognomical traits as the patient represented in Fig. I., Plate No. HI. The physiologico-pathological effects were the same in both cases described, and represented in the drawings. The motion of the tongue re- mained, and the general and special sensibility also continued unimpaired. Voice, deglutition, and speech were not interfered with. The primary branches of the portio dura having been divided in front of the ear, the muscles under the influence of this nerve became paralyzed on both sides, and the countenance assumed an impassible and immovable expression. The lower eyelid failing to move toward the upper made it impossible to 86 close the eyelids, and the eye, from this cause, was easily suffused with tears. The branch of the fifth pan which joins and courses along the portio dma was divided with that nerve, and the dental branch of the fifth pair was also cut during the operation. The sensibility imparted to the integument through the infiuence of these last-mentioned branches became also modified after division. These functions, interfered with for a time, became gradually restored, as happened after the operation first described, taking place grad- ually and slowly through the restored innervation and the vivification of the nervous cicatrices. I was assisted in this operation by several distinguished colleagues, and my life-long friend Professor Valentine Mott, the last surgical operation, I believe, at which he was present before his death, and in which he mani- fested as much interest as in the earlier days of his scientific triumphs. [Vide Plate IV.]* * Fig. I., indicating the line of incision, was taken some time before the operation, and is given at about one- fifth of the natural size. The patient persisted in closing her mouth while sitting for the photograph, hindering the inside view. Fig. II. represents tlie pathological specimen, and is of natural size. ON SHOCK AND COLLAPSE, and THE PRIMARY TREATMENT OF INJURIES; INCLUDING THE CONSIDERATION OF THE TIME OF ELECTION FOR CAPITAL OPERATIONS REQUIRED AFTER EXTENSIVE LESIONS. General Observations.—The treatment and management of the injured during the first few horns after severe lesions have been received, such as occur in railroad accidents or from wounds inflicted by projectiles on the battle-field, often decide the fate of the sufferer, and turn the delicately bal- anced scale in his favor, by the restoration of the vital powers, or, adversely, by their speedy annihilation. The overwhelming effect of a violent shock, profoundly agitating and disarranging every organ and function of the body, places the system frequently below the starting-point of spontaneous reac- tion, and without judicious and timely assistance the diminished vitality soon becomes extinguished. The authors who have written treatises on surgery seem to have passed over, with brief notice, the analysis of the pathological phenomena wrhich follow upon great perturbations of the system from extensive external injuries. Until within a comparatively recent period the treatment applied to them has not been based upon precise prin- ciples deduced from the physiological facts connected with the chain of morbid phenomena which soon become developed after severe mutilations. No longer ago than the time of Boyer and his disciples it was the invariable custom, when an accident of serious character took place, to bleed freely in order to prevent anticipated inflammation, and while such practice may be advisable in many instances after reaction has been established, it is now S8 well understood that spoliative venesection would be the sure forerunner of disaster to the patient. In the works of Astley Cooper, of Abernethy, and other authorities of their time, we find only short notices on this subject; and even in the works of Velpeau, Malgaigne, Lisfranc, Neiaton, Syme, Liston, and Bilroth, the phenomena and therapeutic management of shock and its effects are only briefly commented on. The works on military surgery do not afford much more information on the subject, and in searching through the volumes of the Leeous Orales, delivered by Dupuytren at the Hotel Dieu, of Taris, with all his great experience and means of observation, the matter is only cursorily spoken of. Articles scattered through the periodical litera- ture of the last ten or fifteen years treat this subject with more accuracy and detail; but it is one of much importance, and admits of still farther consid- eration and investigation. The term shock is used frequently as synonymous with collapse, proba- bly from the fact that in some cases the effect follows the concussion so instantaneously that they appear to be identical. Shock may be regarded as the source of the nervous symptoms that take place after the occurrence of an accident, concussion being the first link of the chain of the consequent morbid {menomena; wThile the word collapse should properly be used to express the extreme prostration of strength and the agitation and perturba- tion of the nervous system which follow upon all severe injuries. If the word shock is at all applicable to general symptoms, it would be to acci- dents that are followed on the instant after the receipt of the injury by the suspension of vital phenomena or actual death, examples of which are found in the sudden deaths that sometimes follow a blow on the epigastrium, or the overwhelming effect of a fall from a great height, or in the mortal derangement occasioned by a shell or cannon-ball—injuries which admit of no appreciable sensibility after the fatal impression has been made. It is not possible here to trace the connection of one function giving way succes- sively after another. Nothing is manifest but the immediate sequence of the cause, namely, the mortal effect. Here the impinging force or momentum and the effects show themselves so instantaneously that the source of the ^ymptoms and the symptoms themselves—that is to say, the fatal disturb- 89 ance and its accompaniments—are apparently merged into one phase. Yet there must be an interval of time, although, perhaps, inappreciable and devoid of sentiency, between the initiatory concussion and the consec- utive changes that follow, which changes terminate in reaction or in the immediate suspension of vitality. Health and Disease.—The term health is used to denote the physiolog- ical condition of the body in which the functions are so well balanced that every action is in perfect harmony and regularity. In order that this state shall be maintained, the organs of circulation and respiration must be unim- paired, the nervous system act with sympathetic accuracy and exactness, and the character and composition of the blood, upon which the vital phe- nomena are dependent, must be normal. The deviations which occur in the performance of these functions constitute disease, and this may be brought about by whatever produces anaemia or hyperemia in any of the parts or organs of the body, or whatever may pervert, increase, diminish, or alter the physiological impressionability of the nervous system to the influence of the blood. Other sources of disease originate in the vitiation of the blood itself, by the introduction of poisons directly into the circulation, either from inoculation or absorption of the virulent material, or from miasmatic and atmospheric agencies admitted into the blood through the medium of the pulmonic system. These different agencies in the production of the changes which occur in the transition from the normal to a diseased condition seldom act alone, and, if so, but for a very brief period. One pathological phenomenon follows in quick succession upon the other, so that whether the first phase may have occurred from defective or excessive circulation of the blood in parts or in the whole of the body, or from injury or perverted susceptibility of the nervous system, or from direct admission of poisonous material into the blood, the general system is soon involved in universal commotion more or less violent, which ends in resolution or death. In the restoration to health the morbid symptoms gradually disappear, and the various functions re- sume their normal operations. But the progress toward death is not so easily followed, and should be studied and considered in order to meet 13 90 emonrenoies and to counteract the tendency toward dissolution in the differ- ent stages of collapse. The Phenomena of Disease, and their Progress toward Death.—The different phenomena of disease which mark the gradual progress of the changes as they advance in succession toward death have been considered by various physiologists ; but the investigations of Bichat, published in his Hecherehes sur la Vic et la Mort, did much to elucidate the delicate mysteries of approaching death, and the fundamental distinctions that he described as death beginning at the head, death beginning at the heart, and death begin- ning at the lungs, remain still as the nomenclature best suited to the consid- eration of this subject. Sir Benjamin Brodie and others have enlarged om* knowledge in this direction by the numerous experiments made upon living animals, as well as by observations Avhich they have recorded as seen upon man. In cases of shock which terminate fatally after the lapse of several hours, the initiatory steps toward dying commence with the reception of the external injury. Life is frequently extinguished after severe lesions by that mode of dying which is denominated asthenia, but in complex injuries the manner in which the different vital functions become finally exhausted is not always the same, the successive order in which the annihilation of the vitality occurs beginning from more sources than one. For example : A light-weight rider while training a colt was violently thrown. His foot caught in the stirrup, and he was dragged over the ground by the frightened animal. AVhen picked up his skull was foimd to be badly fractured, and several ribs and one leg were broken. He died in a few minutes after he was rescued. Here we have, on the one hand, death beginning at the brain the injury to which, extending to the medulla oblongata, paralyzed the muscles of respiration, while, on the other hand, the contusion and the frac- tures of the ribs and leg propagated their depressing effects through the spinal marrow and cardiac ganglion to the heart, annulling its action by the diminished supply of nervous influence which necessarily followed. Although the distinctions enumerated by Bichat may not be altogether sufficient, yet it is better to accept the arrangement he has offered as form- ing the most simple basis from which to start in considering the various 91 phenomena of disease in their tendency or progress toward dissolution. If the pathology of sudden death from external injury be now better under- stood, the explanations in given cases will be rendered more easy by having but few distinctive heads, yet sufficiently comprehensive, to which they can be referred. The vital organs—the brain, the lungs, and the heart—respond so rapidly and intimately to each other, and the performance of their func- tions is so closely dependent the one on the other, that it is in exceptional cases only that it becomes possible to study the different forms of dying in an isolated manner. In cases of severe limited injury, such as occurs from the crushing of a limb from a railroad accident, where the vital functions are suddenly stopped, or of poisoning by substances whose specific action is directed to an organ or set of organs, the progress to death may be traced to an insulated commencement. But the greater number of instances of external injury resulting fatally are examples of death proceeding from a complication of disturbing causes. The distinctions, then, as laid down by Bichat, may be regarded as suf- ficiently comprehensive to enable us to analyze the phenomena of disease or of injuries in their tendency toward death, and to refer them to a primary source according to the lesion which may claim attention. Bichat probably took this view, and refrained from extending his fundamental distinctions to other organs, such as the stomach or the medulla spinalis, in order to render the explanation of the subject less complicated. While admitting the dis- tinctive arrangement of Bichat as sufficiently ample or comprehensive, it cannot be doubted that since his time physiological investigations have much enlarged our information on the subject, and that the pathology of sudden death and of the different modes of dying is now better understood and more minutely described. At best, in the complex study of the various phenomena which tend to produce death, we have to seize upon some pri- mary and important derangement and trace it to some given organ; and to accomplish this it will be found that reference to the brain, the heart, and the lungs will be abundantly full and precise. When death is occurring from disease, as from fever of a grave type, a variety of pathological processes is usually at work at the same time, i)2 which complicate the analysis of the phenomena that are slowly tending toward the destruction of the vital functions, although there may be a marked inclination toward one or other mode of dying, indicated by the particular organ or set of organs most deeply implicated. Thus, for exam- ple, we find in typhus the lungs sometimes become mainly affected during certain epidemics, while in others the brain or abdominal viscera are the principal organs associated with the febrile condition. In the extinction of life from external injuries, the advancing steps are often more distinct and more easily followed in their progress toward dissolution than in prolonged diseases ; yet fearful lesions are inflicted by violence which complicate the mode of dying on account of the number of organs that become suddenly implicated and disturbed, as happens when the body and limbs become entangled in machinery, or when a heavy wall or embankment is precip- itated with the rapidity and force of an avalanche on a group of laborers while at work. For a better comprehension of the subject in hand, and that the indications of treatment in collapse tending toward death may be clearly met, we may here take up in succession the consideration of the different modes in which life may be extinguished. Adopting, therefore, approx- imately the fundamental distinctions of Bichat, we may proceed to examine the mode of dying that begins at the heart, as this form very frequently pre- sents itself in collapse from dangerous injuries. There are two modes in which death commences at the heart: in one instance the heart is deprived of its natural stimulus, the blood, by the quantity reaching its cavities not being sufficient to maintain the nec- essary action; besides, the quality of the blood may be so devitalized as to be deprived of its stimulating characteristics. When the circulation thus fails, and the cavities of the heart do not receive the requisite supply of blood to induce its contraction, although the power to do so may remain the term anamiia is used to designate the condition. Examples of death occurring in this manner are met with more particularly in cases where large vessels are womided, as on the battle-field or in suicide where the huge arteries are divided, in post-partum hemorrhages, or where large aneurisms become suddenly ruptured. In such or similar instances, in post- 93 mortem examinations, the chambers of the heart are found empty or nearly so, contracted, and not filled with blood, as happens in some other condi- tions about to be mentioned. The symptoms manifested in this mode of dying are often blended with those which follow severe shock unattended by hemorrhage. There is more or less insensibility, a fluttering, quick, and irregular pulse, obscure vision, pupils sometimes dilated, giddiness, cold and clammy surface, with pallor of the countenance and lips. There is also fre- quently great jactitation, with tossing of the limbs and body, with general restlessness and nervous delirium; if the sensibility be not too much an- nulled, there is nausea and vomiting, the respiration is irregular, the patient sighs and gasps, and finally death is ushered in by repeated convulsions. The other form of death that begins at the heart is called asthenia, and depends on a loss of the contractile power of the heart from defective inner- vation, and not from a want of supply of blood. It is the most common form of death which follows collapse from the shock to the nervous system in severe external injuries where there is little or no hemorrhage. The exper- iments of Sir Benjamin Brodie have proved that the action of certain poisons also is to annul the nervous power of the heart, so as to arrest the circulation and destroy life ; and here we have the post-mortem examination revealing that the cavities of the heart are filled with blood, the right cavities con- taining purple blood and the left scarlet blood. It may be here mentioned that syncope, a condition of suspended animation dependent on a failure of the circulation to reach the brain, is common to both forms of death com- mencing at the heart. The mode of dying the commencement of wThich Bichat attributed to the lungs, is now very properly called apncea* (a priv., and nvuv, to breathe), which literally signifies " privation of breath." The term asphyxia (a priv., and a^siv, to beat), signifying a want of pulse, was formerly used to denote this condition by a faulty nomenclatme. The term suffocation is appropriately used to designate that condition which follows the abrupt obstruction of the entrance of air into the lungs by the interposition of * Vide The Principles and Practice of Physic, by Sir Thomas Watson. London. ni some direct obstacle, or from paralysis of the muscles of the larynx, as may happen after a violent blow upon the box of the larynx. The imme- diate effects of the interception of the entrance of air into the lungs are met with in various forms of interrupted respiration, as in cases of drowning, of strangulation, of severe double pneumonia, of suspension of respiration from forcible pressure upon the chest and abdomen annulling the play of the dia- phragm and intercostal muscles, and where there has been injury to the spinal cord in the cervical region above the origin of the phrenic nerve. In these and similar instances, where the air cannot have free entrance into the chest, there is a stagnation of blood in the lungs, inducing the circulation of venous or carbonized blood through the system, poisoning the brain, the spinal marrow, and the other parts of the nervous apparatus, and producing general impairment and extinction of the functions of life. The pathology of the internal changes which take place in this mode of dying has been studied and described by Haller, Bichat, and others, and at a later date by Mr. Erichsen, of London. The fundamental source of the symptoms which occur is the lack of oxygen in the lungs, and the consequent absence of the normal change that should take place in the chemical com- position of the blood. The blood in the pulmonic vessels becomes charged with carbonic acid, and, from the first, losing its proper stimulating influ- ence, begins to circulate more and more slowly, ultimately becoming almost stationary or stagnant in the capillaries of the lungs. The blood remains venous, and in this state passes from the lungs through the pulmonary veins into the left chambers of the heart, and thence, by the aorta and its branches, through the different organs of the body. The blood, thus deprived of its vitalizing principle, and loaded with carbonic acid, is not suited or adequate to supply the proper stimulus to the organs it permeates and reaching the brain and spinal marrow, the effects are soon manifested by jactitation, insensibility, and convulsions. The blood continues to flow more tardily and in smaller quantities into the left auricle and ventricle of the heart, producing but feeble contractions, owing to the deficient supply it receives. After death this side of the heart is found to contain but a small quantity of dark blood, while on the pulmonic or right side the ventri- 95 cle and auricle, with the contiguous rente cavce, are found to be distended with dark blood, and the general venous system to be filled and gorged with the same dark fluid. The general symptoms occasioned by apncea, or obstructed entrance of air into the lungs, when sudden, are marked by struggling efforts to effect respiration, by vertigo, insensibility, convulsions, twitchings or tremors of the limbs, and relaxation of the muscles and sphincters, while the action of the pulse becomes more feeble and fluttering, the heart continuing to beat for a short time after other signs of life have fled. When death comes more slowly, as in pneumonia or in croup, the respiration is labored and dis- tressed, the countenance livid and leaden-colored, the eyes are turned up with the aspect of despair, and delirium is ushered in by the circulation of venous blood in the brain. In many cases, if the cause of the obstruction to the entrance of the air can be speedily removed, animation may be restored by the maintenance of artificial respiration. The blood, by degrees becom- ing oxygenated, begins to circulate through the pulmonary capillaries, reaches the heart and brain in the arterialized condition, and the impaired vital functions are gradually restored. According to Bichat, another mode of dying is death commencing at the brain, and this is said to be death by coma. Examples of this occur from such injuries to the brain as produce compression sufficient to impress the medulla oblongata, and from certain poisons which, taken in toxic quanti- ties, suspend the functions of the brain. Laceration of the middle artery of the dura mater, or of the vessels at the base of the brain, or the entrance of a bullet into the cerebral substance, produces coma which very frequently terminates in death. In such cases as these just mentioned, the immediate cause of death is similar to that wmich results from apncea; but in those instances of injury which are preceded by compression of the brain, life becomes extinguished by the paralyzed condition of the respiratory muscles, which lose their power on account of the lesion of the nervous apparatus, while, in cases of apncea, death takes place from the non-aerated condition of blood from interruption to the entrance of air into the lungs. In poison cases, such as result from opium, producing coma, artificial respiration may 96 be favorably resorted to, as in apncea, to keep the lungs inflated and sup- plied with air, thus promoting decarbonization and the oxygenation of the blood until the coma shall have subsided. Coma is often associated with other modes of death arising from different primary causes. For example: If there exist a combination of fracture of the skull and depression, or of laceration of the middle artery of the dura mater, with, at the same time, extensive loss of blood from wound of a large vessel, resulting fatally, there will be death commencing at the brain—" coma ;" and death commencing at the heart, from defective circulation of the blood—"anaemia." If to the above combination be added extensive injury, as from a railroad accident crushing a limb, there will be death occurring from coma, from anaemia, and from asthenia, these distinctive modes taking place almost simultaneously, and overwhelming the general system. Moreover, if in the same case an injury had been received on the body of the larynx, sufficient to paralyze the dilator muscles of the rima glottidis, or some influence destroying the action of the genio-hyo-glossi muscles, so that the tongue would fall back upon the upper orifice of the windpipe, the entrance of air into the lungs would be intercepted, and apncea also would be the result, thus producing death from all the distinctive sources as enumerated by Bichat. Anatomical Eemarks.—From what has been stated it is evident that it is through the medium of the nervous system that the primary effects of injuries are communicated to the general animal economy. The heart and arteries are subordinate to the action of the grand sympathetic nerve and to its connections with the cerebro-spinal axis. When the blood becomes de- vitalized or contaminated by the admission of morbid or poisonous material into the circulation, so that the contents of the vessels in passing through the organs disturb the functions of life, the pathological results must still be referred to the morbific influence that is necessarily impressed upon a portion or the whole of the nervous apparatus. Sometimes the immediate result following the reception of a local injury—upon a limb, for example__is merely a greater or less disturbance of the functions of the parts on the distal side of the injury. An arm receiving a sudden blow may remain par- alyzed or torpid for a considerable length of time. The paralysis while it 97 lasts may be complete, or the muscular or motor powers may alone be affected, the sentiency remaining undistmbed, or the sensation may be impaired while the other functions retain their integrity. More frequently, however, the impression of a severe injury is carried in a centripetal direc- tion toward the great nervous centres. The painful sensations carried to the sensorium by the afferent cords are returned to the injured part by the efferent branches, and the remote sensations sometimes experienced, as well as the convulsive muscular spasm which often takes place after severe lesions, must be attributed to the reflex action of the medulla spinalis. The numerous commissures of the brain, and the continuous communication of the cornua of the gray matter of the spinal cord with the motor and sensory strands, as well as the interlacing of the filaments from the spinal nerves with those from the ganglions of the great sympathetic nerve, afford an explanation of the numerous complicated and distant sympathies which become manifested and developed after severe injuries. Although a local injury may be followed immediately by a torpid condition of the adjoining parts, amounting, in some instances, to muscular paralysis and effacement of sensibility, the morbid impression may rest confined or limited in its effects, and the system escape entirely from any sympathetic influence. Most frequently, however, a lesion of even moderate severity is very soon followed by constitutional symptoms of more or less gravity, generally indi- cating the extent of the injury inflicted, and the simplicity or danger of the impression received by the nervous system. Moreover, in different cases the extension of the primary effect of a severe lesion is radiated over the system in a variety of ways and in different grades of intensity. Injuries that are followed by Shock and Collapse.—The injuries so severe as to be accompanied by shock, followed by collapse, and which ordinarily become the subject of treatment, may be, in the main, included in the subjoined category of lesions: severe contusions; extensive w^ounds; fractures of the large bones of various kinds; injuries that take place by machinery in factories; gunshot wounds; railway accidents, accom- panied by violent concussion of the body, or by the crushing of a limb from the passage of the wheel of a railway carriage; injuries of the head, U 98 with or without fracture of the skull; profuse hemorrhages; extensive burns, such as occur from steamboat and boiler explosions ; injuries to the spinal column; surgical operations of magnitude; and dislocations of the large joints. To these may be added vivid mental emotions and their influences. Mental emotions undoubtedly destroy life by the overwhelming perturbation which they produce through the whole nervous system, death occurring most probably by the intensity of the effect becoming localized upon the cardiac ganglion and nerves, so as to paralyze the functions of the heart, while at the same time the blood becomes deteriorated and devitalized, as in cases of death following a stroke of lightning. This extreme result of psycho- logical influence is, however, not common, although in many instances, especially in railway accidents and in gunshot wounds, and still more so in cases of suicide, the morale is greatty affected, and modifies to some extent the character of the symptoms as well as the final result. General Symptoms.—As has just been stated, the influence of a shock following upon a severe injury may be trivial and limited in its effect, or it may be radiated over the system in the greatest degree of intensity. In describing the general symptoms of shock, a case of great severity must be supposed to exist which shall serve as a type of such accidents, and to em- brace the signs characteristic of collapse in its gravest form. The symptoms of collapse are generally described en masse, as if they were all present at one time, and occurred simultaneously. This is not so, except in extreme cases, for they appear in succession, and run from a condition of stunning or partial torpor into a state of general insensibility, terminating in slow reac- tion or in coma and dissolution. For example: A boy about twelve years of age, while playing on the platform of a railway carriage, the train being in motion, fell between the couplings of the car, and was run over, the wmeels crushing the right leg a short distance below the knee. The train was immediately stopped and the boy dragged from under the wheels. I saw him at this moment, having just left the same train at the station where the accident occurred. He was pale, stupid, staring wildly, the lips livid, the surface beginning to get cold and leaden in hue, the pulse feeble and slower than natural, sensibility 99 diminished; could answer questions with difficulty, and monosyllabic when answering; complaining of no pain; respiration slow, feeble, and sighing. In this condition he was carried into the depot building and laid on a table, with the head low. The bleeding was stopped by a garrot tourniquet got up on the moment. There was some delay in procuring instruments before an operation could be performed, and during this period all the above symp- toms gradually increased. The pulse became more feeble, so as to be scarcely felt at the wrist, the respiration was almost imperceptible, skin cold and clammy, the countenance and lips of leaden hue, torpor and complete insensibility, with coma—in fact, the boy appeared to be moribund. This patient recovered, after amputation, and will be alluded to hereafter, when speaking of the treatment. Another case of a somewhat similar character presented itself to me, in which symptoms were present that were absent in the one just spoken of. An adult, about forty years of age, was run over by the wheels of a street car, and had the right leg crushed, breaking the bones, and lacerating the soft tissues in the upper third of the leg. I was requested to see him, and found him lying on the floor of a pharmacy, where he was taken imme- diately after the accident. He was under the influence of spirits at the time of its occurrence. He answered questions wildly; was restless; sick at the stomach, vomiting at times; countenance stupid; pulse feeble and rapid; respiration irregular and feeble; although suffering from the shock, he was not insensible or comatose. His house was at the distance of two miles, along the course of the street cars, and his friends desired that he should be placed in a car and removed to his home. This was accordingly done. A tourniquet was applied over the femoral artery, but, from the jolt- ing of the car, some oozing of blood took place during the transfer. Upon reaching home the tourniquet was tightened, and he was placed in bed ; but by this time—a period of about an hour—the symptoms had all become aggravated. The pulse had increased in rapidity and feebleness, the respi- ration was rapid, irregular, and sighing, the restlessness had turned into jactitation, and the nausea into increased recurrence of the vomiting. There was great tossing of the body from one side of the bed to the other; 100 hawking and spitting ; irrelevant, vulgar, and disconnected sentences, spoken quickly and with irritability. The insensibility increased, with a death-like coldness and clamminess of the surface. This condition soon passed into entire insensibility, convulsion, and coma ending in death. Here we have two cases occurring from lesions very similar in character and extent, yet in neither case were all the possible symptoms present. This may be so, however, and every symptom previously described become manifest between the occurrence of the shock and the termination in reac- tion or death. The difference between these cases was probably that in one more blood was lost immediately after the accident than in the other. The instance given of the light-weight rider who was thrown so violently that he fractured the leg, several ribs, and the skull, embraced almost every possible condition; but in that, as in most instances where such violent injuries are received, he was killed outright. Collective Symptoms.—The collective symptoms ensuing upon severe shock may be given as follows: torpor; stupor; rigor; pallor, and leaden color of countenance ; cold sweat and clammy skin; anxiety; hurried breath- ing ; restlessness at times, at others complete lethargy and inability to be roused ; pulse feeble, sometimes rapid, intermitting, and fluttering, at others scarcely perceptible at the wrist; sickness, nausea, and vomiting; glazed eye, with stupid expression and incoherency; respiration feeble, sometimes rapid and irregular, sometimes slow and stertorous, or scarcely perceptible ; syncope; delirium; great thirst; suppression of urine and suspension of secretions; insensibility; coma; often spasms; tremors; convulsions; jactita- tion ; and contraction or dilatation of pupils. There have been instances known in severe railway accidents, in steamboat explosions, and from causes of like severity, where the concussion to the general system was so profound that though the patient, for some minutes after the accident, conversed, or even walked about without apparent injury, suddenly fell dead. In such instances of unexpected and unlooked-for cessation of the functions of life the suddenness of death is most probably caused by the rapid devitalization of the blood, resulting from the desperate character of the injury, inducing such condition as is met with at times in typhus ambulant and in some 101 abruptly fatal cases of yellow fever, although in these maladies the disinte- gration of the circulating fluid progresses more slowly. This obscme and illusory condition, fraught with insidious danger, and indicated only by neg- ative signs, is apt to be overlooked, or not considered to belong to the previous category, which it strictly does, being a species of collapse, followT- ing shock, where the injury has been so great as to paralyze all the organic functions. Etiology.—Previous to the last half century it would not have been possible to have comprehended or explained the pathological phenomena following immediately upon the receipt of a severe injury, for the reason that at that time the anatomy and philosophy of the nervous system were not sufficiently understood. The discoveries of Charles Bell, of Magendie, Longet, Claude Bernard, Brown-Sequard, and the experiments of Marshall Hall and others, have opened up a new field in this direction, and afforded explanations of numerous morbid manifestations, both in internal and exter- nal pathology, which were not comprehended previously. The physiological divisions, histology, and general properties of the nervous system have also been studied more carefully. The earlier writers seem to have been aware of the peculiar characteristic of the nerves which enables them to conduct to and from the great centres the impressions through which wTe become cog- nizant of the existence of external agencies. The important facts elucidated by the experiments of Charles Bell and of Magendie, localizing the distinct seat of the motor and sensory properties of the spinal nerves, proved to be the starting-point of many other disclosures in connection with the physiology and functions of the cerebro-spinal system. Following upon the important fact that the anterior roots of the spinal nerves are endowed with motor power, and that the posterior roots are exclusively sensory, came, as if by analogy, the partition of the functions of the cranial nerves into those of motion and into those of special and general sensibility. Putting to one side the nerves of special sense, as the olfactory, the optic, and the acoustic, the gustatory branch of the fifth pair and a part of the glosso-pharyngeal, we have the motor cranial nerves, viz.: the third pair, or motores oculorum communes; the fourth pair, or pathetici; the sixth pair, or motores externi; 102 the nerve of mastication, from the small root of the fifth; the seventh pair, or portio dura, the nerve of expression, with the intermediary nerve of Wris- berg; portions of the eighth pair and of the spinal accessory; and the ninth pair, or hypoglossal: while as the sensory cranial nerves we have the large loot of the fifth pair, or trifacial; part of the second division of the eighth pair, the pneumogastric; and the sentient part of the glosso-pharyngeal. The pncumogastric and spinal accessory are almost from their commencement joined by various nervous branches, and early in their course become nerves of mixed character. Besides the action of the medulla spinalis as a great nerve centre, wTe find that it is composed of white and gray nervous matter, the fibres of the white matter, in conjunction with the gray substance of the cord, acting as co-ordinators and conductors of sensory impressions from the periphery toward the centre, while the gray matter forms a connected chain of ganglia which act as a congeries of nerve centres, receiving impressions and generating the so-called vis nervosa, and with the antero-lateral columns of the cord serving, to a greater or less extent, as a conductor of motor influence from the centre to the periphery. The medulla spinalis, taken as a whole, with its antero-lateral and posterior columns, presents numerous commissural connections and decussa- tions along its anterior portion, most plainly distinct at the medulla oblon- gata, and also along the posterior portion almost throughout the whole extent of the cord. The cord also contains the elements of the important function of " reflex action," and, in conjunction with the grand sympathetic, the vaso-motor influence upon the blood-vessels. Thus we have the medulla spinalis and medulla oblongata affording the basis of explanation of many of the phenomena following severe external injury. Impressions from the periphery are conveyed through the posterior roots to the cord, and conducted onward to the brain, while the stimulus generated by the encephalic nervous centres is conveyed centrifugally from the brain, and passes from the cord along the anterior roots of the spinal nerves toward the periphery—reflex action and the vaso-motor influence, referred to before acting their part separately or in combination. The commissures and points of decussation in promoting the reciprocal action of different portions of 103 tfce nervous system must not be overlooked. Following up the nervous connection, we have the cerebral ganglia at the base of the encephalon as well as the cineritious matter of the cerebellum exerting their influence upon the organs of special sense. The perturbations after severe lesion conveyed along the spinal cord, passing through the medulla oblongata, the pons varolii, the crura cerebri and cerebelli, the optic thalami, and the corpora striata, are radiated directly upon the gray matter of wThich the encephalic ganglia and convolutions are composed, and are thence transmitted and dis- tributed over the whole or a part of the nervous system. The several points of decussation of the fibres across the median line from one side to the other, and the large and small commissures, act also in promoting the dispersion of the morbid or baneful effects of shock. The grand sympathetic system of nerves comes in also to play a part in the general disturbance or upsetting of the normal functions. The cerebro- spinal axis thus intimately connected in its various parts is equally in close communion with the organic set of nerves by the anastomosing net-work that exists between the branches of one class and those of the other, from the cephalic ganglia at the head to the ganglion impar near the coccyx, the last of the thirty-two or thirty-four ganglia of the sympathetic. These branches of communication betwreen the sympathetic and the cerebro-spinal nerves exert a marked and pervading physiological influence over all the organs of the body, and when disturbed become large participators in the development of the symptoms associated with collapse. From this cursory glance at some of the functions of the nervous system, it is very evident that wre must learn through it the interpretation of most of the symptoms that take place as the immediate effects of severe injuries from external causes. Without running the theory too far, it may be said that nearly the whole range of disease appears to commence by a species of shock rever- berating and undulating over the nervous system. What else can be said of the influence of malaria, or a poisonous atmosphere contaminating the blood and bathing the nervous system, in the production of intermittent or malarial fever ? We have the initiatory cause leading to collapse, manifested by the cold stage, followed by the reaction. In yellow fever, in typhus, in poison by 101 the bite of a venomous serpent, in the exanthemata, and in the sudden effu- sion of blood in cerebral apoplexy, we have a cold stage initiating the reaction which follows if the system be not overwhelmed by the primary shock. Physiological Mechanism and Analysis of individual Symptoms follow- ing Shock.—The rate at which nervous conduction progresses in the human subject in the sensory and motor nerves is estimated at about one hundred and eleven feet per second. Between the time of the receipt of a severe injury, the shock, and the commencement of the manifestations, or of the symptoms of collapse, there is consequently an appreciable space of time, although necessarily of brief duration. It is difficult to designate the minute pathological changes which are so suddenly radiated over the system. The explanation of the several symptoms which are manifested succes- sively after the infliction of severe external injury follows to a great extent upon the comprehension of the mechanism heretofore sketched. Torpor, Stupor.—Torpor, stupor, partial insensibility, and general pros- tration supervene almost immediately, and can be accounted for by the disturbance of the general nervous system, which is the immediate sequent to the shock. The injury inflicted upon the nerves at the seat of lesion is transmitted and radiated over the entire telegraphic communication of nerv- ous cords, centres, and ganglia, modified by commissures and the several points of decussation, and multiplied by the excito-motor and vaso-motor influence. In many instances the fundamental or intimate nature of the pathological changes which take place after shock, as in the pathological conditions of some forms of insanity, of epilepsy, and of catalepsy, has so far eluded the examinations of histology, of chemistry, and of the microscope. At the moment of the receipt of the shock the fibres of the white sub- stance or the cells of the gray matter may not be appreciably changed within the scope of the present means of exploration; but, whether from electric influence or otherwise, a great perturbation takes place, and the very principle of life seems to be attacked and overwhelmed for the time. The essential natme of the nervous fluid or force—the imponderable agent by which the operations of the nervous system are carried on—is not solved in our present state of information, and may be said to be the -ultimate cause 105 of certain characteristic phenomena. It has been claimed by some physiol- ogists to be identical with electricity, but the experiments made by Prevost and Dumas in 1823, and later by Matteucci and Longet, appear to disclose facts that are opposed to this hypothesis, as they failed to demonstrate the existence of a true electric current in the nerves in action. According to Cuvier, it is by or through the agency of an imponderable fluid that the nerves act; that all the animal fluids being drawn from the blood by secre- tion, there is no reason to doubt that the nervous fluid does belong to the same category, or that the medullary substance does secrete it: "II y a grande apparence que c'est par un fluide imponderable que les nerfs agis- sent......tous les fluides animaux etant tires du sang par secretion, il n'y a pas a douter que le fluide nerveux ne soit dans le meme cas, ni que la matiere medullaire ne le secrete......les fonctions nerveuses, c'est-a-dire, la sensibilite et lirritabilite musculaire, sont d'autant plus fortes dans chaque point que leur agent y est plus abondant; et comme cet agent, ou le fluide nerveux, est produit par une s^creUion, il doit etre d'autant plus abondant quil y a plus de matiere medullaire ou secretaire, et que cette matiere recoit plus de sang." Longet gives the following resumS in relation to the hypothesis regard- ing the identity of the nervous fluid with electricity: "1. II n'existe, jusqu'a present, aucune preuve directe et certaine en faveur de l'hypothese des courants electriques dans les nerfs. " 2. L'electricite' et la force nerveuse ne sont point identiques. " 3. Dans l'etat actuel de la science, il y a temerite a affirmer qu'ils sont totalement differents, et qu'ils n'offrent pas la moindre analogic "4. Le nevrileme, qui transmet de faibles courants electriques, ne peut transmettre le principe nerveux. " 5. L'electricite n'est probablement qu'un simple excitateur de la force nerveuse persistante, et son action doit etre assimilee a celle des irritants mecaniques ou chimiques." The theory that the nerve cells of the gray or ganglionic matter generate nerve force, and that the white strands and cords conduct from the nervous centres to the periphery the force or influence thus generated, seems to be 15 106 the most reasonable, and serves to explain more satisfactorily than any other hypothesis the various symptoms which follow upon severe shock to the general system. With the supposition that the gray matter of the ganglia and of the encephalic convolutions secretes the nervous fluid, it can be well understood that the cessation or interruption of this secretion w^ould be followed by systemic disturbance. The question is now definitively settled by positive experiment that the sensory nerves and posterior columns of the medulla spinalis convey impres- sions from the periphery to the nervous centres, and that the antero-lateral columns and the anterior roots of the spinal nerves transmit the motor stim- ulus from the centre toward the circumference, and also, that through the agency of the excito-motor mechanism impressions are transmitted to the nervous centres, and again from them reflected in a peripheric direction upon the different portions and organs of the body. Let us take, then, a patient with a limb shattered by a cannon-ball or shell, or a patient with the lower extremity crushed below the knee from the passage of the wheel of a rail- way carriage—in the latter case the bones broken and comminuted, the muscles, arteries, and nerves divided and crushed, and the lower portion of the member hanging by loose shreds of cellular tissue, fascia, and contused ecchymosed skin to the upper portion. In both of these instances the morbid impression from the local injury is transmitted along the nervous trunks to the medulla spinalis, thence along the medulla oblongata through the cerebellar and cerebral crura and cranial ganglia, to reach, by means of the radiating white nervous fibres, the gray matter of the cerebral and cere- bellar convolutions. The morbid impression thus impinging upon the gray matter destroys, to a greater or less extent, the power of secreting the nerv- ous fluid by its proper organ or tissue. The nervous strands and cords, on the other hand, whose function it is to transmit the nervous stimulus toward the general periphery, are no longer supplied by the proper active principle of the nerves, and thus the tissues and the organs one after another give indications of disturbance, or cease to perform their accustomed func- tions. In addition to this train of action, the chemical relation of the blood corpuscles becomes deranged, the electric balance of the blood disks is 107 disturbed, and the blood itself becomes devitalized. While this general perturbation is progressing, other symptoms become manifested wThich admit of a more detailed and minute analysis. In connection with what has just been stated, another important fact must also be mentioned. The nerves of general sensibility and those of motion are entirely distinct at their origin at the cord, but beyond the intervertebral ganglia, and as soon as they have emerged from the vertebral canal, they become united in a common envelope, and thenceforth become mixed nerves. Some of the cranial nerves have a similar general disposition of sensitive and motor roots, such as the fifth pair, the seventh, the eighth, and soon after their origin become nerves of mixed character. The result of this arrangement is that each of the spinal nerves and some of the cranial, with their branches, partake at the same time of the characters appertaining to the nerves of motion and of sensa- tion, and when directly excited cause pain and local contraction. Moreover, the branches of the rachidean and cranial nerves, after their emergence from their respective ganglia, receive branches of anastomotic communication from the ganglia of the grand sympathetic nerve along its entire extent. The mixed nerves are thus in direct communication with the nervous col- umns of the medulla spinalis, which receive and transmit impressions to and from the great nervous centres. The psychological manifestations, such as fear and panic, produced by shock are brought about by a nervous mechanism similar to that which causes those impressions that take their origin from the common sensory and motor nerves of the medulla spinalis and encephalon. The sensations transmitted to the brain from the seat of injury serve as a stimulus to the emotional part of the brain, and from this ganglionic medium are reflected upon the excito-motor system of the cerebro-spinal axis, throwing the mus- cular apparatus of the body into tremor and involuntary convulsive action. It is probable that the intellectual and affective portions of the brain, when under certain conditions of activity incited by external impressions, may also become the seat from which is radiated upon the excito-motor apparatus the stimulus that produces the manifestations of reflex action upon the gen- eral system. 108 There are certain physiological laws which regulate the transmission of the nervous fluid in health that are also applicable to the nervous system when thrown into a pathological condition. Putting aside the peculiar action of the excito-motor function, it is necessary, in order that sensation shall be perceived and voluntary motion produced, that the sensitive nerves and the motor nerves remain in communication with the encephalon, either directly, or indirectly through the medium of the medulla spinalis. Nervous impres- sions are carried toward the nervous centres centripetally, like the current in the veins toward the heart, while the impressions which transmit the principle of movement, like the blood in the arteries, pass in a peripheric or centrifugal direction. When the sciatic nerve, for example, is divided, and the free end of the distal portion irritated by mechanical or galvanic excita- tion, no sensation will be produced, but the muscles supplied by branches taking their origin below the point irritated will be thrown into contraction, while, on the contrary, the free end of the proximal portion, which remains in connection with the cerebro-spinal axis, under the same stimulus, will evoke sensations in all the parts where its nervous filaments are distributed, but no appreciable signs of motor influence will be evinced. The ulnar nerve struck at the elbow between the olecranon and the epitrochlea trans- mits directly and at once, through the nervous filaments wiiich take then origin below the seat of injury, a disturbed motor influence upon the muscles to wiiich these filaments are ramified. The sensation of pain, referred to the part where the blow was received, and along the ulnar side of the ring ringer and both sides of the little finger, is transmitted to the sensorium first, and returned upon the remote parts by nervous communication, travelling, as previously mentioned, at the rate of one hundred and eleven feet per second to and from the sensorium, before sensation can be perceived. A similar principle of action is revealed when the galvanic stimulus is applied upon the medulla spinalis still united to the encephalon. Having cut the entire cord transversely, it is found that the galvanic stimulus, applied upon the caudal extremity of the posterior column, produces no sensation, but applied upon the cephalic segment, exquisite sensibility is the result. The same irritant applied upon the antero-lateral column in the cephalic 109 section produces no evidences of sensation, but violent contractions in the muscles of the pelvic extremities are the immediate effects.* Prochaska and Legallois first made known, and Marshall Hall still far- ther developed the fact by experiment, that the medulla spinalis and medulla oblongata, besides other functions, possessed the characteristics of a distinct and independent nervous centre, and that when separated from the encepha- lon they could still remain the seat of peculiar and remarkable phenomena. The reflexion which takes place from the sensitive nerves upon the motor nerves through the intermediate agency of the medulla spinalis and medulla oblongata, considered as indispensable centres, is described by Marshall Hall as automatic, or altogether independent of volition. This author confines the function of reflex action solely to the rachidean nerves, and excludes the nerves of the encephalon, asserting that what is termed reflex action is never provoked by a sensation. Herbert Mayo, and after him Muller, however, regard the theory of reflexion that takes place from the cranial sensory nerves upon the motor nerves through the intervention of the encephalic masses as applicable to all the automatic movements which take place after various sensations. The panic-stricken criminal receiving sentence of death is an instance of this. The sound of the judge's voice undulating upon the acoustic nerve produces impressions that are trans- mitted to the emotional part of the gray matter of the brain, from wiiich they are radiated upon the cranial motor and rachidean nerves, producing trembling and involuntary contractions of the whole muscular system. Even brave men have been struck with this involuntary trembling upon going into battle for the first time, the series of sensations commencing with the boom of the yet distant cannon. In view of the facts just stated in relation to the laws which preside over the transmission of the nervous fluid, it may be concluded that the * When in Paris, several years since, I had the privilege of assisting at numerous vivisections, performed by M. Longet, in illustration of this part of the physiology of the nervous system. Some of these experiments proved conclusively that the gray matter of the brain generates the nervous principle or fluid, and that the white matter has the mission of serving as the conductor, the gray matter alone giving the character of nervous centre to the medulla spinalis. 110 immediate effects of a severe injury upon a part where the nerves are of mixed character, as upon a limb, will be of a duplex nature. The motor filaments supplying the parts below or beyond the seat of injury will be directly affected so as to produce local spasm or more or less loss of mus- cular power, the nervous influence manifesting its perturbation centrifugally. On the other hand, the nervous sensory filaments will act on the proximal side of the injury centripetally, and transmit the impressions from the seat of lesion along the nervous trunks to the spinal cord, and thence to the nervous centres. From these will emanate all the various complex phenom- ena which are radiated over part or the whole of the system by nervous communication, and by reflex action producing in the aggregate the symptoms of collapse. As the ganglia of the great sympathetic are supplied by sensory and motor filaments, it is probable they are also endowed with the power of reflex action, and that this system acts an important part in producing the symptoms of collapse in those injuries which are attended by severe succus- sion or jar to the body without other evidences of lesion. The effects of extensive external lesions are modified by the severity and intensity of the impressions conveyed to the nervous centres, and the consequent total or partial suspension of the secretory function of the cells of the gray matter. Thus we may have the shock of so severe a character that vitality becomes extinguished; or, on the other hand, if the intensity of the impression be of less severity, the secretory function of the nerve centres is only partially suspended, and we have shock followed by collapse, which may admit of healthful reaction, and recuperation of the disturbed and depressed organs. Taking for granted the hypothesis that attributes to the cells of the gray matter the power of secreting the nervous fluid from the blood, as the bile is secreted from blood in the liver, we can easily understand that in proportion as the nervous fluid fails to be produced or generated, and is no longer conducted along the nervous cords, the function of one organ after another must necessarily become to a greater or less extent altered or suspended. Torpor, stupor, delirium, coma, loss of intelli- gence, of sensation, and of motion, necessarily follow as sequents upon the Ill paralyzed function of the gray matter of the medulla spinalis and of the encephalic ganglia and convolutions. From apparently opposite conditions, although in reality the same, torpor, stupor, coma, and delhium can also be produced from excessive loss of blood, as is seen in cases of profuse hemorrhages occurring from woimds of large arteries, or from destructive uterine hemorrhage during and after labor. The brain and spinal marrow cease to receive the necessary amount of the proper stimulus, and from the shock to the system which supervenes, and through the same net-work of nervous communication, a series of symp- toms occurs similar in character to the collapse which results from extensive injury, whether the lesion be from a crushed limb, an extensive burn, or a fractured skull with depression of bone. Syncope takes place. The system may react, or, with the continuance of the cause, vitality becomes extinct. Nausea, Yomiting.—Other organs are reached through the medium of individual nerves, and manifest their sympathy by signs of morbid pertur- bation. The stomach, under the influence of the pneumogastric and of the semi-lunar ganglion and coronary plexus, after certain injuries, shows signs of commotion by the interruption of digestion, by nausea, retching, and vomiting. The nervous communication is traced, in case of injury to the soft tissues of the neck or to the thoracic or pelvic extremities, from the seat of lesion to the medulla spinalis, medulla oblongata, and brain, thence along the par vagum to the stomach. In injury to the brain itself, the perverted nervous influence is conveyed from the cephalic cineritious centre more directly along the par vagum; while if the trunk is the principal seat of lesion, as from extensive scalding from boiling water or steam, or from vio- lent succussion, the morbid impression is transmitted along the thoracic and abdominal spinal nerves and the corresponding ganglia of the sympathetic to the medulla spinalis, to be ultimately radiated thence along the greater and lesser splanchnic nerves to the solar plexus, the semi-lunar ganglion, and coronary plexus upon the stomach. In some cases of severe general injury, the influence of the shock may be transmitted simultaneously through all of these various communications, perturbating or destroying the functions of the main organ of digestion. 112 The Heart and the Circulation.—The heart and arteries enact so essential a part in the animal economy, and are so freely supplied with branches and filaments from the several classes of nerves, that they are necessarily in the highest degree susceptible to impressions resulting from injuries received upon any part of the body. The abundant supply of nerv- ous agency, which invests the central organ of the circulation with such important qualities, affords it an amount of vitality that apparently renders it to a certain extent independent of the cephalic and spinal nervous centres. It is well known to physiologists that the whole of the encephalic mass, with the exception of the medulla oblongata, can be gradually removed without directly destroying the action of the heart; yet, at the same time, it is so easily affected that its movements may be arrested by a sudden and intense psychological or physical impression originating in the brain, or transmitted from the seat of an external injury to that organ, to be thence conveyed to the heart by the pneumogastrics. In fact, so great is the inherent vitality of the heart, that it can be actually cut out from the body, and still continue to contract, and to retain for a time its irritability and impressionability to mechanical and galvanic stimuli. With an organ so constituted and with such numerous relations, it might be inferred that a severe shock would produce great disturbance in the performance of its normal functions, and that the anatomical arrangement through which the various nervous impres- sions are conveyed should be of a complex character. The heart is supplied with nervous influence through the cardiac nerves of the great sympathetic, the cardiac nerves of the pneumogastric, and from branches of the spinal accessory. The sympathetic cardiac nerves, three in number on each side, are derived from the three cervical ganglia, and form, with the cardiac nerves of the pneumogastric, the deep cardiac plexus. The superficial cardiac plexus, which lies beneath the arch of the aorta, is formed by the left superior cardiac nerve, the left inferior cardiac branch from the pneumogastric nerve, and filaments from the deep cardiac plexus. From the cardiac plexuses emanate the anterior and posterior coronary plexuses, the branches of which are distributed, as then names imply, to the surface and substance of the heart with the branches of the anterior and posterior coronary arteries. In 113 addition to the coronary plexuses, recent dissections have demonstrated that besides the ganglion of Wrisberg, in the superficial cardiac plexus, there exists a dense net-work of nerves, upon which are found numerous ganglia, the branches of wiiich are distributed to the surface and muscular substance of the heart. These organic nerves are derived from the six cervical sym- pathetic ganglia, and from the superior thoracic ganglion on each side, thus making in all eight masses of gray nervous matter, wThich, if united into one ganglion, would form an aggregate of cineritious material as large as the entire nervous system of some of the articulata, or even of some of the infe- rior vertebrata. In some of the animals placed low in the zoological scale almost the entire nervous apparatus upon which vitality depends is composed of the organic or sympathetic class of nerves. It can thus be understood that the heart may play the part of a separate existence, and although connected with the cerebro-spinal system, may, notwithstanding, perform functions inherent to itself, and entirely independent of the nervous supply that it receives from the division of the nervous system to which the functions of animal life more particularly belong. But these organic functions, vastly important in them- selves, like the centrifugal force in mechanics, to be of use, must be governed and regulated in order to bring about their harmonious action. Admitting that the grand sympathetic supplies the organic sentiency which renders the heart susceptible to the stimulus of the blood, and by which its con- tractions are produced, other agencies are needed through which different manifestations, such as continuous regularity of action and of force, take place, both of which are sustained in the normal condition of the organ. The pneumogastric nerve comes in here to supply the want. This nerve is exclusively sensory at its origin, but, emerging from the cranial cavity, it receives motor filaments from several nerves which become joined with the trunk, and is converted into a mixed nerve. By the addition of motor influence derived more particularly from the communicating branch of the spinal accessory, the heart becomes endowed with muscular tonicity, and, through reflex action, with the co-ordinate influence that presides over the regularity of its movements. The heart, which under the influence of the 16 1M sympathetic alone would act without order, assumes rhythmical regularity and force under the agency of the pneumogastric. Division of the pneu- mogastric nerves in the neck is not followed by stoppage or arrest of the action of the heart, as might be anticipated, but by acceleration of the number of pulsations and diminution of force. After the section, powerful galvanization of the extremity of the nerve in connection with the heart paralyzes the motor filaments of the trunk, and arrests the action of the heart, which remains in diastole and flaccid while the current is kept up. From these experimental facts, the solution may be obtained of certain manifestations of irregular, rapid, and tumultuous cardiac action taking place apparently from nervous exhaustion and perturbation of the pneu- mogastrics at their origin and along their course, whether resulting from disease or from external lesion. This symptomatic condition of the heart is often met with after severe traumatic injuries, or during the initial stages of organic disease of important organs, such as the heart, liver, or kidneys, and indicates the existence or commencement of a general deterioration of the vitality of the system.* * This erratic condition of the heart, caused by exhaustion and disturbance of the nervous supply, and associated with the phenomena alluded to, has not received the attention its importance would indicate, and the rationale of the symptoms has not been intelligibly given. It has been best described by Bouillaud in his Traite Cliniquc des Maladies du Cceur, is often met with in surgical practice, and is probably of similar origin to the peculiar state of the system, and of the heart and circulation, defined by the late Mr. Travers, in his work on Constitutional Irritation as "prostration with excitement," occurring as a sequence of external injuries followed by collapse. Bouillaud describes as follows the action of the heart alluded to: " H est des cas oil les battements du cceur se succedent a des intervalles de duree ine"gale, et tantot ces battements se font tous avec la meme impulsion, tantdt au contraire avec une impulsion inegale. Cette irregularity, cette veritable ataxie, cette sorte defolie des battements du cceur Bi j'ose me servir de cette expression, coincide ordinairement avec des intermittences plus ou moins frequentes: rien n'est ventablernent comparable au d6sordre tumultueux, a l'6trauge confusion qui regne alors dans les battements du cceur. Cet organe nous offre, dans ce cas, l'image d'une machine completement derang6e et tout h fait d6- mont6e; toutes les lois qui regissent ses mouvements, si bien regie's, comme nous l'avons vu, a l'6tat normal sont bouleversces; et si jo ne craiguais d'abuser ici du style figure^ je dirais qu' k l'ordre e"tabli par les lois de la nature olle-meme, a succe"d<5 le plus complet 6tat d'anarchie. J'ajouterai que l'espece de trouble que nous signalons est jusqu'aun certain point, pour les fonctions du cceur, ce qu'est pour les fonctions du cerveau le deTire l'alienation mentale; et de la l'expression me'taphorique Aefolie dont je me suis servi plus haut. "Les irregularities du cceur que nous venons de mentionner, et dont on ne peut se faire une juste et complete idee qu'en les observant soi-meme, se partagent en deux especes distinctes: dans la premiere espece, le d^sordre est tel, que non seulement le rhythme normal du cceur est derange', mais que chacun des battements entiers et complets de cet organe different de ceux qui le suivent comme de ceux qui l'ont pre'ce'de'. Dans la seconde espece au contraire 115 The central organ of circulation is supplied so profusely with organic and involuntary motor power derived from the grand sympathetic, that it possesses in an unusual degree the characteristics of individual and inherent vitality, somewhat analogous to that of those animals that have the rudiments only of a cerebro-spinal system, and depend for their existence mainly upon the agency of the organic nerve centres. It is principally through the in- fluence of this class of nerves that the automatic movements of the heart take place under the stimulus of the blood. But the movements of diastole and systole require to be regulated, and the pneumogastrics execute the mission of restraining these movements, so as to place them under the rule of rhyth- mical order. Besides, a nerve has lately been described by Cyon and Lud- wig, which is formed by a branch from the superior laryngeal nerve and by one from the trunk of the pneumogastric, which passes downward along the neck, and joining in the chest with filaments from the sympathetic, reaches the heart between the pulmonary artery and the aorta, and is dis- tributed to its muscular tissue. Experiments made upon this nerve seem to prove that it possesses, under excitation, through its reflex action, a decided depressing influence upon the action of the heart, and from this it has been called the depressor nerve of the circulation. It will thus be seen that the central organ of the circulation is freely supplied with organic sensory and motor branches from the sympathetic, the pneumogastric, and the communicating branches of the spinal accessory, and that the numerous nervous filaments which are distributed to the heart are of a mixed character, and place the organ in communication and correlation with the cerebro- spinal axis, as well as with the nerve centres of the ganglionic system. It les irregularites se succedent re"gulierement, si l'on peut ainsi parler, c'est a dire qu' a chaque battement complet du cceur en succede un autre qui lui ressemble: en sorte qu' il reste encore ici quelque trace de cette tendance a la supreme loi de l'ordre, qui eclate de toutes parts dans le gouvernement de l'economie vivante. Disons enfin que les deux especes d'irre'gularite's peuvent quelquefois se succe'der chez un seul et meme individu, a des intervalles de tenvps plus ou moins eloigner"......... ........."Si l'on nous demande maintenant quelles sont les conditions morbides sous l'influence desquelles apparaissent les differentes aberrations du rhythme des battements du cceur, nous re"pondrons, sans entrer dans des details qui seraient deplaces ici, que tant6t elles sont purement dynamiques, nerveuses, vitales, et que tant6t, au con- traire, elles coincident avec de graves lesions organiques, soit aigues, soit chroniques."—Traite' Clinique des Maladies du Cceur, par J. Bouillaud, Professeur de Clinique Medicate d la Faculti de Medicine de Paris, etc. 116 would be the work of elaborate physiological investigation to designate and separate the properties and exact functions of each distinct kind of nerve in the various pathological and healthy actions of the heart. Investigations and experiments on this portion of the nervous system sufficiently prove that the heart, for its movements, its muscular tonicity, its force, its timbre, and rhythm, is greatly dependent upon the diversified sources of its nervous supply, and that when the pre-established harmony and balance of nervous power between the several classes of its nerves become interrupted or destroyed, perturbation and tumult in the performance of its functions will necessarily take place. The inherent independence of the heart, however, in the performance of its movements, is certainly remarkable. Experiments made upon cold-blooded animals, where the irritability of the tissues remains for a considerable time after death, prove that it will pulsate after the cavi- ties are emptied of blood, and also, that in a vacuum, wmen removed from the stimulus of the air, or when exsected from the body, and thus cut off from all connection with the general nervous system, it will continue to contract. Upon the application of a stimulus, such as the point of a needle, contractions will still take place after the animal has been poisoned by woorara, which is known to paralyze the motor set of nerves, and even por- tions of the heart, when detached, will remain impressionable and give signs of irritability. Mr. Erichsen has shown that the heart loses its irrita- bility after the greater portion of the blood sent to its muscular fibres is cut off, by ligature of the coronary arteries. It would appear from this, that there may be some connection between the movements of the heart and the per- formance of the function of nutrition continually at work in its intimate structure. The exigency for the supply of oxygen existing in the tissues, and the organic changes that take place during assimilation, with appro- priation of oxygen, and disassimilation, with elimination of carbonic acid, may create, by reflex action, a necessity for movement, a " besoin d'agir," analogous to the " besoin de respirer" which takes possession of the muscu- lar apparatus of respiration through the same nervous agency. If the systole and diastole of the heart be considered to depend, in part, on the oxygen demanded for its nutrition, and, in part, on the presence of the circulating 117 fluid in its cavities, these influences must still be regarded as originally ema- nating from the agency of the diversified nervous ganglia and branches by which its substance is supplied, and the reflex action resulting from the con- nection of these with the medulla spinalis and medulla oblongata. An organ so highly endowed as the heart must be profoundly impressed and pertur- bated by the shock of a severe injury, and its action will be changed and modified by the intensity of the injury, the natme of the organ injured, and the seat or location of the lesion. The character of the changes that take place in the cardiac movements may range from the fluttering, feeble, and rapid action that one observes after sudden and trivial succussions to the general system, to the slow and labored impulsion following upon severe lesion to the brain from fracture of the cranium, with depression of bone and effusion of blood. It has been proposed to measure the action or beat- ings of the heart in disease by the use of the cardiometer, but such instru- ments, ingenious as they appear to be, in practical surgery are more curious than applicable in calculating the symptoms that occur after external injuries. The frequency, regularity, and force of the action of the heart afford, to a certain extent, correct information concerning the general condition of the system, making allowance for correlative circumstances, such as age, sex, climate, peculiarities, muscular activity, etc., and in disease the indications of treatment are often deduced from the character of the impressions impart- ed to the touch and to the ear. The Pulse.—The arteries possess the property of elasticity, and at each ventricular systole respond by an almost synchronous expansion.* Being sometimes superficial, readily recognized, and easy of access, they are select- ed for convenience to study the nature of the pulse, in preference to the more tedious and inconvenient exploration of the heart. The blood-vessels, like the heart, are supplied by their proper nerves, derived principally from the sympathetic, the filaments of which are distributed to the arteries as far as their ultimate ramifications. A set of nerves forming a net-work of fila- ments among the muscular coats of the arteries, and having the functions or * The progressive retardation of the pulse as we recede from the heart, calculating the difference between the ventricular systole and the pulsation of the artery in the foot, has been estimated at one-seventh of a second. 118 capability of regulating their calibre and the quantity of blood sent to the several tissues, were first noticed by M. Brown-Sequard, who named them vaso-motor nerves, on account of their peculiar characteristics. These nerves regulate the local circulations, also the circulation in the secretory glands, which require at times an additional supply of blood when under the influ- ence of their special stimuli; and it is probable that a similar nervous agency is exerted over the muscles, the brain, and other parts of the system which are liable to be brought suddenly into action. The phenomena of blushing, and the leaden pallor that spreads over the countenance from mental emotions, are mentioned as common examples occurring from this source of nervous action. The extensive anastomoses between the sympathetic nerve and the ordinary nerves of sensation and motion render it difficult to determine exactly the origin of the vaso-motor filaments; but the physiological experi- ments recorded up to the present time seem to prove that the vaso-motor nerves derive their source exclusively from the cerebro-spinal system. The arteries, from then elasticity and contractility, and from the abundant nervous distribution with which they are supplied, possess inherent qualities that are independent of the mechanical impulse imparted by the ventricular action of the heart, and by which the successive wraves of blood are injected into the arterial system. The effect on the heart and arteries of a severe shock will be understood when the physical conditions are considered upon which the character and quality of the pulse essentially depend. The proper amount of the nervous power of the heart, the normal condition of the mech- anism which that power directs, so as to propel the blood into the arteries, the quantity and quality of the blood in the circulatory system, the healthy character of the arterial tunics, and of their vaso-motor supply, are the necessary conditions for the natural pulse. When one or more of these conditions become abnormal, the several morbid varieties of the pulse that are observed in practice are met with. In severe lesions, as from a crushed limb where asthenic symptoms are present, the nervous power of the heart becomes diminished, the blood is not propelled into the vessels, and the pulse becomes small and feeble. So also in anaemia, where the loss of 119 blood has been exhaustive, the pulse diminishes at times so as to be scarce- ly perceptible at the wrist, on account of the absence of the necessary sup- ply of blood to the heart. In cases of apncea, the pulse will be frequent, feeble, and weak from the loss of nervous power, and from stagnation of blood in the capillaries of the lungs and in the right cavities of the heart. In pure coma, as happens in compression of the brain from fracture of the skull or from laceration of cerebral vessels, the pulse at first will be slow and full, but the nervous power of the heart soon becomes diminished, and its action ultimately becomes rapid and feeble. Where the action of the heart and pulse is rapid and bounding but easily compressible, and aft- erward becoming feeble, irregular, and accelerated, embracing, with other symptoms, the condition described by Mr. Travers as characteristic of " pros- tration with excitement," the nervous power of the heart is failing. There is a condition of the heart, already alluded to, characterized by a sudden com- motion of the organ, where the beatings are sensibly felt by the patient, and the pulse runs up to 160 in the minute, or even so rapidly as to be beyond counting, and continues at this rate from a few seconds to a minute or more, and then suddenly resumes its ordinary rhythm. This form of cardiac per- turbation, called " folie du cceur," sometimes met with in collapse, is indic- ative of nervous exhaustion of the nerves of the heart, more particularly of the pneumogastric, which presides over the rhythm and muscular tonicity of the heart. When, with other unfavorable symptoms, the pulse becomes continuously rapid, running up to 160 or upward, and at the same time is irregular and feeble, the nervous exhaustion is well-nigh completed, and there is probability of dissolution. Some years since the sphygmograph was introduced first by Vierordt, and afterward, in an improved form, by Maret, for the purpose of measuring the amount of dilatation and movements of the arteries, and for indicating more exactly the character and quality of the pulse in disease. But the pulse is subject to numerous anomalous variations, even in health, and can- not be altogether relied upon as the absolute criterion of the pathological condition of the system. A case came under my observation lately, where the pulse beat quite normally in an adult who had received a pistol-shot a 120 few hours before, the bullet lodging in the anterior lobe of the brain; and it is well known that in some instances of insidious shock, and in the earlier stages of purulent infection, the pulse will sometimes beat without abnormal variation. Some of the older physicians, among them Heberden, considered the pulse by no means an adequate guide in forming a correct judgment of disease, and that, if exclusively relied on, it would sometimes lead to erro- neous conclusions. The instrument of Maret, ingenious as it is, and useful in experimental physiology, cannot be turned to much practical account in determining the nature and import of the pulse in complicated affections, where, as yet, more reliance must be placed upon observation of the correla- tive facts, and the knowledge which is acquired by experience through the medium of the touch. The pulse, however, notwithstanding its shifting and anomalous phases, and the various conditions of the vital powers and of the idiosyncrasies by which the circulation may be modified, must be regarded as of great importance in clinical practice. Ranging, in the suc- cessive stages of life, from the new-born infant with the pulse of 130 or 110 beats in the minute, to the adult male with 70 or 75, it has been characterized, in its relation to time, as frequent or rare, quick or slow; in the relation of force, as strong or weak, hard or soft, full, small, or wiry, free or compressed; in the third relation of equality, as the irregular pulse, with respect both to time and force, with the varieties of each, as the intermitting, the rebounding, the fluctuating, or wavering pulse. The compressible and incompressible pulse may be added, and with those just designated may be regarded as the most distinct and unequivocal prognostic and diagnostic signs that are afforded through the instrumentality of the pulse. Depressed Temperature of Surface.—One of the most prominent symp- toms of collapse is a depressed condition of the temperature of the body; in fact, a cold, clammy surface is one of its characteristic features. The expla- nation of this manifestation is best reached by considering the nature and sources of the normal supply of animal heat to the system. The term calor- ification was used by Bichat to express the evolution of caloric that takes place in the animal economy during life, and was described by him as a function subordinate to the fulfillment of the performance of all the other 121 functions. The vagueness here is in the nomenclature, in making use of the word function, instead of distinctly defining the liberation of heat as a result, and not as a special act in the economy, such as digestion or respiration. Oxygen is dissolved as oxygen in arterial blood, and disappears in part or entirely in the capillary circulation. Carbonic acid is taken up by the venous circulation, and is held in solution, or in feeble combination with the alkalies, as carbonates and bicarbonates, to be expelled from the lungs in expiration, when freed by the action of pneumic acid. It is also ascer- tained that the tissues themselves have the property of appropriating oxy- gen, and of eliminating carbonic acid along with the other products of their physiological decay. Admitting these facts, the theory of Bichat, referring the development of animal heat to the general result of all acts of assimilating composition and of disassimilating decomposition which take place in the entire organism, is preferable to the more limited doctrine of Lavoisier, that ascribed the evo- lution of animal caloric solely to chemical action taking place in the pul- monic system. The theory of latent heat, originating with Black of Edin- burgh, may enter into the explanation of the evolution of animal heat. During the process of nutrition, while the operations of assimilation and of disassimilation are going on, the equilibrium of the atoms in the alimentary compound present in the blood becomes disturbed and changed, and the elements arrange themselves into new forms, one set of atoms becoming utilized for repair of the tissues, while another is eliminated from the system in the form of excrementitious material. It is quite probable that while this molecular interchange or metamorphosis is taking place, heat is neces- sarily produced and liberated, as occurs in some kinds of fermentation, and also in the transformation of certain oxides, as the white oxide of calcium, which has a great affinity for carbonic acid and for water, with wrhich it rap- idly combines to form a hydrate, while at the same time there is a great evolution of caloric. Among the many hypotheses given out at different times, the theories of Lavoisier and of Bichat alone merit consideration at the present day, but they still leave certain details unexplained. As the nervous system maintains over nutrition a certain power, so in the pro- 17 122 duction of caloric the sympathetic and cerebro-spinal systems exercise a regulating influence. Section of the sympathetic on the side of the neck is followed by increased vascularity and heat in the region where the branches are distributed, and from this it might be inferred that injury to this portion of the nervous apparatus could not have any effect in the gen- eration of animal heat; but the vaso-motors of the nervous system, ules dilatateurs ccrebro-rachidicns et les constricteurs sympathiques" so called by Bernard, exercise an important influence. Besides, in shock produced by grave lesions followed by collapse, the nervous battery, composed of the ganglia of the great nervous centres, is greatly perturbed; nutrition is generally interfered with, and the production of animal heat, its invariable coincident, is diminished or altogether arrested. On account of the ina- bility of the heart, from loss of nervous power, to propel the blood through the system, the circulation in the smaller arteries and capillaries also be- comes feeble, or is altogether suspended, and this part of the process of calorification is impeded, or ceases to be performed. From these several causes the temperature of the surface necessarily becomes lowered, and assumes in some instances the coldness of death. In cases of shock the ruddy appearance of the healthy countenance is changed almost imme- diately into a dull, leaden pallor, and the vermilion lips assume a pale, livid hue. Some of the causes that operate in producing the change of tempera- ture of the surface, are also the sources of the altered appearance of the face. A deadly pallor of the countenance is often produced by the action of the vaso-motor nerves in vivid mental emotion, resulting from the con- tracted state of the calibre of the arterioles and capillaries that ensues, while the amount of blood distributed to the surface is lessened by the en- feebled action of the heart, and leucocytes take the place of the red glob- ules of the blood in the diminished amount of circulating fluid that reaches the vessels. The cold, clammy moisture that is generally present in shock followed by collapse cannot be called a secretion, but is, no doubt, a transu- dation or exosmose of some of the liquid and saline constituents of the blood, which escape through the cutaneous tissues from the relaxed capillaries, and become cold, in keeping with the low temperature of the surface. 123 Disturbed Respiration.—In cases of shock, respiration, like the circula- tion, is disturbed from similar causes, that is, from the failure of the nervous supply emanating from the nervous centres to be transmitted along the proper nerves to the pulmonic apparatus. The pneumogastric and sym- pathetic nerves play an important part here as in the action of the heart. The act of respiration, like that of the circulation, partakes, in a great degree, of a mechanical character, the latter simulating a hydraulic, while the former is of the nature of a pneumatic, machine. In both instances, however, the organs themselves are animated from nearly the same sources. The pneu- mogastric and sympathetic nerves supply the organic and vivifying influ- ence to the lungs, and also, in connection with the alteration that takes place in the blood, preside over the chemical interchange of the gases, while the general sensory nerves transmit to the medulla oblongata the " respiratory sense," the besoin de respirer, or the sensory impression of want on the part of the system which induces, by reflex action, the respiratory movements. As artificial respiration becomes an important element in the treatment of severe collapse, its mechanism may here be alluded to. The muscles of the rima glottidis, which opens and closes for the entrance and transmission of air to and from the lungs, are animated by the inferior laryngeal branches of the pneumogastric nerves; but another set of nerves, which take their origin from the medulla spinalis, supply the numerous muscles which effect expansion and contraction of the walls of the thorax during inspiration and expiration. Of these the phrenic, or internal respiratory, the branches of which are mainly distributed to the diaphragm, and the posterior thoracic, or external respiratory of Charles Bell, which arises from the fifth and sixth cervical close to the spine, and supplies the serratus magnus, are the most important. The other muscles connected with the mechanism of respiration are, in general, animated by nerves from the medulla spinalis. It may be generally stated that inspiration is effected by descent of the diaphragm and elevation of the ribs, while expiration is produced by the rising of the diaphragm and descent of the ribs. The external intercostal muscles, eleven in number, take their origin from the lower border of each rib, and are attached to the upper border of 124 the rib below; the fibres of each have an oblique direction from above down- ward and forward. The internal intercostals are attached to the inner bor- ders of the libs, and take a direction from above downward and backward, nearly at right angles to the fibres of the external intercostals. Several other muscles are attached to the thorax and spine, thorax and head, to the scapula, and upper part of the humerus. These, when in action, are capable of eleva- ting the entire chest or the ribs; and when their insertions at the thorax become movable points, they will act as muscles of inspiration. Some of these muscles, such as the diaphragm, the scalenus anticus, scalenus medius, scalenus posticus, the external intercostals, the sternal portion of the internal intercostals, and the levatores costarum, are called into action during ordinary inspiration. Some, such as the serratus posticus superior and sterno mas- toid, act when respiration is labored, and are called ordinary auxiliaries; while other muscles, which generally have a different function, but wmich are brought into action wiien respiration is exceedingly difficult, such as the levator anguli scapuhvj, the superior portion of the trapezius, the pectoralis minor, a portion of the pectoralis major, and the serratus magnus, are called extraordinary auxiliaries. The general elasticity of the pulmonary tissues and of the cartilaginous and osseous walls of the thorax, especially in the young, renders the act of expiration more passive in its character than that of inspiration. When the muscles of inspiration, or those which increase the capacity of the chest, cease their action, the natural resiliency of the costal cartilages and the tonicity of the muscles which have been put in action will reduce the chest to its passive dimensions. Certain muscles, too, draw the ribs downward which in ordinary respiration do not elevate the ribs; and many chest move- ments, such as are made by the tenor or the public orator in singing or speaking, require prolonged and complicated efforts of expiration, wmich also bring numerous muscles into play. The muscles of ordinary expirations, or those muscles which diminish the transverse and antero-posterior diameters of the thorax by depressing the ribs and sternum, are the internal intercos- tals at their osseous attachments, the infracostals, and the triangularis sterni. These muscles receive their nerves from the thoracic spinal nerves. The 125 auxiliary expiratory muscles that diminish the vertical diameter by crowd- ing up the abdominal viscera, so as to press upward the diaphragm, are the obliquus externus, the obliquus internus, the transversalis, and the sacro- lumbalis. Other muscles are sometimes brought into action by forced ex- piration, as the serratus posticus inferior, the inferior fibres of the serratus magnus, and the inferior portion of the trapezius. These may be called auxiliary muscles, and, like the muscles of ordinary expiration, are animated by the mixed spinal nerves from the dorsal and abdominal sections of the medulla spinalis and sympathetic. In injuries where the function of respiration is primarily attacked, or in lesion of the medulla spinalis from fracture or dislocation of the spinal column above the origin of the phrenic nerve, we have examples of extinc- tion of life from apncea, or, according to Bichat, of death beginning at the lungs. From this brief risumi given of the mechanism of respiration, we find that the nerves which animate the different portions of the pulmonic apparatus are derived from the pneumogastric, the cervical, dorsal, and lumbar spinal nerves, and from the sympathetic, after sending its communi- cating branches to the other nerves. The respiratory apparatus, from the importance of its functions, is easily disturbed when deprived of the vivify- ing and balancing influence maintained by the nervous force transmitted along these nerves in the normal condition of the great nervous centres, and in cases of severe injury speedily manifests symptoms of perturbation, according to the locality, and in proportion to the extent or impression of the lesion. Respiration, since the experiments of Yolkmann made known in 1841, is really not supposed to depend on the lungs for its seat, but the sensation of want of air is regarded as being dependent on the deficiency of oxygen in the tissues, and on the impression thus produced and conveyed by the nerves of general sensibility to the medulla oblongata, to be thence reflected upon the pulmonic apparatus through the medium of its proper nerves. Allowing this supposition to be correct—that the respiratory sense lies in the general system, and not in the lungs alone—and granting that respiration is the process by which all the tissues and organs receive and appropriate oxygen 126 from the blood, yet the respiratory apparatus, that is, the thoracic walls, the muscles of respiration, the lungs, and the nerves by which these structures are vivified, must be reckoned as the principal mechanism by which the in- troduction of oxygen into the blood and the exhalation of carbonic acid are mainly effected. The process of respiration may be interfered with by direct injury to the brain, or to the medulla spinalis above the origin of the phrenic nerve, and severe and sudden lesion of the medulla oblongata is followed by immediate death. More frequently the effect of a severe injury, as the crushing of a limb by the passage of the wheel of a railroad car, is trans- mitted to the nervous centres, and thence radiated upon the nerves of the pneumatic apparatus. In this case the thoracic wall and lungs cease to play, the supply of oxygen is cut off from the blood, carbonic acid is not elim- inated, the contents of the systemic capillaries become stagnant, the various tissues and organs do not receive or appropriate oxygen, and the patient is destroyed by apncea. In such cases the mouth is open, and there is a gasp- ing for air, as a fish, when landed on the beach, moves and expands the gills in a dumb effort to obtain the oxygen of its native element. The average number of respirations in the adult may be estimated at from sixteen to twenty in the minute, but these are subjected, like the impul- sions of the circulation, to the physiological influences of age, sex, posture, sleep, muscular effort, etc. As in relation to the pulsations of the heart, age has a marked influence on the respiratory act, ranging, during the succes- sive periods of life, from 44 respirations per minute in the infant, soon after birth, to the average standard of 18 respiratory acts in the adult aged from thirty to sixty years. Approximately it may be considered that at the age of five years the number of respirations per minute is 26; from fifteen to twenty, 20; from twenty to twenty-five, 19; at thirty, 16; and from thirty to sixty, 18. The ratio of the respiratory movements to those of the heart in health has been computed to be in the proportion of four pulsations of the heart to one of respiration. This is, in the majority of instances, constant in health, and also in disease, where the pulse is accelerated, except where the pul- monary tissue is affected or altered in structure. In some cases of external 127 injury, however, and often in approaching dissolution, this relative action of the circulation and of respiration does not hold good, the pulse beating very rapidly, wiiile the respiratory acts are slow. These figures may serve as approximative data in relation to the abnormal respiratory movements as observed in cases of shock and collapse. Restlessness, Jactitation.—Restlessness and jactitation, often met with as symptoms in collapse following shock, are referable to the same cause, viz., a change in the character of the blood, producing a morbid impression upon a portion or upon the whole of the nervous centres, which is reflected back along the efferent nerves upon the locomotor organs. In restlessness following shock there is a morbid and, to a certain extent, an uncontrollable feeling or necessity to change from place to place, and in jactitation the body is tossed about from one position to another, even when there remains no longer any consciousness. It has already been related that the sensation of want of air—the " besoin de respirer"—felt on the part of the system, wThich induces the respiratory movement, is believed to be dependent on a defi- ciency of oxygen in the tissues, producing an impression which is conveyed to the medulla oblongata by the nerves of general sensibility. This expla- nation, which, in some cases, may be applicable to the occurrence of rest- lessness, jactitation, and muscular commotion, will probably supersede the theories of Marshall Hall, of Reid, and of the elder Berard, and to it can be referred, with much reason, the rationale of many phenomena apparently automatic which follow upon injuries. In profuse hemorrhages, besides the change in its composition, the cir- culating mass becomes deficient in quantity, and the diminished supply of oxygen thus resulting to the system affording new abnormal impressions, may thus promote morbid reflex manifestations upon the muscular system. Moreover, restlessness and jactitation may also result from direct irritation of certain portions of the brain, as of the tubercula quadragemina, received during severe injury, as in concussion, and thence reflected upon the general locomotor apparatus. Convulsions.—Convulsions are a still more intense manifestation of mus- cular commotion occurring frequently after shock. They are ushered in by 128 sudden and violent contraction of the muscles, sufficiently powerful to pro- duce contortions of the face, and an irregular movement of the body and extremities, with tremors of greater or less violence, in many instances fre- quently repeated, with intervals of calm and relaxation. The muscles are the organs apparently affected, but the convulsive act is one of abnormal innervation, showing itself by signs of morbid reflex action. Convulsions often occur without any inflammation or appreciable organic change in the solid tissues, but are dependent on irregularity of the circulation, the condi- tion of the blood, or the accumulation of cerebral serosity. In uraemia, in albuminuria from pregnancy, in Bright's disease, and in conditions of the system associated with apncea, the blood is known to be vitiated by excre- mentitious materials which have not been eliminated from the system, and to be from this cause the source of convulsions. The morbid impression on the nervous centres, originating from contaminated blood, and kept up for a considerable time upon portions of the encephalon, may-produce a condition of local irritation upon the cerebral structure which may remain, and prolong the symptoms after the subsidence of the original cause. The experiments of Flourens, of Longet, and of Brown-Sequard prove that lesion inflicted deeply upon the tubercula quadragemina produces convulsive movements from direct irritation of the cerebral structure, examples of which are met with in concussion of the brain, in the irritation produced by depression of bone from fracture of the cranium, and in the effusion of blood into the sub- stance or on the surface of the brain, the disturbance being transmitted in such accidents to certain parts of the encephalon. Thus we see that after shock following severe injuries or hemorrhages, the convulsive act may be produced by the diminished quantity or the alter- ed condition of the blood abnormally impressing the nervous centres, or the irritation may be from the seat of local injury within the cranium to portions of the brain, to the medulla oblongata or medulla spinalis, and thence reflect- ed upon the muscular system, or, again, the focus of convulsion may be toward the general periphery, as in the crushed limb, and the morbid im- pression be carried up from the seat of injury to the medulla spinalis and then reflected upon the muscular apparatus. 129 Arrest of the Secretions.—The secretory organs and glands, such as the liver, the kidneys, the follicles of the skin, and mucous membrane, are presided over by the nervous apparatus, and cease to exercise their func- tions in severe cases of collapse. The excessive thirst present, when sensi- bility remains, can be accounted for by the interrupted secretion of the membrane of the mouth and fauces, and possibly by the sensation of a want of fluid, arising from a deficient supply of oxygen in the blood, causing an automatic craving for drink through reflex action. As already stated, the transudation of moisture, producing what is called the cold, clammy sweat of collapse, may be considered as a kind of exosmose resulting from the gen- eral relaxation consequent upon faulty innervation, and not as a secretion. Condition of the Pupil.—The iris, with its pupil, is placed before the retina as a sentinel of protection to guard it against injury, and to modify the admission and the intensity of the rays of light before they impinge upon it. The nervous mechanism by which the actions of the pupil are carried on is very complicated, and in health its susceptibility to impressions from without and within the cranium is extremely delicate. In disease it may be morbidly sensitive, or its movements may be abnormally sluggish and tardy, or it may be absolutely immovable, remaining so either in a state of contraction or of dilatation. In collapse, the pupils are contracted and immovable in many cases where concussion simply has taken place. They are, at times, dilated, and not susceptible to the influence of light, as in injuries of the head where concussion is accompanied by compression of the brain. It may be inferred from this that in external injuries dilatation of the pupil accompanied by immobility is indicative of a lesion more profound than when the iris is in a state of contraction, or, in other words, that the impression of injury on the system has been radiated more extensively and penetrated more deeply. In the administration of anaesthetics, it is found that the organic nerves are the last to be affected, the cerebro-spinal system being the first to respond to their influence. The nervous distribution to the iris is quite complex, and it is only by the consideration of the anatomical mechanism that the various conditions which it assumes in accident and disease can be 18 130 explained. The lenticular ganglion is composed of a small centre of gray matter situated between the inferior oblique muscle of the eye and the optic nerve, and receives its sympathetic influence from the superior cervical ganglion by way of the cavernous plexus, which, after giving off small branches to the mucous membrane of the sphenoidal sinus, to the dura mater of the basilar process, to the pituitary body, to the third, fourth, and sixth pair of cranial nerves, and to the ganglion of Gasser, sends a branch, relatively of considerable size, to the ophthalmic ganglion. Thus formed, it receives a branch from the motor oculi, or third pair, which supplies its motor root, while the nasal branch of the fifth pair, carrying with it also the sympathetic connection, supplies the sensitive root, in this respect resembling the ganglions on the spinal nerves. From the anterior part of the ganglion thus formed, the ciliary nerves take their origin, and after trav- ersing the sclerotic, pass between that membrane and the choroid to reach the iris, where they are distributed. The experiments of Budge and Waller go to prove that the filaments of the sympathetic wmich preside over dila- tation of the pupil make their connection with the spinal cord between the sixth cervical and the second thoracic nerves, and it is at this point that the inferior cilio-spinal centre is said to be situated. There is also described a superior cilio-spinal centre, possessing the same influence over the dila- tation of the pupil, in communication with the superior cervical ganglion, and located higher up in the cord, near the origin of the sublingual nerve. The tubercula quadragemina and optic thalami are also, no doubt, nervous centres through which the movements of the iris act, and contribute to the protection of the retina and the enlargement and perfection of the field of vision. Two distinct nerve centres seem to be in correlation with the two sets of nerves which regulate or preside over the movements of the iris. One of these centres, the tubercula quadragemina and optic thalami, through the optic nerve and the third pair, presides over the reflex contractions of the iris: and the other centre, localized in the spinal cord, influences dilatation of the pupil through the branches of the grand sympathetic. From these data we perceive that this delicate structure is in communion with all the 131 organs and tissues of the body that are supplied by nerves, and that, although the analysis is complicated, we can thus account for its activity and rapid sympathy with physiological or pathological impressions, and, while sensibility remains, for the dilatation or contraction of the pupil in accordance with the greater or less intensity of the impressions made upon the cilio-spinal or cilio-cerebral nervous centres. Permanent pressure upon the retina may occur from an engorged or congested condition of the choroid; or it may be amaurotic, and then the pupil is dilated from disease within the globe of the eye itself; but when the pupil is dilated following upon a severe injury of the head, and the globe of the eye is healthy, there is reason to believe that there is lesion of or pressure upon the optic nerve and the tractus opticus, or upon the cilio-ganglionic masses in which they terminate or with which they are connected. In very severe concussion wmich may be recovered from, the pupils may be dilated, but in such cases the molecular arrangement of the ganglionic centres is rudely shaken and jarred. As a general rule, however, the abnormal pupil indicates serious injury, or compression of the optic nerve and the ciliary nervous centres. Contraction of the pupil, often met with in medical diseases, is frequently present in concussion when the brain is not fatally injured, and indicates a pathological condition of the cerebral structure, but not generally the total obliteration of its function. Cases of severe injury to the brain are sometimes met with where there is contraction of one pupil and dilatation of the other, and here we should expect to find the pupil dilated on the side opposite to that on which there existed the most serious injury to the brain. Varieties of Shock and Collapse.—The organs and tissues of the body are constructed and supplied so differently with nervous influence that the impressions made on the system from injuries of such severity as to produce shock must, as a physiological consequence, be accompanied by diversified phenomena. Besides the variety of locality, other circumstances are pre- sented which will often change the character of the symptoms in serious accidents. Thus, for example, a person may be wrounded by a pistol bullet passing through the temple and lodging in the anterior lobe of the brain. 132 He may be knocked down by the concussion, but will get up and walk for a distance of several rods to his home, and lie down upon a lounge, manifesting but few signs of so grave an injury, while another person having a limb crushed from the passage of a railroad car will be affected with symptoms of shock and collapse so severely as to threaten dissolution. From the vast net-work and numerous ramifications of the different divisions of the nerv- ous system, and from the decussations and commissures uniting the several lateral ganglionic masses of the cerebro-spinal system, as well as from the varied functions and unequal sensibilities of the component structures of the body, it might be expected that impressions resulting from external in- jury and followed by shock would not always be attended with symptoms of equal severity or by phenomena of a similar character. The effect of a shock may be limited or localized, or the force falling upon more organs than one, its intensity will be distributed in different directions, and the symp- toms consequently modified. If the influence of the shock has been directly imparted to the encephalon, as takes place in concussion of the brain, cere- bral perturbation will be first developed, while in severe lesions of the extremities the organs of circulation and respiration, and the splanchnic organs, will manifest signs of derangement as the primary effects. The amount of concussion, or the intensity of the force applied, as well as the situation and nature of the organs affected or implicated, must be taken into account in estimating the possible effects in particular cases of shock. Where the impinging force has been comparatively slight, the more trivial symptoms will be present, as coldness of the surface with clammy sweat, paleness, and a sense of depression, accompanied by increased frequency of respiration, a rapid pulse, tremors, and anxiety. Where the shock has been more severe, the signs of collapse are more marked; sensibility and the motor power are lessened; the intelligence wTavers and shows signs of incohercncy; the pulse is feeble, small, tremulous, and sometimes inter- mitting; the respiration becomes irregular and sighing; the countenance assumes a leaden and pallid hue; there are rigors, with a cold surface and clammy sweat, vomiting, and sometimes convulsions. A train of symptoms still more serious, indicating what may be called the third grade of collapse, 133 is recognized by symptoms of a very grave character. The manifestations met with in the second form just enumerated are more aggravated, and to them are added delirium, coma, insensibility, irregular respiration at long intervals and faintly perceptible, the pulse so feeble as scarcely to be felt at the wrist, involuntary discharges at times, with cold clammy moisture and deadly coldness of the surface. In the fourth form of shock the general vitality and functions of the body are overwhelmed, the patient is speedily plunged into entire insensibility, the intelligence is annihilated, the pulse and action of the heart become imperceptible, the respiration is gasping, occurring at long intervals, the surface cold and clammy, and, with half-closed glassy eyes and fallen jaw, the patient dies comatose or in convulsions. This succession of morbid phenomena is the typical or ordinary sequence of injuries followed by collapse. Other conditions are met with of a more anomalous character occurring after severe lesions, different in their progress and mode of termination, and if not understood, are apt to lead to erroneous prognosis and misdirected treatment. Latent Shock.—Two conditions of the system resulting from injuries are met with where the term latent shock may appropriately be applied. In one case, the impression made upon the vitality is much greater than is indi- cated by the amount of the external manifestations of lesion, the source of the gravity of the symptoms being occult and obscure, or altogether hidden. In the other, the effects of the injury are developed to a much less degree than the great extent of the lesion wrould lead the observer to anticipate, the nervous system being rendered too torpid and too prostrated to appreci- ate or take cognizance of the real gravity of the accident. In both instances the effect does not appear to be commensurate or in correlation with the cause. One variety of latent shock is characterized by the absence of any mark of external violence, as in cases of sudden death or severe collapse from sharp blows upon the epigastrium, from the concussion, comminution, or laceration among the deep tissues or internal organs produced by wind or spent ball, or from similar injuries inflicted by the general concussion and contusion that take place from destructive and fatal railroad accidents. Persons receiving such injuries, although pale, will have the circulation and 134 the respiration scarcely affected. They have the power of locomotion for a brief period, and will get up and walk. There will be no expression of pain, but the countenance will be wild and staring, as if panic-stricken. Sud- denly signs of great prostration are manifest, the powers of life become exhausted, and the patient sinks gradually into coma and death. In cases of this character there is no time for the development of inflammation or of marks of external injury, on account of the sudden annihilation of the vitality. The phenomena of such accidents are explained by the occurrence of internal lesion and disorganization from mechanical contact of some hard material, such as a cannon-ball, or from laceration of the deep tissues, as happens sometimes from severe concussion, or from abrupt devitalization of the blood, as in case of death by lightning. Numerous theories have been suggested in explanation of cases of sudden death taking place without external evidences of local or general injury. The following interpretation, given by Baron Larrey, is the most lucid and correct, and although referring mainly to what is called wind or spent ball, embraces the general principles applicable to this class of accidents: " A cannon-ball is propelled at first with a rectilinear movement; and if, during this part of its course, it strikes against any part of the human body, it carries it away; but the ball, after having traversed a certain dis- tance, undergoes some change of motion in consequence of the resistance of the atmosphere and the attraction of the earth, and turns on its own axis, in addition to the direct impulse received from the explosion of the powder. If it should strike any part of the body when the velocity with which the ball is passing is greatly diminished, it does not carry it away, as in the preceding case, but, in consequence of its curvilinear or rolling motion, it turns round the part in the same manner as a wheel passes over a limb, instead of forcing a passage through it. The soft elastic parts, such as the skin and cellular membrane, yield, while the bones, muscles, tendons, arteries, etc., offering a greater degree of resistance, are either bruised or ruptured! If the ball should strike one of the cavities of the body, the viscera suffer in like manner." A good example of latent shock that came lately under my observation 135 was that of a boy about fifteen years of age, who was sleeping on a mattress on the floor of a room where the plastering of the ceiling happened to be loose. A club of college boys had the apartment above, and were engaged one evening in rollicking games, dancing, jumping, etc., in the course of which a large portion of the ceiling fell, striking the boy on the abdomen wThile asleep. He was awakened by the blow, and was seized with great pain, coldness of the surface, quick feeble pulse, hurried respiration, and the usual concomitants of severe collapse. These symptoms, added to others of a still graver character, continued until death closed the scene, about five hours after the accident. Externally there was no sign or mark of injury, but the post-mortem revealed a lacerated rupture of the small intes- tine of considerable extent, through which a large lumbricus had crept, and was found in the cavity of the peritoneum. There was no sign of peritoneal inflammation. The case of William Poole, the pugilist, who received a gunshot wound in the heart, furnished an instance of the fallacious calm that takes place in severe injuries between the time of the receipt of the shock and its termina- tion in death. Poole received his wounds during a deliberate onslaught made on him by some five or six persons armed with Colt's revolvers. The first ball took effect on his right thigh, and brought him to the ground. While thus prostrate, another assailant placed the muzzle of a pistol close to his chest, and discharged its contents. He immediately jumped up, and reeling toward a door, rested, as if stunned, against it for support during some minutes. He then fell, exclaiming that he was dying, and remained senseless, cold, almost pulseless, and apparently moribund for about four hours. From this condition he rallied, and became so free from the usual symptoms of severe injury, that his medical adviser considered that the ball had really not penetrated into the thoracic cavity, and my opinion was sought to corroborate or dispel this favorable view of the case. I found him sitting up in bed, his back resting on pillows as a support, apparently at ease, and conversing with numerous acquaintances who had come to visit him. His countenance exhibited no expression of anxiety, and he answered placidly and without effort the questions I put to him. His 136 pulse was eighty, the respiration easy, the surface of the body normal in temperature and moist. The stethoscope revealed the existence of no diffi- culty in the respiratory passages, and the normal tick-tack of the heart beat with healthy precision. There were no signs of inflammation or of effusion into the pericardium. These favorable symptoms continued until the eighth day after the accident, when he received, against positive orders, the visits of more than a hundred people, with whom he conversed. His own state- ment was that he felt quite well. The next morning, about eight o'clock, he was in a high state of irritability; pulse one hundred and twenty; skin hot and dry; complained of pain generally; respiration troubled and more fre- quent. An aperient was ordered, by which the symptoms were much allevi- ated. On the tenth day the pulse was one hundred; countenance anxious; the adnata tinged yellow; complained of debility, but said he had no pain about the heart; signs of effusion. He passed a restless night, notwith- standing the administration of an anodyne; pulse one hundred and twenty; countenance more anxious; respiration much troubled; inability to remain in the recumbent posture; symptoms gradually becoming more grave. At two o'clock the next morning the patient was rapidly sinking; pulse almost imperceptible, and with difficulty counted; respiration short, frequent, and difficult; extremities cold; countenance pallid and hippocratic. From this time he continued to sink, and expired, without a struggle, at 5 a.m. This case will be recorded in full hereafter. The case of James Fisk, Jum, the Erie Railroad manager, presented also an instance wiiere the injury was exceedingly severe, and yet the dis- tressing symptoms following the shock soon subsided. Fisk wTas shot on the stairs of the Grand Central Hotel, about 4 p.m., with a revolver. The ball entered the abdomen on the left side, about five inches above the level of the umbilicus, and two inches to the right of the median line, passing obliquely downward and to the left through the abdominal wall, and trav- ersing the small and large intestines and mesentery, pierced the tissues be- low Poupart's ligament, and lodged in the groin on the opposite side, near the insertion of the psoas magnus. Upon receipt of the injury he fell, and was taken to a room in the hotel, the symptoms of collapse following imme- 137 diately upon the shock. He complained of great pain in the abdomen, the surface was cold, clammy, and moist, pulse rapid and feeble, respiration fre- quent, his features pinched, and he was more or less stupid in answering questions. These symptoms soon passed off, and I saw him at 11 p.m., seven hours after he had been shot. In the mean time he had been seen by the hotel physician, through wThom several others had been called in. A pas- sive reaction was being established, but morphine subcutaneously and inter- nally had been administered in large quantities. I found him with few signs of collapse. His countenance was somewhat pale, the pulse was seventy- two, the respiration rather slowT, intelligence dull but correct, and when ques- tioned he stated that he had very little pain. I had to return to the country immediately, and left suggesting caution in the farther administration of opium. The morphine, however, was continued in unusual quantities, and Fisk died apoplectic at 5 a.m., about thirteen hours after the receipt of the injury. Fisk's wound was severe, and might have proved mortal, yet there was no abdominal effusion of any kind except a small portion of blood to the extent of a silver half dollar in form of clot. There was no evidence of peritoneal or other inflammation, and the orifices made by the bullet were closed, and apparently would have become united. There is no doubt that his death was accelerated by the excess of morphine that was administered. The two following cases are examples of fatal injury where the effects of shock were latent, and entirely disproportionate to the gravity of the lesion: Case I.—Ferdinand Holland, a native of France, aet. 62, while driving on the road in the country was overturned with his top wagon, August 5, 1865, and received an injury of the head. Dr. Freeman, of West Farms, saw him within a quarter of an hour after the accident, and found him sitting on the curb-stone by the side of the road. He acted in a very obstinate man- ner, and would allow nothing to be done for him, and walked over half a mile to the house of a friend. He conversed intelligently for two hours, the pulse and temperature of the body remaining nearly natural, and in other respects he was free from the ordinary signs of collapse. In three hours he became insensible, and began to sink rapidly. A dispatch was now sent to New 19 138 York for me to meet Dr. Freeman in consultation, and I reached the case seven hours after the occurrence of the accident. He had received a fracture of the cranium, with depression of bone on the anterior part of the right tem- poral region, but as the symptoms of approaching dissolution were apparent, 1 advised against an operation. He died at half past three a.m., eight hours after the receipt of the injury. At the post-mortem examination there was found a fracture of the lateral portion of the frontal bone, a portion of which, nearly an inch in diameter, was driven into the substance of the anterior lobe of the brain to the depth of two inches. Case II.—On September 13, 1873, I was called in consultation, also by Dr. Freeman, of West Farms, to see E. Miller, aged 54 years, who had shot himself with a pistol about seven o'clock on the morning of the same day, The ball entered the right temple, making an aperture in the cranium through which some blood and cerebral substance oozed out. He had fallen from the effect of the shock, but immediately got up and walked, with the pistol in his hand, about half a mile, over two fences, to his home, and laid him self upon a lounge, telling his family that he had shot himself. He was intelligent, and answered all questions rationally for twelve hours after, with but trivial signs of injury. He was conscious twenty-four hours, but from this time he gradually became confused in mind, and sank by degrees into a state of coma, and died forty-eight hours after the infliction of the injury. The post-mortem showed that the ball had passed through the skull, and had traversed the cerebral structure in a lateral direction, slightly downward, and was found embedded in the anterior lobe of the right hemisphere of the brain, within an inch of the mesial line. I select these cases from others of similar character on account of the illusory calm that soon followed upon the shock, and as likely to lead from this to an erroneous prognosis. It does not follow, however, that a favorable condition, moral and physical, of a patient soon after the receipt of a severe injury is always the precursor of an untoward termination. Persons of a naturally strong physical constitution, of strong will, and possessing a char- acter full of courage, sometimes tolerate, without serious manifestations, severe local injuries, and pass safely through the different phases of restoration. 139 Another variety of latent shock, where there are extensive marks of external injury, and where the signs of collapse are trifling in comparison with the amount and extent of the lesion, is typically illustrated by the fol- lowing case: At the battle of Spottsylvania, during the recent civil war (May, 1864), I saw a soldier brought in on a stretcher to the surgical head-quarters, Ninth Army Corps (Burnside's), immediately after he was wounded. The mutilation from the explosion of a shell was frightful. Both lower extremities—one below the knee, the other through the lower part of the thigh—were shattered, hanging only by shreds of skin and muscular tissue. The right arm above the elbow was in a similar condition. This man possessed his intelligence perfectly, conversed about himself, and related that the first intimation he had of being injured came to him when, finding himself on the ground, he made efforts to raise himself with his right arm, and feeling his inability to do so, turned his head toward that side, and found it bloody and shattered. The signs of collapse wrere so little marked that amputation of the three limbs was gravely considered. Such cases generally sink gradually, termi- nating in low muttering delirium, coma, and death. The suddenness and intensity of the shock seem to put a stop to the farther elaboration of the nervous power by the central ganglia, and in proportion as the surcharge distributed among the nervous trunks and branches and other tissues becomes exhausted, the vitality is slowly annihilated. In the case of the soldier, the cause of death was asthenia, that is, death beginning at the heart, from nervous depression and want of power of the organ to propel its contents. In the case of Poole, the bullet was embedded in the muscular tissue of the ventricular septum, and extensive pericarditis was developed in the progress of the case, accompanied by much effusion into the cavity of the pericardium. He died from asthenia, or death begin- ning at the heart, the pericarditis and effusion complicating and aggravating the primary effects of the shock, which, from its intensity, may have also changed the character of, or to a certain degree devitalized, the blood. Fisk died from a combination of asthenia and coma, or from death beginning at the heart and at the head, but might have died from asthenia 140 alone, or death beginning at the heart, had he not been overwhelmed with the cumulative toxic influence of the narcotic drug too freely administered. The post-mortem revealed, among other pathological conditions, serous effu- sion on the surface and in the ventricles of the brain. The case of pistol-shot of the brain, and that of fracture of the cranium with depression of bone, are instances of coma, or of death beginning at the brain, the act of respiration gradually ceasing to be performed as the func- tions of the brain and medulla oblongata become destroyed. Complicated Shock.—There is another variety of shock, which may be called complicated, from the insidious merging or mingling of intercurrent sources of trouble with the original symptoms which strictly appertain to and are dependent upon the shock of the primary injury. For example, a soldier receives a traumatic lesion near the ankle from a fragment of ex- ploded shell. The solution of continuity is not larger than a silver dollar or the palm of the hand, but the tissues are contused, ecchymosed, and injured down to the bone, which also seems to have suffered. The shock is not severe, and soon passes off, succeeded by a passive and moderate reaction. The functions of the several organs are performed well, the skin is cool, may be slightly moist and flabby, the tongue is moist and clean, the circulation and respiration about normal, the intelligence not apparently affected, and the person may feel well enough to express a desire to attend to business affairs. The wound, however, is not of a healthy character, the process of exfoliating the killed tissues on some parts of the wound is inactive, gran- ulation does not progress, the wound looks glassy, pale, with a thin ichorous discharge coming from the surface, there is transudation of venous blood from the wound, and the edges show no signs of reparation. There is but little pain about the local injury, and, in fact, but little inconvenience is felt from it. Sometimes, however, from the second day to the third or fourth week, the scene changes. The patient becomes irritable and restless. He will have repeated chills, followed by a hot skin, and again succeeded by a viscous sweat. The expression changes, the adnata begins to present a yel- lowish hue. the skin assumes a dull icteric color, and is hot and dry. The respiration is more rapid, the pulse becomes frequent and quick, the tongue 141 dry and furred, and the physiognomy stupid, uncertain, anxious, and staring. We have here a series of symptoms indicative of blood-poisoning from the wround, added to the primary effects of the original injury. Such a condition is not unfrequently met with after important surgical operations, as well as from injuries received by accident, and when once fully developed is fre- quently followed by a fatal termination. The symptoms just cited corre- spond to those in the case of the late Captain E----, who was wounded at the first battle of Bull Run, July, 1861, and was brought on to New York for treatment. He was struck by a portion of an exploded shell on the out- side of the ankle, tearing off the gaiter and shoe, and producing an irregular contused solution of continuity nearly as large as the palm of the hand, and injuring the tissues severely as deep as the osseous structure. The os calcis was laid bare, and also contused. The general symptoms for a time were favorable, but the wound never had a healthy aspect. During the fourth week from the time he was injured venous bleeding took place from the wound, and a chill ushered in symptoms of purulent infection, from wrhich he rapidly sank, and died on the third day after the attack.* A partial post- mortem examination only was permitted: pus and coagulum were found in the veins leading from the wound. In this case the length of time between the traumatic injury and the fatal result was such as to leave no doubt as to the cause of death; but in some instances the untoward result takes place so soon after the accident that death has been attributed to the nervous in- fluence of shock alone. The following case is related by M'Clellan, of Phila- delphia, as an instance of what he calls "insidious shock," referring the symptoms to the nervous impression received at the time of the accident: " One of the most striking cases of this kind of shock I ever knew occurred, about twenty years ago, in the person of Mrs. S----, the very beautiful and delicate wife of a Portuguese merchant, then resident in this city. She had been upset in a buggy from a too rapid turning of the horse, and on attempting to leap out at the instant of the overset, she produced a bad compound dislocation of her right ankle inward, and a comminuted fracture * For particulars of Captain E----'s condition before I saw him, I am indebted to Professor W. Detmold, who had the case in charge from the beginning. 142 of the lower portion of the fibula. Her family physician was so struck with the condition of her system that he had me called into consultation on the third day. I found her perfectly free from pain and febrile action, with a soft and tranquil pulse, and natural respiration. Her tongue was clean but quivering, and the intestinal, urinary, and cutaneous secretions had gone on very well. But the wound had neither adhered nor inflamed. The parts had become slightly pulpy, and discharged a thin sanies, without any attend- ing inflammation or disagreeable odor. Her skin, however, presented an orange hue, and her countenance expressed great fright or alarm, although her mind was perfectly composed. The points which I have aimed at in the text were exactly marked in her face. She was composed and smiling about the lips, but suspicious and threatening about the eyes and forehead. Every time I came up to her bedside she would stare at me with corrugated brows and wrinkled forehead, with an expression of apprehension and aston- ishment or surprise. I of course gave an unfavorable prognosis; and although every attempt was made to sustain her by moderate stimuli and cordials, she rapidly declined into irretrievable exhaustion. The next day (the fourth) I found her respiration hurried and irregular, her countenance more anxious, although she was still destitute of fever and delirium. The ensuing night, however, she became flighty; her heart palpitated and fluttered; she fell into twitchings or convulsions, and died before the occurrence of mortifica- tion, or even of decided inflammation." The grave symptoms which are here described were rapid in their appearance, and certainly progressed in a very insidious manner, but they were undoubtedly caused by the supervention of blood poison, originating from the wound, and not by a new series of pathological changes directly taking place in the nervous centres through which the shock primarily operated. Cases of similar character occur at times in private practice, but are more frequent in hospital wards, where patients are sometimes overcrowded, and the air less pure and wholesome. A lady with scirrhus of the breast came from Maryland to consult me. I performed the operation for removal on a Monday. On the second night after, the patient was attacked by a chill, hard cough, and pain in the right side with difficulty of breathing. On 143 the third day there was fever, hot, dry skin, wild and staring expression, with glassiness of the eyes, the adnata tinged yellow, restlessness and loss of appetite, quick, irritable pulse, and wandering intellect. The difficulty of breathing and other symptoms of toxaemia rapidly increased, and the patient died on the fifth day from the date of the operation. About the same time I operated on a case of lithotomy in the adult male, by the bilateral section of the prostate, in the State Emigrants' Hospital. The patient was attacked, on the third night after the operation, with cough and restless- ness, and difficulty of breathing. A similar train of symptoms occurred as those mentioned in the breast operation, and the patient died on the fifth day after the extraction of the stone. In both cases, examination of the cadaver showed evidences of purulent absorption in the lungs, and there was also effusion into the cavity of the pleura; in the case of scirrhus, on one side, and in the other, on both sides. In both instances the character of the wound was unhealthy. It may be supposed that toxic effects from a traumatic lesion cannot take place at so early a period as that just stated after solution of con- tinuity has been produced. Septic material can be furnished from an un- healthy wound within less time than forty-eight hours after it is received, and can be rapidly introduced into the general circulation by the veins and lymphatics. Purulent infection may occasion death soon after it has taken place, but generally six, eight, or twelve days elapse before the ter- mination of this disastrous complication. At times, the symptoms are pro- longed for some weeks, with signs of amelioration and hope, but these are often deceptive; in fact, the prognosis is not favorable wiien patients be- come affected with this grave intercurrent event. I may add here, that the cases of rapid dissolution occurring from two to eight days after injuries with shock, while apparently progressing favorably, are frequently to be at- tributed to toxaemic infection associated with an unhealthy morale and a cachectic diathesis. The entrance of morbific material into the circulation, and the alteration which consequently takes place in the blood, produce a series of adynamic and typhoid symptoms in the general system, which, taken collectively, have 144 been designated by different names. This nomenclature has generally been based on the supposed etiological theory of the cause from which the patho- logical condition is supposed to have originated. The names generally used to express this condition are phlebitis, pyaemia, and septicaemia: other names also have been applied, as purulent infection, purulent absorption, purulent metastasis, and purulent diathesis. With the diversity of designa- ting terms, the paramount fact is always acknowledged that a poisoned con- dition of the blood is the source of the various depressing and pathognomo- nic symptoms. If any addition were to be made to the classification of the different modes of dying as already adopted by Bichat, the train of morbid phenomena resulting in death from blood-poisoning would be readily accept- ed as a distinct mode of dying, considered apart from death beginning at the heart, at the lungs, and at the head. Certain it is that after serious accidents and surgical operations, and the traumatism following parturition from the separation of the placenta, and the usual laceration of the cervix uteri, vagina, and fourchette, a class of symptoms varying in grade and intensity often arise, which terminate in death. It has been proposed to draw a line of demarcation between pya>mia and septicaemia, basing the differential diag- nosis upon the invariable presence of an increase of heat as denoted by the thermometer, and by the absence of recurring chill during the progress of septicemia. The symptoms as described, even by those who advocate this distinction, are, in a great degree, common to both, and, without leading to any practical error, may be considered as varieties only of the same disease. The difference in the abnormal manifestations resulting from poisoning of the blood should be viewed as generical, and the term toxaemia be selected in preference to any other, as not implying in advance by technical denom- ination the special nature of this morbid condition. The words septicaemia and pyaemia should be regarded as expressing specific varieties of toxic invasion. Numerous authorities might be cited who advocate the exclusive influence of the absorption of pus, originating from the surface of a wound or from the inner coat of the veins, with or without an embolic deposit of coag- ulum, as the cause of typhoid or septic disease, while others of equal merit dwell upon the putrescence that takes place after labor from the decomposed 145 coagula in the cavity of the uterus, and from the thrombi in the venous sinuses, as being the sole primary cause of the various typho-adynamic con- ditions which often follow upon child-birth. There is a diversity of causa- tion in the sources of blood-poisoning, and it follows that there should be some variety in the correlative symptoms. As a general rule, the symptoms of pyaemia are more commonly met with after traumatic injuries and surgical operations, while those of septicaemia are more frequently present in the toxaemic puerperal maladies. But the placental surface of the recently delivered womb and the uterine venous sinuses may furnish pus as well as the peculiar putrescent material at times present in the cavity and walls of the uterus. With the compound poison derived from this source, another modification of symptoms takes place, different in character, and marked by more intensity than those met with in either of the other forms of toxaemia. The inhalation of the impure air of hospital wards, absorbed through the lungs into the circulation, is also a source of toxic influence to the blood, and becomes a predisposing cause of purulent and septicaemic infection. It may be mentioned here, although not immediately connected with the primary effects of injuries, that there exists a self-producing blood poison that origi- nates within the system, and is capable of producing septic symptoms anal- ogous to those of more obvious origin. This idiotoxic influence, described by Yirchow, emanates from disintegration of structure, terminating in a path- ological process, which he calls necrobiosis, to designate a latent disorgani- zation or death of tissue in the organs. By a somewhat similar process of change, the concussion or shock incident to severe accidents is sometimes remotely followed by disorganization of structure of some part of the organ- ism, the origin of which may be referred back to the antecedent injury. The fluids of the body are also subjected to a morbid metamorphoses, which may produce idiopathic blood-poisoning. The introduction of infusorial molecules into the circulation, through the medium of the lungs or by direct transmission from the surface of a trau- matic lesion, is believed to be the cause of changing the character of the blood, so as to render it highly poisonous to the system, and productive of highly nocuous toxaemic disease. The purulent ophthalmia of armies and of 20 146 public institutions, where large numbers of adults or children are crowded into badly ventilated wards, is known to be caused and maintained by the implantation of cryptogamic particles upon the palpebral conjunctiva* By the aid of the microscope, a species of alga1, termed bacteria, has been found in septicemic blood, and which has been regarded as the source of the char- acteristic symptoms of toxaemic disease. It has been asserted, however, by some experimenters, that these products were the effect of the morbid changes already taken place in the blood, and not the cause of its toxic con- dition. Experiments lately made by M. Pasteur, and recorded in a paper read by him before the Aeademie de Medecine of Paris, seem to prove that infusorial bacteria, when introduced into the circulation of some of the inferior animals by injection, are not only deleterious in their effects, but, in some instances, rapidly produce death. The subject is one of great importance, and is again claiming the attention of scientists.j- liuulent infection, then, is a complication of wounds from external injury, or from the incisions of surgical operations, and probably, as has been stated, is developed at times spontaneously. Whether from putrid infec- tion, or from purulent absorption from the surface of a wound, or from the admission of pus into the circulation secreted from the calibre of inflamed veins, a group of symptoms may suddenly supervene, after an accidental or intentional wound, which frequently are the harbingers of a fatal termination. These symptoms often do not show themselves before the expiration of ten or twelve days after the occurrence of the lesion. Sometimes they are devel- oped as late as the second or third week, but, at other times, they are abrupt- ly ushered in as early as the second, third, or fourth day, and occasion death * When first appointed as Snrgeou-in-Chief to the State Emigrants' Hospital, I found, grouped in badly venti- lated wards, about 350 children and adults affected with purulent ophthalmia. The disease had been contracted by many of them in the crowded transport sailing vessels, which had brought them from the old countries to America. It was introduced first into the hospital by the new arrivals from the ships, and kept up there by overcrowding and badly regulated accommodations. The number of blind had so increased during the four previous years as to create discussion and anxiety with the State authorities in regard to the future support of those thus rendered help- loss. The disease readily yielded to the adoption of improved hygienic measures, and to the rapid application of the solid stick of nitrate of silver to the everted granular palpebral, immediately followed by the use of a camel's- hair brush dipped in a neutralizing solution of muriate of soda. The disease was undoubtedly of infusorial origin. t ride Report of the Aeademie de Medecine, Paris, March, 187?. 147 within forty-eight hours after the receipt of a traumatic lesion. During the night of the third or fourth day after amputation of the breast, for example, I have seen patients suddenly seized with a chill, and dry hacking cough, heat of skin, and pain on one side of the chest. The adnata would soon become icteric, and the other preliminary symptoms indicating purulent infection would appear, the patient gradually becoming overwhelmed, and dying with- in forty-eight hours from the appearance of the unfavorable symptoms. A hospital patient was treated for extensive varicose veins", in one of the wards of the hospital, by the use of the figure of 8 ligature with the introduction of several needles under a group of enlarged veins belonging to the internal saphena, at the upper and inner part of the leg. On the third day signs of purulent infection presented themselves, and he died suddenly on the fifth day. Pus was found in the veins, and small purulent deposits disseminated on the surface and in the substance of the lungs. It is not necessary that there should always be an external solution of continuity, for a bone may be fractured and split near a joint, inflammation and suppuration may occur on the surface and in the spongy osseous tex- ture, and be followed by purulent infection and sudden death, an instance of wiiich has recently come under my observation. If, on making the morning visit on the third or fourth day after a lesion has been received, a patient who has apparently been doing wrell the previ- ous day is found with the adnata beginning to assume an icteric hue, with the countenance more or less stolid, the skin slightly yellowish with reddish streaks, the lips pale, and the eye staring with glazed expression when spoken to, and the skin covered with an abundant sweat, these signs being ushered in by a chill which has lasted from a quarter to half an hour, such change assumes a serious import, and the prognosis becomes decidedly un- favorable. If these symptoms continue unchecked the heat of surface now returns, and the sweating stage may last one or two hours, and this accession, during which the pulse may have been normal or but slightly accelerated, is followed by calm and a general amelioration. Sometimes two or three of these exacerbations occur during the twenty-four hours, and if the case is prolonged they may simulate the type of intermittent fever, the chill coming 1 18 on periodically at the same hour. While these constitutional signs are apparent, the solution of continuity remains indolent and pale, the suppu- ration is less in quantity, and the pus assumes a sanious and fetid character. If the case be one of amputation by flap operation, and the line of incision has partly imited, the adhesion gives way and separates, and the flaps are ashy and flabby. As the malady progresses, the countenance, changed from the first, becomes more altered, the skin is leaden or more deeply tinged with yellow, and at times covered with sudamina. The conjunctiva, like the skin, assumes a deeper icteric hue, the constitution also shows signs of being more deeply impressed, the patient is overcome with a sensation of debility and prostration, the torpor is increased, and he remains in a half- si eepy condition, oppressed with continual agitating dreams, and confused by a vague and passive delirium which is augmented during the night. If spoken to abruptly, however, he will become aroused, and if interrogated will answer correctly any questions that may be addressed to him. The general perturbation in the system goes on increasing, the respira- tion generally is accelerated, the inspirations, running up to thirty or forty in the minute, are full and deep without stethoscopic abnormal signs. Often, however, there is a hacking cough, accompanied by expectoration of yellow- ish, frothy sputa, at times tinged with blood, or presenting the iron-rust color- ation of pneumonia—these symptoms being generally pathognomonic of the presence of metastatic abscesses in the lungs. These pneumonic symptoms are often preceded by or associated with sharp pains on one side of the chest, indicating that the pleura has participated in the inflammation of the lung. A similar pain is sometimes felt in the region of the liver, also indicative that the inflammation which surrounds the metastatic collections of pus has ex- tended to the peri-hepatic serous membrane. The pulse at this stage of the malady is rapidly running down, and is small, frequent, and easily compres- sible. The functions of the digestive organs are much disturbed. In the commencement of the attack, the tongue, which was soft and humid, and cov- ered with a whitish coating, has now become loaded with a dark-colored sooty covering. There are sordes on the teeth, disinclination for food, and at times diarrhoea. 149 Not unfrequently patients who have suffered from the foregoing series of symptoms will be seized with a severe pain in some part of the body, often in the vicinity of a joint, such as the knee, ankle, elbow, or wrist, or the pain may be felt on the trunk, or along the course of the neck and extremities. This pain is so acute at times as to preoccupy the mind, making it the only source of complaint, and superseding all the other signs which belong to purulent diathesis or infection. If the painful spot be examined, a doughy, puffy, cedematous swelling will be perceived, ordinarily not larger than a split walnut, that has its seat in the subcutaneous cellular tissue. The skin soon becomes red, and fluctuation is perceptible, the swelling assuming the character of a phlegmonous abscess. At other times the purulent collection forms in the articulation, and the capsular sac of the joint becomes distended and painful, and the movements are impeded, and ultimately completely sus- pended. It may be here remarked that patients dying from purulent infec- tion frequently exhale a disagreeable and peculiar odor. Finally, the de- pression increases, the torpor and stupor run into coma, the respiration and circulation become more and more embarrassed, and the patient expires. In this malady, from the commencement of the attack, announced by the first chill, life is seldom prolonged beyond the twelfth day. Sometimes a decep- tive calm intervenes after the initial chill. Two, three, or more days may elapse without any return of chill. This lull in the symptoms may indicate a favorable turn in the disease, but experience has proved that the symp- toms of purulent infection will usually return, and very frequently destroy the patient. I have observed recoveries take place where the metastatic abscesses were confined to the subcutaneous cellular tissue of the extrem- ities, the parenchymatous organs remaining exempt from the purulent infec- tion. Although the fatal termination of this complication of external injur- ies may be delayed, as before stated, at times, the disease progresses with rapidity, and the patient perishes suddenly, within twelve or twenty-four hours from the commencement of the symptoms.* * I have introduced the subject of purulent infection as a complication of shock and collapse at some length, as it occurs, at times, as such, and is incorrectly regarded as a group of symptoms belonging to the primary nervous impression of the injury. The medical attendant, when made aware of the fact, must diagnosticate for himself. 150 A complication of shock at times arises that is characterized by an aberration of the intelligence distinguished from other forms of delirium by its exciting cause, which is ordinarily one of external violence, by its freedom from fever, and by the analogy which it bears to delirium tremens, or to that condition of the nervous system which is brought on by the excessive use of intoxicating drinks. Dupuytren, who first described this morbid state, designated it by the name of nervous delirium—" delire nerveux"—and more recently, from its association with severe injuries, it has been called traumatic delirium. At times this kind of nervous delirium is developed suddenly during the first days after the occurrence of an accident, or the invasion may occur less rapidly, and be preceded by certain signs that serve almost as infallible precursors. This complication of shock from external lesions is met with most frequently in persons of broken-down constitutions the result of excesses either mental or physical, in those of nervous temperament, of timid disposition, and of excessive impressionability to external influences. It appears commonly as a consequence of fractures or dislocations, or of severe injuries of any kind, or as resulting from extensive wounds, or from surgical operations. Although generally occurring within a brief period of the accident, it may show itself at any time during the progress of such injuries as those just mentioned, or toward their termination. It is met with more frequently in hospitals than in private practice, in men more often than in women, and is rarely or never seen in the very young. When in Paris, as a student, following the clinical lectures of Roux, Blandin, NeTaton, Velpeau, Gerdy, Be"rard Bouil- laud, Piorrv, and of other great masters in surgery and medicine, the subject of toxic infection was receiving much attention. At that time it was the custom at the H6tel Dieu, at La Charit6, La Pitie, and the other large hospi- tals, to dress wounds after surgical operations so as to heal by second intention, rilling the wound with charpie spread with a simple cerate. It was very common to see patients thus treated attacked with purulent infection. The overcrowded wards, also, in those hospitals, particularly during the cold season, favored the development of tox- emic disease. In the remarks on the progress of purulent infection and nervous delirium, I have made use of some notes taken at the clinique of M. Nelaton.— Vide Dupuytren, "Lecons Orales;" Velpeau, "Me"decine Operatoire •" Se"- dillot ; P. Be"rard, article "Pus," du Dictionnaire de Medecine, en 30 volumes. During the first period of my service, from 1*50 to 1865. at the State Emigrants' Hospital, owing to the accumu- lated number of immigrants throughout the country, the hospital was always full, and many cases requiring surgical operations were admitted. For two or three years, partly on account of the overcrowded condition of the wards cases of purulent infection frequently occurred. Afterward, in operations, I adopted the plan of the early removal and changing—within twenty-four hours—of the first dressing. Such cases rarely occurred in amputations after this. This subject will be considered under the head of "Treatment of Shock and Collapse." 151 In cases of nervous delirium, the brain, already before the accident pre- disposed to unnatural impressionability, soon after the receipt of the trau- matic lesion, begins to manifest signs of functional disturbance. Upon the receipt of a shock, the reflex function of the nerves transmits various impres- sions to the important organs. It naturally follows that the effects of an injury will influence the vital properties of the brain as well as of the other more remote and distant organs, and by reason of the communication of the commissures derange its functions and arouse into activity the latent suscep- tibility to receive new morbid impressions by which cerebral irritation is produced. The derangement of the principle of innervation once established, the increased ingress of blood into the parts now suffering from morbid irritability tends to augment and sustain the morbid action there present in the form of traumatic delirium. In this etiologic description the point of inflammation has not been reached, but the brain is placed in the dangerous condition that leads to serous effusion. The symptoms are in accord with the pathological condition of the encephalon. As there is no inflammation there is no fever, and the objective signs indicate and point out the organ or organs of the brain where the irritation is most concentrated and intense, according as the intellectual faculties, the sentiments, propensities, or special senses are most ostensibly affected and perturbed. For example: a me- chanic while at work becomes entangled in machinery, and has a limb crushed and fractured. He receives a shock, followed by collapse. He is removed to a hospital, or sent to his home, and a moderate reaction comes on in the course of twenty-four hours. Signs of nervous delirium begin to show themselves, and within forty-eight hours he is out of his senses. This man has been overworked, he has been badly fed, and, besides working in an un- healthy, overheated factory, he sleeps in an unwholesome and badly ventila- ted chamber, and has few home comforts. While his general physical con- dition is thus unsound, his brain and nervous system have been specially overtasked. The organs of vision and of hearing have been continually, while at his work, in a state of prolonged overaction, and, moreover, he may be a political agitator or a Communist, and in continued excitement about the wrongs which capital has inflicted on labor; with him la propriete c 'est 152 le vol. If the entire brain be not in a state of undue excitability, such a pa- tient will probably see all kinds of imaginary objects and hear unusual sounds. He will be violently combative, from his supposed unsatisfactory social condition, muttering incoherent sentences, and raving about subjects that had preoccupied his mind before the accident. The shock has been car- ried to the cerebral ganglia, and thence reflected upon those portions of the brain most ready to take on diseased action, and so the symptoms may be varied according to that part of the brain most likely to give way, or to be brought into pathological activity. This affection is very much allied to delirium tremens, and if the cause of the antecedent abnormal cerebral im- pressionability has been the free use of alcoholic stimuli, the symptoms of delirium may become manifest Avithin a few hours after the shock has been received. Hospital and army surgeons are apt to be familiar with this kind of complication, but it is often met with in private practice. Persons who have had a severe shock from any external cause are liable to this complication. It becomes developed after attempts to commit suicide, after important surgical operations, or after extensive and dangerous lesions. The symptoms begin to show themselves often as soon as the night following the occurrence of the shock ; at times not until twelve, twenty-four, or forty- eight hours have elapsed. The patient from being comparatively comforta- ble will become restless, and make abrupt and.sudden movements with the head and arms, catching unmeaningly at the bed-clothes. His eye will be- come more vivid, and assume an expression unnaturally inquisitive and suspicious. He will continue speaking and muttering short and incoherent sentences. The intelligence becomes confused about surrounding objects, and some prominent idea about his occupation, his tastes, habits, age, or sex seems to control and preoccupy the wandering mind. There is continual jactitation and inability to sleep. The head, face, and neck are covered with profuse sweat. The eyes become brilliant and congested, the countenance excited and flushed, the patient grows violent and unmanageable; he keeps uttering angry and menacing expressions of ill-nature, and sometimes of re- venge. The general insensibility is so great that a patient with a fracture will, if not restrained, tear off the retentive bandage, and jump out of bed 153 moving hurriedly across the room, heedless of the dangling limb, and appar- ently unconscious of pain, or, after an amputation, will throw himself out of bed, as if making efforts to escape from the attendant. The constitutional symptoms are not in correlation with the commotion and perturbation of the nervous system. The pulse is comparatively tran- quil and natural, and the action of the heart is not increased beyond the influence of the restlessness and jactitation. There is no change in the reg- ularity of the functions of secretion and excretion, but digestion is suspended. The appetite is gone, and if food and drink are urged upon the patient he will eject them from the mouth with violence and temper. This condition lasts for two, three, or four days, and terminates either in restoration or in death. When a favorable result takes place, the symptoms subside as abruptly as they appeared; profound sleep, which had fled from the patient, takes pos- session of him, and at the end of ten or fifteen hours he awakes, feeble, but sensible to pain and to his condition, in possession of his intelligence, and without any recollection of what he has just passed through. The appetite becomes re-established, the original injury takes its natural course toward recovery, and the case progresses thenceforth without complication. Some- times this kind of delirium may be renewed by two or three consecutive attacks, after one or two days of remission, the disease subsiding gradually, and each subsequent relapse becoming milder in character. Delirium tremens, or mania a potu, is another complication occurring after injuries attended by shock and collapse. This affection is a magnified type of " nervous delirium," marked by symptoms of greater severity, and is the form of this variety of mental disease to which confirmed and habitual drunkards are most liable. It occurs more frequently among nationalities where the habit of freely using strong alcoholic drinks is prevalent than with people who are accustomed only to the milder beverages procured from malt or from the grape. In both of these remarkable cerebral conditions, the latent morbid predisposition engendered in the nervous system by prolonged and abnormal stimulation is evoked or brought into activity by the depressing influence of the shock. Mania a potu is ushered in usually within the first twenty-four or forty-eight hours after the receipt of an injury, by general 21 151 inquietude, restlessness, tremor, unnatural watchfulness, incoherent loquacity, and mental illusions, often with a frequent pulse, cool skin, and perspiration. There is wakefulness, insomnia, an anxious expression of the countenance, tremor of the hands, and of the tongue when extruded for examination. There is a strange expression of alarm and suspicion about the eyes, which glance rapidly around from one object to another as if desirous of eluding an anticipated danger or injury. The perturbed mental condition goes on in- creasing, although the patient may assert that he feels well. He continues to speak hurriedly and irrelevantly, and is tormented with a succession of hallucinations assuming the character of alarming and ludicrous apparitions. Snakes, dogs, elephants, flies, and other animals appear to his disordered imagination, disgusting objects are seen crawling over the bedclothes, and he supposes, at times, that persons have entered his apartment to injure or to kill him. In order to avoid such imaginary dangers he becomes greatly agitated, cries out aloud for help, or threatens and raves in the most violent manner. Strange noises haunt his fancy, he hears sounds around him, or refers them to an adjoining chamber. His mind and body are in contin- ued agitation and activity. He picks up supposititious objects, such as coin or pins, calls out to some imaginary person, starts with terror from some frightful phantasm, assails those who take care of him, and insists that they are confining him for sinister motives. If contradicted, he be- comes exasperated, although at times, if dealt mildly with, he may answer questions reasonably, and for a while be manageable without restraint or co- ercion. Often, however, as the disease progresses, the patient becomes furi- ously delirious, and can with great difficulty be restrained from inflicting violence upon himself or upon others. He loses all recognizance of his at- tendants or friends, and at this stage, if not closely watched, will accomplish self-destruction in one way or another. As in nervous delirium, patients thus attacked after injuries are strangely insensible to pain, tossing about or jumping from the bed with a fractured or amputated limb, if not re- strained, and insisting upon renewing their business occupations. The pulse varies according to the character or temperament of the individual. In some instances it is full, hard, and frequent: most commonly it is soft, full, 155 quick, and without tension. The skin is sometimes above the ordinary tem- perature, at others natural and moist. There are signs of gastric disorder, with loathing of food, and excessive craving for cold drinks. The duration and degree of violence of delirium tremens vary in different persons accord- ing to the habits, temperament, and amount of antecedent excesses. It is a complication much to be dreaded, from the additional dangers it entails upon a patient already suffering from the effects of shock and collapse resulting from antecedent injury. The disease, if slight, often passes off in a day or two; if more acute, the symptoms continue unabated for five or six days or longer, remitting somewhat during the day, and showing exacerbation at night. In aggravated cases the symptoms become more severe, and assume the character of wild and ungovernable mania, ending in cerebral effusion, convulsion, coma, and a final fatal apoplectic sleep. Under the head of complicated shock may be placed those cases of sud- den or rapid death that take place unexpectedly, and while the patient has been to all appearance progressing favorably. Persons so severely injured as to have the nervous system impressed by shock may, at the same time, be already suffering from angina pectoris, or from some cardiac affection, and suddenly die. It is not intended here to classify under this head such chronic cases, or the group of phenomena associated with pain and other chronic morbid symptoms in the chest ending in sudden death, and which simulate angina pectoris. The change in the blood and the perturbation of the circulation that take place after severe injuries may lead to congestion of the right side of the heart, producing paralysis from overdistension, or spasm of the muscular tissue of that organ, causing unexpectedly syncope and death. Thrombosis of the pulmonary artery and embolism of the heart are known to cause death suddenly in the puerperal state from inopexia, and hyperinosis of the blood, as intercurrent complications.* A similar condition of the system may take place soon after the receipt of severe injuries, or a latent hyperinotic predisposition may have been already established in the circulation previous to the time when the injury occurred, favoring the deposit of coagula incom- * Vide Essay by Sir James Simpson, 1854. 156 patible with life in the large vessels and in the heart, nowT thrown into a state of asthenic action as a consequence of shock and of the depression and collapse of the nervous power. The following case, which proved, upon post-mortem examination, to be one of rapid death occurring from embolism and thrombosis of the heart and pulmonary artery, confirms this statement, and shows the possibility of such a condition existing already in the system at the time of injury. I saw the patient, and found him in a state of col- lapse simulating that of Asiatic cholera, on the evening of May 6, in con- sultation with Dr. Maclennan of this city, and transfer his notes, taken from the period of the accession of the symptoms until the fatal termination. " Case.—M. H. K----, et. 38, of sanguineous temperament, about mid- day on 5th May had a sudden feeling of faintness, and appeared so ill as to cause his friends to think him dying, and to send for medical assistance in all directions. Apparently his distress was in consequence of an attack of diarrhtea, with vomiting, which had existed from 8 a.m., accompanied by severe abdominal pain, especially in the right iliac region. Not being at home when the message arrived, I did not see him till about 3.30 p.m. In the mean time another physician had arrived, and treated him with external applications of mustard and hot water, with a subcutaneous injection of ten drops Magendie's solution of morphia, and an injection, per rectum, of fifteen drops of Tinet. Opii. He was somewhat relieved, but continued restless. At this time the pulse was 100, temperature in axilla 98°, perspiring freely, large beads of perspiration covering his forehead, hands and feet cold and damp, patient complaining of excessive wreariness, and easiest while on his knees, with his stomach pressed against the sofa; 5 p.m., pain getting more severe, he had another subcutaneous injection of morphia, ten drops. This gave considerable relief, and he was able to lie in bed on his back. There was great tenderness over the bowels, especially in right iliac region; passed the night in a very restless manner, though not suffering much pain; he had two doses of ten drops each of Magendie's solution at intervals of three hours during the night. He never vomited since the first visit, took considerable quantities of beef tea, yet the coldness of feet and hands and other symptoms of collapse continued the same. Hot water in bottles 157 was kept constantly applied to the hands and feet, without having appar- ently any effect. Monday, 6th, 8 a.m., no improvement—still in collapse; pain not severe during the day; pulse varying from 120 to 130, and very feeble, although quite regular, temperature in axilla 95°, tongue moist, al- though complaining much of thirst. As he continued so depressed, at 3 p. m. I began to give Champagne, which made him feel much better, although without causing any improvement either in pulse, temperature, or coldness of hands and feet. At 9 p.m., Dr. Carnochan was called in consultation, and it was decided to apply a fly-blister for two or three hours to right iliac re- gion, for the purpose of obtaining its stimulating and revulsive effect, and to give twelve grains of calomel, also a grain of carb. ammon. every two hours, with a beef tea injection containing two grains of carb. ammon.; Cham- pagne to be continued. Until 2 o'clock a. m., 7th, he remained very much in the same state, but at this time he had every appearance of dying; pulse feeble, and 160 beats to the minute; respirations short and hurried, and 38 per minute. During this time patient's intellect remained clear, and he expressed himself confident of recovery; hands and feet very cold and clam- my. Champagne was freely given, and constant rubbing of hands and feet kept up for about two hours, when the pulse began to be less frequent, and came down to 140 ; respirations decreased in frequency to 28. At 8 a. m. he appeared better, the blister having risen well; he had had two motions from bowels of dark color and very offensive odor. At about 3 p. m. administered an injection of soapy water, with a table-spoonful of turpentine, as the bow- els wrere much distended. This gave great relief, and patient did not com- plain of abdominal pain any more. About 5 p.m. patient's face became flushed, and the temperature in the mouth went up to 105°; hands and feet less cold. Breathing again became short, accompanied by a short, dry cough, wrhich caused the patient much pain. Symptoms of pneumonia, especially over right lung, were now becoming very marked. No sputa. Sound of heart muffled. The first sound scarcely audible; the second feeble; embolism and heart-clot suspected. Applied turpentine stupes over front of chest, changed from Champagne to brandy milk punches, as patient was tired of the former, although he had not vomited. Calomel had been re- i;>s pouted—carb. ammonia continued. During Wednesday, 8th, he continued in the same state, except for a tendency to wander in his mind, and to talk continuously about his business affairs, very restless all day, and could hard- ly be persuaded to stay in bed, continuing thus all night up to Thursday morning, 9th; pulse 120 to 130 through the night, changing frequently. He seemed to have difficulty in recognizing any one. Suddenly, at 8 a. m., he rose up out of bed, and stood on the floor, struggling as if he felt himself being held down, his eyes were fixed, looking straight before him and a little upward. He then, in a loud, strong, and distinct voice, called out murder about twenty times, his face getting paler all the time, and assuming a most anxious and distressed look. Appearing to be exhausted by this effort, he made no objection, but rather attempted to get back to bed, where, after giving two or three gasps, and his face rapidly becoming purple, he quietly died. The whole time occupied from his getting out of bed until he died being about thirty seconds." Post-mortem.—At the post-mortem examination several small patches of inflammation were found on the small intestines. There was no obstruction in any part of the alimentary canal. The stomach, liver, kidneys, and other abdominal organs were all healthy. In examining the chest, both lungs were found congested and engorged with blood. The heart was normal in position and size. On laying open the right ventricle a large fibrinous clot was found, nearly filling the cavity of the ventricle, and continued into the trunk of the pulmonary artery and into its primary branches to the extent of several inches. The entire length of this coagulum or clot, after being removed and allowed to remain in water for a short time, presented a yel- low, buffy, fibrinous appearance and character, and retained the shape, as if cast or moulded in the ventricle and pulmonary vessels. There was a small fibrinous clot in the left ventricle. The auriculo-ventricular valves and those of the aorta and pulmonary artery were normal. This case is most interesting from the fact that it was possible to trace its progress and symptoms from the first accession of the attack until the revelation obtained from the post-mortem examination. This man had been a free-liver, and was in the habit of frequently taking the Eussian bath, 159 plunging into very cold water after being overheated with vapor. The day before his attack he had seen some friends off on a foreign steamer, had drunk freely and been otherwise dissipating, and had taken one of his favor- ite baths with the plunge. The light patches of inflammation observed on the small intestines were of trivial character, and could not be taken into ac- count in the causation of death. There was great general distress from the first, and as the stomach was healthy, it is probable that the initial symp- toms of abdominal pain and vomiting were the result of reflex influence from the cardiac nervous apparatus. The main symptoms in the case were those of collapse—restlessness, and a general feeling of great distress, rapid and short breathing, quick, frequent, small, and feeble pulse, cold surface, and clammy sweat. The muffled sounds of the heart were attributable to the play of the tricuspid and pulmonic semilunar valves becoming obstructed from entanglement among the embolic deposit, as it accumulated in the right ventricle and pulmonary arteries, and from the retarded pulmonic cir- culation and the diminished quantity of blood on the left side of the heart. There was a small deposit of coagulum in the left ventricle, and the general arterial system was anemic. The functions of the brain were ultimately arrested, and, amidst evidences of great agony, death occurred from nervous exhaustion and asthenia. In fact, the general symptoms were very similar to those resulting from excessive loss of blood, such as cold and clammy surface, countenance pale and anxious, distress and restlessness, tossing in bed, short and rapid respiration, quick, small, and feeble pulse, anemic surface, insensibility, delirium, terminating in death. Had this patient met with a severe injury shortly before the idiopathic attack, the embolic con- dition would undoubtedly have equally supervened, and afforded an instance of sudden death occurring as a complication of shock. This hyperinotic state of the blood, leading to idiopathic embolism of the right side of the heart and of the pulmonary arteries, is more common than is usually supposed, and in many instances, during the progress of dis- ease, or following upon severe injuries, becomes the latent and unsuspected cause of sudden or rapid death. Besides the case just cited, two additional ones have lately come under 160 my observation, in both of which an opportunity was given of making a post-mortem examination. One ease occurred where there were calcareous deposit and imperfection of the aortic valves, and atheromatous degeneration and enlargement of the ascending portion of the arch of the aorta, without, however, the general health being materially affected. The other took place as an intercurrent complication of abscess occurring at the caput cecum coli, from the impaction of a portion of chicken bone inadvertently swallowed. Cask.—D----M----, et. 52, of sanguineo-nervous temperament and robust form, a plumber by occupation, became indisposed while at work on Thursday, 30th May last, with slight diarrhoea and giddiness, but continued to attend to business until Saturday evening. On Sunday morning, June 2, he dressed, intending to spend the day on a visit to some friends in the country. Not feeling well, he went to an adjoining restaurant to get some brandy, and while there fainted, and was taken home and put to bed. Dur- ing the day he continued to feel faint and feeble, and showed no signs of improvement. At midnight he was suffering from great difficulty of breath- ing, but without pain; the countenance was expressive of great anxiety and uneasiness; pulse 140, temperature 101, respirations 40 to the minute, skin moist and clammy, hands and feet cold and damp. Ordered stimulants in the form of brandy and water, and milk punch. Carbonate of ammonia two and a half grains, and five drops of Magendie's solution every four hours. Sinapism to the chest, Monday, June 3, 9.30 a.m.—Patient much easier, breathing without dif- ficulty, although there is distinct mucous crepitation over both lungs. No sputa; pulse 140, temperature 101, skin moist, hands cold and wet; says he is much better; turpentine stupes applied over the chest. At midnight no change; tongue white and moist; no vomiting; has no desire for any thing but water. Tuesday. 10 a.m.—But little change in the condition of patient; tongue more thickly coated, thirst very great, has no pain, skin has a dusky appear- ance, sleeps at short intervals, intellect clear. At 8 p.m., ordered twelve grains of protochlorid. hydrarg., to be followed by citrat. magnes. in the morning. Carb. ammonia continued. 161 Wednesday, 10 a.m.—Patient's condition much the same; medicine has acted; tongue cleaner; pulse the same; sounds of the heart are feeble but regular, and seem muffled and at a distance; hands cold and moist; still very weak; complains of feeling chilly, although the temperature of the room is 70 ; takes stimulants regularly. Although there is no improvement, says he feels much better; ammonia and Magendie's solution continued. At midnight, symptoms much the same. Thursday, 10 a.m.—Temperature 97, pulse 148; respiration more rapid; hands cold and moist; sleeps at short intervals, and when waking has a startled and agitated look. Mutters incoherently, and wanders in his speech, but is sensible when spoken to; says he feels better, although evi- dently sinking. At 6 p.m. pulse becomes more feeble and quicker, other symptoms unchanged. At 7 p.m., while making a remark to one of his fam- ily, he turned over on the left side, and suddenly expired without a struggle. Post-mortem.—The heart was found to be enlarged, and the muscular tissue soft and friable. The right auricle contained some semi-fluid and coagulated blood. The right ventricle was filled with a yelloAvish fibrinous deposit, with a layer of soft red coagulum partially covering it. This was easily washed off, leaving the tough yellow fibrinous deposit entangled with the tricuspid valve, nearly filling the cavity of the ventricle, and extending upward into the trunk of the pulmonary artery and into its two primary branches, so as to fill up and block their calibre. There was a small amount of red coagulum in the left auricle, and the left ventricle was partly filled with a soft dark red-colored clot. The ascending portion of the arch of the aorta was enlarged and lined with atheromatous degeneration, and the aortic semi-lunar valves were insufficient and studded with calcareous deposit. The lungs were greatly congested. There was some pleuritic effusion. The following case of embolism of the heart and pulmonary arteries occurred as a complication of abscess of the ilio-cecal region, resulting from impaction of a portion of chicken bone. Case.—m----B----, an unmarried lady, et. 37, of nervous tempera- ment and excellent constitution, accidentally swallowed a piece of chicken 22 162 bone, which at the time gave some uneasiness that subsequently subsided, and soon the circumstance was almost forgotten. Paroxysms of pain, how- ever, occurred at intervals over the abdominal region, and a general feeling of indisposition was complained of, but not sufficient to prevent her from at- tending to the usual routine of daily life. About three weeks after the bone was swallowed, the pain in the iliac region became so severe as to make it necessary to call in the family physician, Dr. J. S. Crane, with whom I saw her in consultation on the 10th of June last, I found her complaining of much pain in the iliac region, which increased upon pressure. A doughy or boggy sensation was imparted to the hand in passing it over the integuments of the hypogastrium. There was great distension of the abdomen, with tym- panitis, rapid pulse, and restlessness. The mind unimpaired; skin dry and slightly above normal temperature; great thirst; no appetite. The patient thought so little of the swallowing of the bone that it was only by interroga- tions in that direction that the fact became known. From this, and the cur- rent symptoms, the diagnosis was reached that impaction of a foreign body in the appendix vermiformis or in the caput cecum coli had taken place, producing abscess in the iliac region. The series of symptoms just enu- merated continued without much change, except occasional intervals of intermission and exacerbation, until 8 p.m., Thursday, June 20th, wiien she became very restless and unable to sleep, moving automatically in bed; complained of pain in the right side; mind wandering; breathing with diffi- culty, at times suddenly arousing herself and sitting up in bed as if to get relief. Respiration rapid and short, 40 to the minute; pulse 110, smaller, and more frequent. She became chilly, and desired the window to be closed, though the night was very warm. Friction, warm fomentations of brandy and laudanum, wTere applied over the abdomen. Stimuli, brandy, etc., were administered internally. 7.30 a. m.—Had fallen into a lethargic sleep, face and neck becoming purple: continued in this condition, rousing unconscious at intervals until 3 p.m., when she awoke, remarking that the weather had become very cold. She asked for extra blankets. At this time the countenance had become very anxious, and the hands and feet were cold and moist. At 9 p.m. she 163 had a general chill, becoming icy cold; fingers and nails were blue; breath cold; pulse 160 and thready; respiration more rapid and shorter; glassy expression of eyes. 12 o'clock (midnight), asked to be straightened in bed; pulse scarcely perceptible, and impossible to be counted; respiration more feeble and shorter; surface cold and clammy. She uttered some muttering sentences, and lapsed into a state of stupor, sinking gradually; vitality ceased at 2 a.m., Saturday, the 22d June. Post-mortem.—The following is an extract from the notes taken of the autopsy by an assistant: On opening the abdominal cavity some of the intestines were found glued together toward the lower part and to the right of the hypogastrium, so that it was difficult to separate and follow the track of the alimentary canal. The adhesions were most marked at the right iliac region, where, on examination in the iliac fossa, an abscess of considerable size was found. This communicated with the large intestine at the caput cecum coli, and by a canal, along which the finger could be readily passed, extended behind the peritoneum and over the linea ilio-pectinea into the true pelvis. Pus was found also both before and behind the uterus, the ab- scess having burrowed in this direction among the pelvic cellular tissue. The origin and seat of the abscess were in the iliac fossa, and it undoubted- ly had its commencement in connection with the vermiform appendix. The projecting part of this process was mostly removed by ulceration, and con- founded Avith the disorganized tissues forming the walls and in the vicinity of the abscess. In proximity to this seat of ulceration, the debris of the foreign substance, about the size of a compressed bean, triangular in shape, and which had caused the abscess, was found lodged among infiltrated pus and discolored sphacelated cellular tissue. The thorax when laid open was seen to be free from adhesions or other sign of antecedent disease. There was no effusion in the pericardium, and the heart was normal in size and structure; upon opening the right auricle some semi-fluid blood was found. The right ventricle was nearly filled with a tough, dense, yellow-colored deposit, which extended upward into the trunk of the pulmonary artery, past the bifurcation, into the right and left pulmo- nary arteries. The basis of this fibrinous deposit was entangled among the 164 triangular segments of the tricuspid valve and the mesh-work of the chordae tendinee. There was a small portion of soft coagulum resting on the yellow deposit. The left auricle contained some semi-fluid blood, and the left ven- tricle a soft red coagulum of small size. The tissues of the pulmonary artery and of the aorta, with the semi-lunar valves, were healthy, as Avere also the tricuspid and mitral valves. The lungs were sound, but dark-colored and much congested. The condition of the right side of the heart as revealed by the autopsy explains the symptoms Avhich appeared during the last twenty-four hours, and the sudden collapse Avhich rapidly ended in death. In this case embolism apparently began to tell upon the system only about forty-eight hours preceding death. The cases just cited are interesting and instructive, as they show, not by inference but by positive demonstration, that a condition of the blood exists at times in which the circulating fluid is predisposed to be easily disinte- grated, the fibrinous portion separating from the other constituent elements, and forming a solid, yellow, elastic plug, which fills up and assumes the shape of the cavity or tube in Avhich it is deposited. When the numerous constituent elements existing in the blood are considered, it is not difficult to understand that a change in the normal relative proportions of the com- ponent parts can take place, and that as a result, in a partially devitalized state, solid precipitates may form, as in the case where the fluid of the urine has become abnormal in its composition, and surcharged Avith certain ingre- dients. These fibrinous embolismic aggregations probably begin about the tricuspid valve. The blood flowing from the carotid and jugular of an ani- mal still living, if whipped up with a small rod while falling into the basin receiving it, aa ill separate into a fibrinous solid portion and into a remaining fluid portion composed mainly of red and white corpuscules, albumen, and salts. The blood in traversing from the right auricle into the right ventricle has to pass under the tricuspid valve and among and through the intervals or meshes of the chordae tendinee, which connect the columne carnee of the ventricle with the margin of the valve. During the diastole and systole of the heart the tricuspid valve is in continual play, the chorde tendinee be- coming tense and relaxed in following and regulating the action of the 165 valve. The blood, already in a hyperinotic condition, and thus churned and agitated in its transit onward through the auriculo-ventricular opening, be- gins to deposit the new formation. This progresses, with an elongated and gradual aggregation of the mass, until the cavity of the ventricle and the pulmonary artery, and, in some instances, of its primary branches, is filled with the embolismic material, thus obstructing almost the entire circulation. My own conclusion in regard to fatal embolism of the centre of the circula- tion is that its seat almost always is in the right ventricle and pulmonary artery or arteries, that it is of gradual formation, and that it is usually accomplished or elaborated to the extent of destroying life in from tyventy- four hours to four or five days. The first indication of embolism of the right side of the heart and pul- monary artery may be a fit of fainting, but the pathognomonic symptoms are those of general collapse: coldness of the surface, particularly of the hands and feet; small and rapid pulse; muffled and distant sound of the heart; more or less torpor; at times great distress about the chest; rapid, short, and sometimes gasping respiration. Toward the termination, the symptoms increase in gravity. There is often a belief on the part of the patient that he is getting better. The distress increases, the intelligence begins to waver, and there is muttering delirium at times. Death supervenes upon insensibility, preceded usually, a short time before dissolution, by signs of great agony. There is generally mucous rale, and signs of pulmo- nary congestion. In contradistinction to those cases of embolism of the heart and pulmo- nary artery in which the progress toAvard death is rapid but not sudden, there are others in which the fatal result takes place almost instantaneously. Case.—Among others, I select the case of Mrs. R----, et. 23, of good constitution, who was attended by Dr. Maclennan, of this city, in her second accouchement, dining the early part of July, and at whose autopsy I was present. This lady had an excellent delivery, without any complication Avhatever. She Avas having a good convalescence up to the twelfth day after confinement, and was well enough to be permitted to sit up for a short time. She Avas seen by her medical attendant at 1 o'clock p.m., who con- 166 sidcred her in a favorable condition. Soon after this interview she got out of bed, dressed with a loose Avrapper, and seated herself on a chair. Every thing Avas tranquil in the room, her aunt only being present, Avith Avhom at intervals she interchanged some pleasant passing Avords. At 4 p.m., most unexpectedly, she threw herself back in the chair, and after several gasping respirations, suddenly expired. This case affords an example AAmere death occurred almost as suddenly as if the patient had been killed by lightning. I am not aware that the cause of this diversity in the mode of dying in these cases has been satisfac- torily explained. It has been already stated that, in cases of embolism of the heart and pulmonary artery, the formation of the fibrinous deposit com- mences about the segments and mesh-Avork of the tricuspid valve, and that the mass gradually aggregates and extends upward toward the tube of the pulmonary artery. The circulation is not abruptly obstructed, and the stream of the blood is only gradually diminished, the vitality ceasing by degrees, accompanied by the distressing symptoms already detailed. In the cases of sudden death the right ventriculo-arterial opening be- comes in a striking manner the gateAvay of life. The fibrinous deposit in such instances may form more rapidly, but the source of immediate death is the sudden detachment of a portion or of the entire deposit from its original base or attachment around the segments and chorde of the tricuspid valve. During the systole of the heart this fibrinous mass when throAvn off is hur- ried along in the current of the circulation through the ventricle up to the opening of the pulmonary artery, and immediately blocks up the orifice of that vessel after the manner of the valve of a pump. The entire pulmonic circulation being thus in a moment intercepted, unconsciousness and death follow on the instant. It may be suggested that the embolism may begin in the pulmonary artery around the semi-lunar valves. It is not likely that a deposit beginning at this part would accumulate so rapidly as to produce instantaneous death, and, moreover, the post-mortem facts do not support this supposition. Autopsy.—In the case of Mrs. R----, before opening the body, the source of the sudden death was distinctly understood and expressed. Upon 167 laying the chest open, by removal of the sternum, the organs appeared healthy. The pericardium was opened, and contained a small portion of serous fluid. The heart Avas of natural size, and while kept in situ a free incision wras made through the Avail of the right ventricle. A quantity of fluid blood floAved freely through the incision, coming partly from the right auricle and vene cave. Some fragments of detached yellow fibrinous de- posit passed along with the blood. On sponging the right ventricle and carefully freeing it from blood, at the upper part of the ventricle a soft, yelloAv, fibrinous plug as large as a small walnut, irregularly flattened, was found completely blocking the orifice of the pulmonary artery. This, Avhen drawn from its position, revealed a kind of vermiform prolongation that extended along the tube of the artery for about three-quarters of an inch. The tricuspid valve was normal; among the chorde tendinee and along the margin of the valve irregular portions of soft, tough, yellow, fibrinous deposit remained entangled. The left ventricle was next opened in the same way. There was no clot or blood in this cavity, or in the left auricle, and the mitral valve and the surface of the internal walls of both cavities were perfectly healthy. The aorta and pulmonary artery wrere then slit open, and the valves and vessels found perfectly normal. There was a portion of fatty material upon the external surface of the heart, but too small to be of im- portance. The rest of the body was healthy. The conditions Avhich favor this peculiar pathological state of the blood are prolonged mental emotion, and Avhatever produces great perturba- tion of the system, as often takes place in the puerperal state, in hemor- rhages, in aggravated disease, in shock from intense mental agitation, or from severe traumatic lesion.* * I have no doubt that a psychological embolism of the heart and pulmonary artery at times takes place ; that is, by prolonged mental emotion and agitation a condition of the blood is brought about that favors its disintegra- tion, and that the disintegration is more or less rapidly effected upon the occurrence of some sudden or unexpected intercurrent additional cause. The case of William M. Tweed, at one time the political dictator of this State, is an example of this kind. He had suffered much from imprisonment and from mental agitation for several years. At length he was induced to believe that he would be liberated under certain conditions, which ho is said to have fulfilled. I was requested to see him on Monday, April 8th. His physical condition was greatly changed for the worse, and he complained of malaise and general indisposition. He was elated at the prospect of soon leaving his place of confinement. He 168 At times a condition of the system arises after injuries Avhich may be called secondary collapse, indicative of cerebral anemia and interrupted innervation, and of a Avant of capability in the central ganglia to supply the amount of nervous influence requisite to sustain the functions of life. In such instances the vitality seems to rally, and signs of restoration to manifest themselves, but the effort is transitory, and a neAv series of symptoms makes its appearance more unfavorable than that Avhich folloAved immediately upon the shock of the injury. There is noAV collapse, Avith evidences of ex- citement in the system, as if of an extreme attempt to arouse and bring to the rescue the last reserve of the rapidly fading resources. This condition is allied to nervous delirium, but its progress is characterized by evidences of deeper prostration, and offers less hope of a favorable termination. Nervous delirium is generally the result of injury to a system already enfeebled and broken down by irregular courses of life, Avhile secondary collapse, as at present considered, may occur in any condition of the system, and is the product of some single great injury, or, more generally, of one of a complex character, involving several organs, and indicating the extreme exhaustion of the ganglionic centres by which the morbid impressions of the injury or dressed and was about his rooms daily, and showed no signs of incurable disease. He became better on Monday and Tuesday by gentle medication, and on Tuesday afternoon I left him still improving. News of failure of the efforts to secure his release were confirmed, and reached him. The officers of the law, as he supposed, had broken faith toward him, and put an end to the hopes he had entertained of soon regaining freedom. Early on Wednes- day morning I received a telegram, written by himself, that he had passed a bad night, although then better, "all but his heart, where there was great distress." I made an early visit, 8 a.m., and found him very ill. His feat- ures were pinched, the countenance leaden and dark purple, the pulse rapid and feeble, respiration short and frequent, hands and feet cold. The mind was clear; he conversed and begged to be relieved from his great distress • the sounds of the heart were feeble, without abnormal bruit. He continued in this condition during the day, ob- taining some relief from medication; great restlessness, complaining much of thirst. During the night of Thurs- day he frequently got out of bed and sat up on a chair as if seeking relief. The symptoms were relieved only by anodynes and stimuli. Friday morning, 10 a. m.— The mind, although generally clear, wandered at times. He was very restless; the coldness of the surface and of the hands and feet continued; forehead cold and moist; pulse 150; respiration 48 in the minute and short; asking continually for drink. 3p.m.—The symptoms all aggravated; intelligence waning; stupor; pulse thready and not easily counted; respiration more rapid and shorter; cold and clammy sweat over the surface; subsultus tendinum; sinking rapidly. At 4 p. M. he became comatose, and died without a struggle. The family objected to have an autopsy, but in this case the diagnostic signs of embolism of the heart and pul- monary artery were certainly present. 169 injuries were primarily received and transmitted. In such instances the symptoms of prostration most evident at first, although apparently grow- ing more favorable, are succeeded by another series of morbid nervous sympathies. The progress and termination of this class of lesions can be better studied in cases of severe injuries of the head when associated and complicated with lesion of other organs remotely placed relatively to the great cerebral ganglia. Thus, in a railroad accident, there may be injury of the head of such gravity as to produce collapse Avith coma, and a limb may have been crushed at the same time, which of itself Avould have been sufficient to produce collapse. It is not difficult to comprehend that in this latter case the cerebral symptoms may remit, and that the patient, at first insensible and laboring under the collapse from the concussion, may, to a certain extent, be restored to consciousness and to apparent improvement. But a limb having been crushed besides, and the morbid influence from the seat of this superadded injury being still at work, it is transmitted to the central ganglia so as to prolong the original effects of the shock, or to pro- duce a new or secondary phase of prostration and collapse, followed by a new class of symptoms. Thus a chain of morbid phenomena may ensue in other instances of extensive injury to any set of sentient tissues or to any group of organs. The following case will partly explain the varied play of morbid sympathies that takes place when an injury of a diversified or multiform character has been received. Case.—F---- M----, et. 50, of robust constitution and sanguineous temperament, while driving along the street, one Monday evening last Sep- tember, in a light wragon, at a rapid pace, Avas run into by another vehicle and upset. He Avas thrown violently upon the pavement, and struck on the curb-stone Avith the left side and back of the head. He also struck on the left shoulder, and in his heavy fall fractured the clavicle and four superior ribs near their attachment to the spinal column, severely injuring at the same time the upper lobe of the lung of that side. There was also some injury or concussion of the medulla spinalis. He was picked up insensible, and immediately carried to his home, Avhich happened to be Avithin a short distance. He remained comatose during the night, breathing stertorously, 23 170 with a slow, compressible pulse, ranging between 40 and 50 beats to the minute, cold and moist surface, and other signs of collapse. Toward morn- ing, at 3 o'clock, he regained sensibility and consciousness so far as to be able to ask for water, and at times to answer questions rationally. Tuesday, 7 a.m.—Pulse 70; respiration 16 and irregular; the countenance suffused ; speech distinct at times, at others only a semiconscious muttering; complained of great pain in the upper part of the chest and at the shoul- der. In the course of the day the stupor of the concussion kept decreasing, the skin became dry, and rose above the normal temperature. The pulse was rapid, bounding, but feeble; the respiration at times hurried and irregu- lar. There Avas frequent vomiting. At 3 p.m. he had a convulsion which lasted for about five minutes. After it, the pulse rose to 110. Convulsions continued to occur, at intervals of from three to six hours, up to midnight, Avith prevailing restlessness and uneasy moving in the bed. All the symp- toms of excitement Avere undiminished, and there was absolute sleeplessness. Wednesday.—I saw him at 5 a.m., having been sent for to meet the attend- ing physician, Dr. Molony, who had been giving sedulous and skilful atten- tion to the patient. I found him coining sloAvly out of a convulsion, slightly delirious, with tremors and tAvitchings of the muscles. I saw him again at 10 a.m. His skin was hot, the pulse rapid, the respiration hurried and im- perfect. He was conscious, but sometimes incoherent. He did not complain of pain in the head, but of great distress about the thorax and shoulder. Where the head had struck the pavement there Avas a contused Avound of the scalp about an inch in length, and I adAised that this be enlarged in order to be assured that there was no fracture of the skull with depression of bone at this point. There was no fracture. For the rest of the day the symptoms remained unchanged. He slept a little during the night, but was frequently roused, apparently by the pain about the chest. He suffered from great thirst, and in his speech was often incoherent. There was much flatu- lence with tympanitis. Thursday morning.—It was becoming evident that the amount of injury was too great to alloAv one to expect a remission of the symptoms from any treatment. All the manifestations of prostration with excitement grew more 171 aggravated. The tongue, when partially protruded for examination, Avas coated and tremulous, the muscular twitching and agitation, the Avanderings and delirium, were more marked. The pulse rose to 140, with irregular, hurried, and imperfect respiration, about 40 to the minute. The convul- sions continued at intervals of three to four hours. The period of excite- ment seemed gradually merging into one of extreme prostration and col- lapse. A cold and clammy sweat gradually broke out upon the surface, the countenance grew paler and more distressed, the pulse reached 160, small, irregular, and fluttering. The tAvitchings of the muscles and subsultus tendi- num became more acute, the incoherency increased, the eyes became glazed, and with a final convulsion, ending in coma, death supervened. The treatment consisted in the administration of suitable cordials during the first stage of collapse, Avith warmth and friction to the extremities; dur- ing the stage of excitement and prostration, small doses of tincture of aco- nite to reduce the action of the heart, and Champagne to sustain the system and allay the great thirst; toward the last stage, Avhen the collapse became extreme, brandy with carbonate of ammonia Avas added; turpentine injec- tions were twice administered, to revulse from the brain and to relieve flatu- lency. Chloroform was administered at times during the convulsions. The symptoms related in the preceding case are typical of those in- stances of severe injury that, as they progress, merge into a condition that is marked by excitement associated with great prostration. It appears diffi- cult to reconcile the presence at the same time of such opposite phases of the system as excitement coupled with prostration. The increased temper- ature of the surface and of the internal parts of the body Avould not seem to indicate an exhaustion of nervous influence, and the more frequent action of the pulse and of the heart would at first favor the supposition of greater propelling force in the apparatus of the circulation; but upon attentive ex- amination it will be found that the action of the heart is feeble, although the number of its pulsations is greater. English writers have bestowed much study and consideration upon this peculiar state of the system, Avhich fre- quently supervenes upon shock and collapse. John Hunter called it irrita- bility ; and the phrase prostration with excitement, first used by Mr. Travers, 172 has been generally adopted by British surgeons. The explanation of the phenomena given by recent authorities, and generally accepted, is found in the subjoined extract, but it is too vague to be satisfactory : " Now these symptoms of extreme excitement leading so rapidly to fatal exhaustion are unquestionably evidence of excessive action and deficient power. . . . There is no more important subject for inquiry than the relation of action to power in the living body. In the condition of health the bal- ance is uniformly maintained, or at least the supply is equal to the demand. But if from any cause the poAver of an organ, on the function of which life is immediately dependent, be much impaired, this difficulty arises: its func- tions must still be discharged to an extent at least sufficient for the pur- poses of life, and therefore deficiency of power may need to be redeemed by increase of action. But action involves exhaustion, and repose is needed for repair. The greater the effort, therefore, the greater the exhaustion. But again, decreasing poAver must be met by increasing action. Thus cause and effect react each on the other; the relation between power and action be- comes more and more reversed, until at length, the supply diminishing, and the demand for action and repose alike augmenting, the crisis, with rapidly increasing pace, is hurried on. " No organ illustrates this so strikingly as the heart, and under no cir- cumstances better than in the present case. An impression is produced upon the heart, whereby its power is for some time impaired. But, that life may last, it must still to a certain extent circulate the blood. If it be too feeble to accomplish this necessary task at its ordinary rate of action, its frequency must be increased. But action is succeeded by corresponding exhaustion; and so, if the supply prove unequal to the demand, follows pros- tration with excitement, deficient power and excessive action, the pulse in- creasing in frequency as it fails in force."* This explanation is hypothetical, and does not convey a distinct sense of the phenomena in question. In all severe injuries followed by collapse a deficient supply of oxygen to the tissues and organs necessarily follows as a sequel to the general per- * Holmes's System of Surgery ; Travers, On Constitutional Irritation. 173 turbation and exhaustion of the nervous centres. This want of supply creates an impression throughout the system, which, by reflex action, is car- ried to the respective organs whose function it is to furnish the necessary aid. The heart and lungs consequently respond, and act for a time with in- creased but faltering activity. We thus have one cause for the frequency both of the pulse and of the respiration. Another cause of the frequency and irregularity of the pulse arises from the disturbance of the normal bal- ance of functions between the organic and the pneumogastric nerves which compose the cardiac nervous apparatus, and which receive the impression transmitted from the seat of injury. The rhythm and the co-ordinate action of the heart are thus to a certain degree modified and altered. The question noAv arises, how the increased heat of the surface and throughout the body, together with the signs of general morbid excitement of the system, can be accounted for. My OAvn conclusion is that during col- lapse the normal tension of the arterioles is greatly diminished, and that the general circulation having thereby become more rapid and free in cases where there is prostration with excitement, there is an increased flow of blood into the relaxed and dilated systemic capillaries. This is accompa- nied by an abnormal and excessive evolution of heat, consequent upon and OAving to the accelerated chemical changes attending the molecular meta- morphoses of the tissues and organs which in health would be progressing normally in the decay and the repair of the body. " Prostration Avith excitement" has been called imperfect reaction. But the symptoms from the beginning of the changes following upon ordinary collapse being indicative of increasing prostration, and reaction implying an improvement of the existing morbid state, the term reaction is incorrect. Secondary shock may also arise from mismanagement in the primary treatment of injuries, such as occurs from abrupt removal of the wrounded on the battle-field to a great distance, or in cities by unnecessary change of locality. In civil practice, cases like the following are met with: J---- F----, et. 68, in attempting to get upon the platform of a street car while it Avas in rapid motion, missed his footing, and was thrown with violence upon the pavement, breaking the right femur high up toward the trochan- 174 tors. I le was picked up insensible and carried into a store, and from there Avas removed to one of the temporary municipal hospitals near the City Hall Park. He Avas placed properly in bed, and by the aid of cordials and a temporary adjustment of the fracture he was made comparatively comfort- able. There Avas a favorable reaction on the following morning. About mid-day, for some reason, he Avas transferred to one of the larger hospitals in the upper part of the city, some four miles off, over badly paved streets. This caused a repetition, as it were, of the original shock, and wras followed by renewed symptoms of collapse. He continued to sink gradually, and died about noon the next day. If this patient had been allowed to remain where he wras doing compar- atively avcII, and had not been transferred under such unfavorable circum- stances, it is probable that he would have recovered. The battle of Spottsylvania took place on the 18th May, 1864. Many men were brought to the medical head-quarters of the different corps badly Avounded by exploded shells, Minie-balls, and cannon-shot. Some of the most severe lesions were accompanied by splintered and comminuted frac- tures of the large bones of the superior and inferior extremities. They were placed in shelter-tents and received a certain amount of attention, but, for the moment, there was a want of such retentive apparatus as is required in the treatment of fractures. Still, by the use of cordials, quiet, and anodynes, many of the injured began to rally from the collapse. On the night of the 20th, an order Avas issued from head-quarters for an advance of the army in the direction of North Anna, the wounded to be transported beyond the reach of Confederate skirmishers to Fredericksburg, where a number of military hospitals had been organized, as the basis of the ambulance corps. Freder- icksburg is distant about twenty miles from the battle-field, and the roads at that season were in a very bad condition, almost impassable in many places, and at others made up of trees laid crosswise over the morasses, forming the common corduroy road of the South. In this instance a military necessity, in the opinion of the general-in-chief, required that the wounded should not be exposed to fall into the hands of the enemy, and removal became imper- ative. This necessary alternative was an unfortunate one for the severely 175 injured, such as those who had the femur or other large bones shattered by a shell or ball; for beside* the dreadful suffering experienced from the rolling and jolting of the wagons of the ambulance over the rough roads, many of such cases, and cases of injuries to the splanchnic cavities, had a renewal of collapse, and succumbed to a repetition of the first shock, occasioned by the inevitable jolting of their transportation.* After capital surgical operations the balance betAveen life and death is sometimes decided against the patient by mistakes or negligence in the after-treatment, causing development of secondary shock. Case.—About six weeks ago I was called to see Mrs. B----, an elderly lady, et. 78, of Aviry constitution, and, for her time of life, possessing a fair condition of health. She was suffering from irreducible strangulated femoral hernia, with the usual concomitant symptoms present to such a degree as to render an operation necessary. This was carefully performed, without anes- thetic, by the patient's desire, and without complication, except the presence of extensive adhesions between the intestine and the inner surface of the hernial sac. The bowel was returned entirely liberated, and although of claret-color, was free from any odor of incipient gangrene. The collapse from the operation was not excessive, and a comfortable reaction was estab- lished about twelve hours after the operation. On the afternoon of the fol- lowing day, by the administration of a half-ounce dose of castor-oil, the per- istaltic action of the intestinal canal was established, followed by a healthy evacuation. On the third day the patient was so far free from any unpleas- ant symptoms that on my visit her brother, who in early life had practiced surgery, met me at the door very much gratified, saying that his sister had passed the ordeal, and he considered her out of danger. Quiet was enjoined, and light nourishment with wine and water ordered. On the afternoon of the same day the patient took a fancy that she needed an enema, and insist- ed upon the nurse administering one at once. This acted with severity, and the effect proved to be too much at her age. She was thrown into a second- ary collapse, from which she never rallied, but continued to sink gradually, * Instances of this kind will necessarily occur during a protracted and active campaign. I mention the bat- tle of Spottsylvania, as I happened to be present. 176 and on the afternoon of the fifth day after the operation she expired from exhaustion. Indirect Effects of Shock.—Certain conditions of the system, marked by adynamia or asthenia and a general failing of the vitality, occur some- times after injuries of gravity, and are followed by indirect pathological results not always in correlation Avith the character or extent of the shock received, but Avhich ultimately terminate in death. For example: a person driving in an open Avagon, with the seat insecurely fastened, by a sudden start of the horse is thrown out backAvard, striking the ground violently on the back, fracturing the ribs, injuring the lungs, and shoAving signs of con- cussion of the medulla spinalis, and, for the time, of general collapse. The patient may recover from the immediate effects of the shock, but vitality languishes, the general health becomes irretrievably impaired, and death ensues sooner or later, as occurred in the case of an eminent actor that came under my observation several years ago. The remote or ulterior effects of shock upon the system after severe injuries is a subject of much interest, and of sufficient importance to claim special consideration, apart from the primary treatment of injuries. The deleterious effects upon the blood from sudden and violent impres- sions made upon the nervous system, whether from psychological or physical causes, or from the simultaneous combination of both, are often the source of dangerous and fatal complications.* The devitalization of the blood is a rapid sequent in instances of injury resulting from lightning. In high states of emotion the secretions are often abruptly changed, so that an offensive odor is suddenly emitted from the cutaneous or respiratory surfaces; and it is said that the bland and nutritious character of the mother's milk will be changed at times under intense mental agitation into a poisonous fluid, fatal in its effects upon the child. From this it is eAident that the blood, which normally is the natural source of life, as well as of nutrition and secretion, may become converted, from the changes which take place in its structure and vital properties, as * In the case of M----B----, page 161, the patient had suffered greatly from mental agitation and depres- sion for over two years previous to her last illness. The temperature, when given, is from the axilla or mouth. 177 well as in its chemical composition, into a fluid of a dangerously toxic char- acter, and unfit to sustain the functions of life. When the impression of the shock is of less intensity, the devitalization may not be so complete and de- structive, yet the change may be so great as to lead to inflammatory action of an adynamic type, associated Avith perverted molecular nutrition and de- generation of the tissues. Under the head of complicated shock it has been stated that pyemia Avas to be considered as one of the formidable complica- tions. The blood becomes so decomposed that an ichorrhemic form of pyemia is produced by the generation of a noxious fluid in the blood itself. A state of the circulating fluid thus in a degree idiopathically generated, although from a remote traumatic origin, induces universal disturbance of all the organs and functions, accompanied at times by traumatic fever of a typhoid character, by nervous delirium, by purulent deposits, by diffused inflammation in the great intermuscular planes of areolar tissue Avith puru- lent infiltration, by inflammation of the mucous membrane with diarrhoea, and of the serous membrane with effusion. It has been stated that one of the results of shock and collapse, es- pecially in the protracted form, is a condition of the blood Avhich favors the separation of its constituent elements, and leads to the formation of fibrin- ous deposit in the right ventricle of the heart and in the tubes of the pul- monary arteries. This condition of the blood would, under similar circum- stances, induce the formation and implantation of small, isolated, irregular, fibrinous products upon the mitral valve, either toward the base near the auriculo-ventricular opening, or toward the margin of the valve. One or more of these warty-shaped deposits may become detached or dislodged, float along the left ventricle in the direction of the arterial current toward the aorta, and, passing omvard, form a veritable embolism in any of the tissues or organs, thus blocking or interrupting the circulation at some point where the calibre of the vessel is insufficient to permit of the transit. In this manner various intercurrent diseases, originally depending upon shock and collapse, may be developed, and give rise to other complica- tions, such as the embolismic form of pyemia. Einbolismic granules or deposits of fibrin may occur in any part of the 24 178 circulatory system, but the mitral and aortic valves generally are the locali- ties or sites where they are at first implanted, and from Avhich they are dis- lodged and thrown off to pass along Avith the current of the circulation.* The right side of the heart is most liable to be the seat of large, yelloAv, fibrinous deposits, the blood being venous, and more readily separated into its ele- mental parts by the anatomical arrangement of the tricuspid valve than that on the left side, Avhich, being arterial, and less agitated or lashed by the mitral valve, is not so subject to disintegration-! When clot is found on the left side of the heart, as in case of thickening of the mitral valve Avith contraction of the left auriculo-ventricular opening, the coagulum fill- ing the left auricle retains in a great measure the red character of clot composed of all the constituents of the blood. Under the microscope, the deposits heretofore described as lodged in the right ventricle and pulmonary arteries presented the histological character- istics of fibrin. When formed rapidly they are of a deep yellow or tawny color, retaining still some of the red corpuscles of the blood ; Avhen occurring in protracted asthenic disease, forming slowly, and freed from coloring mat- ter, they assume a light chrome-yelloAv tinge, resembling in this respect the appearance of adipose sarcoma recently removed. Physiological correlative Conditions avhich modify the Effects of Shock.—Various circumstances modify the effects of shock upon the system, one of which—the temperament of the individual receiving a severe injury— * The type of endocarditis which is often associated with rheumatic inflammation is at times the source of millet-seed-shaped vegetations springing from, and implanted in a pedunculated form on, the mitral valve. One or more of these may be detached from the mitral valve, pass into the arterial circulation, and become lodged in one of the smaller arteries. If stopped in the middle cerebral artery, as sometimes happens where it courses along the fissure of Sylvius, embolism of that artery will be the result, inducing ramollissement of the contiguous parts of the brain, and consequent rupture of the vessels involved, followed by hemorrhagic effusion extending to the base of the brain and over the cerebral hemispheres, general paralysis, and speedy death a case of which I have lately seen. t The mitral is supplied with fewer chordae tendinese than the Eustachian valve; also, the systemic side of the heart, on account of embolismic obstruction of the pulmonary artery, receives less blood. The left auricle is liable to be filled or gorged with red clot where there is coarctation of the left auriculo- ventricular ostium with thickening of the mitral valve as far as its base. In such cases the left ventricle will be found nearly empty, without fibrinous deposit, partly on account of the impeded play or action of the mitral valve and partly from the small quantity of blood usually passing through the ventricle. 179 should be particularly taken into consideration. The word Avas vaguely used by the ancients, who supposed that the peculiarities of the natural organization depended upon the admixture and relative preponderance of four humors of the body then admitted by them—the blood, the lymph, the bile, and the atrabilis or black bile. It Avas believed from observation that certain predisposing and regulating influences presided over the actions of the body in health and in disease, and modern authors recognize a theory of similar purport, based, however, upon the more precise facts of general anat- omy and physiology. The term may be said to signify the general result or manifestation, for the organism, of the predominance of one organ or of one system over others in the same individual. The doctrine of the tempera- ments has been modified, since it is understood that it is to the special func- tions of the encephalon that the inclinations or affections, the passions, the intellectual faculties, and the moral qualities are to be mainly attributed, and not altogether to the constitutional peculiarities or structure of the organization. The temperaments are now grouped under four heads—the sanguineous, the lymphatic or phlegmatic, the bilious or choleric, and the nervous. These are seldom strictly distinct or pure, but run into different combinations, such as the nervo-bilious, the nervo-lymphatic, and the nervo- sanguineois; or the preponderating indication may be placed first, as the sanguineo-nervous, the sanguineo-lymphatic, etc., in order to indicate the relative activity and excess of the ruling element. In fact, the combinations and peculiarities of constitution in regard to the various relative proportions of the preponderating influences in the organism are exceedingly complex, and can be grasped and weighed accurately as to their import in disease or in health only by experience. The consideration of the temperaments thus viewed becomes a study of the physiological anatomy and histology of the organism, by which each temperament is made to designate a special condi- tion or type of the constitution. The term sanguineous temperament is applied to individuals of florid complexion, whose constitution is marked by a greater natural development of the vascular system, in whom the blood-vessels are larger, more filled Avith blood, and Avho also present a predisposition to inflammatory affections. 1(^0 Where the organism of the individual exhibits a generally spare develop- ment of adipose tissue, and Avhere there is an evident display of activity, and tendency to unusual impressionability and irritability of the nervous system at the centres and at the periphery, the term nervous temperament is used, and in such individuals a predisposition to nervous disorders is knoAvn to be present. Those who have light hair, pallid complexions, thin skin, a considerable development of the adipo-cellular tissue, thick lips, apparently cold-blooded, Avith an inactive expression, belong to the lym- phatic temperament, and are predisposed to derangements of the lymphatic system, to scrofula, to tuberculosis, and other strumous diseases. The bil- ious temperament is attributed to those Avho possess a dark complexion, dark hair and eyes, a stolid countenance and sluggish circulation, and Avho are liable in an unusual degree to derangements of the chylopoetic viscera. The term choleric or melancholic temperament, which has been ascribed to the influence of the black bile, is noAv only used in a figurative sense. If the hypothesis of the ancients, however, be erroneous as to the cause, the men- tal condition which gave origin to the name is a reality, and dependent on a sufficiently valid cause, for the psychological condition known as melan- cholia is often the result of the influence of the deranged hepatic system reacting upon the brain through the medium of the grand sympathetic. Such, in brief, are the main characteristics of the distinct types of the several temperaments as now recognized; the various shades of combination are too complex to be here enumerated, and are left to the judgment and discrimination of the observer. By the study of the temperaments useful knoAAiedge can be gained in regard to the particular constitution of each individual, that may, in cases of shock followed by collapse, afford general information in forming a prognosis and in directing the treatment. The diatheses are allied to the temperaments, modify the organism, and tend to influence the effect of impressions made upon the system. The sev- eral diatheses are diAided into distinct heads; and although their influence may not always be perceptible, the peculiarities of the constitution repre- sented by them should not be overlooked. According to some authorities the definition of the term has been confounded with the word temperament * »MU*i£'S *s. *•*"•'■ *;-■) > mi by F d'Orleans PRIMARY TREATMENT OF INJURIES FIELD AMBULANCE S ER V I C E _ B E AR I N G WO U N D ED TO HOS PITAL Scene behind a /wrtton of the tine of battle at dairiesJ fill. la. dune 27'/' /So':' , p!ieaii;> . i s'C; .-.:* 181 but while the latter does not imply the presence of any disease, the word diathesis is usually intended to convey the idea of an abnormal condition, in other words, that all the tissues or fluids of the body, or some certain ones among them, are tainted with an abnormal pathological alteration or change in their condition. The diatheses are more latent than the temperaments, and yet they become developed into morbid activity under the influence of a new or sudden pathological cause, and thus produce a modified phase in disease, whether of internal or external origin. A person laboring under any of the several diatheses, such as the syphilitic, the scrofulous, the can- cerous, or the scorbutic, is not able to withstand the effects of a traumatic lesion as well as one free from taint; and if the cachexia be very marked or pronounced, reaction after a severe injury is on this account modified and retarded, or prevented altogether. The hemorrhagic diathesis Avould certainly make a serious complication in cases of shock from injury, in Avhich a solution of continuity occurred in the form of an incised or contused wound. For example, a boy after recov- ery from ophthalmia was sent to the Kefuge Department of the State Hospi- tal. While playing with his companions in the grounds, he tripped suddenly and fell, striking the forehead on a sharp stone. He received an incised wound about two inches in extent along the left side of the forehead, ten lines above the superciliary arch. He was stunned, and showed signs of collapse. He was removed into one of the hospital wards, and the house assistants found it impossible to stop the bleeding. The hemorrhage Avas kept in abeyance only by compresses and direct pressure maintained by the hand for some hours, until I saw the patient. Several styptics had been tried, such as the application of ice, solution of per chloride of iron, etc., but without avail, and the boy was gradually sinking from loss of blood. In the emer- gency I called for some long Carlsbad pins, and passed them deeply through the wound, inserting the points half an inch from the margin, and bringing them out at a place equidistant from the edge on the opposite side of the cut, and placing each pin about half an inch apart along the course of the incis- ion. This done, a figure of 8 ligature was passed around the first pin, joining it to the next by crossing the same ligature over the lips of the wound to 25 182 reach the second pin, and so on until the wound Avas completely covered and blocked. This proceeding seemed to arrest the bleeding for the time. A moist compress Avas laid over the wound, and a roller bandage applied so as still farther to keep up the pressure. The boy Avas now placed in bed, and beef tea and other light nourishment given him at short intervals, Avith brandy and ammonia. Gallic acid was administered internally. There Avas a slight improvement in his condition, but the symptoms of collapse contin- ued. The bleeding had now lasted for some ten hours, as often as the press- ure had been removed from nine in the morning until seven in the evening. He was restless during the night, and slept but little, tossing uneasily. In the morning the pain in the head became so severe that I was sent for, and saAv him about ten o'clock. The bandages were moist Avith blood, and bulged outward opposite the Avound. It was evident that the removal of the entire dressing was required. When this Avas done, a large soft fluctuating tumor was found under the pins, diffused among the tissues and layers of the scalp, and projecting fonvard. In shape and size it resembled the half of an orange. Upon removal of the pins a quantity of fluid blood gushed forth, leaving some soft dark-colored clots at the bottom of the wound. The bleeding still con- tinued en nappe from the general surface. The clots were speedily wiped aAvay, the surface of the wound cleaned, and a sheet of compressed sponge Avetted Avith a solution of the perchloride of iron laid firmly in the wound, so as to be in contact with the entire surface. A compress, in which Avas enveloped a layer of sheet-lead, Avas then laid over the sponge, and a firm roller bandage placed around the head. The patient Avas kept in the recum- bent position, in a cool temperature. Nourishment and brandy were given at intervals, and acetate of lead and opium administered internally. Keac- tion could not be brought about, sickness at stomach and vomiting super- vened, and it became apparent that vitality could not be sustained unless the hemorrhage could be checked. This fortunately wTas effected. Soon after the last dressing the patient became more comfortable, had some quiet sleep, and the sickness of the stomach subsided. There was very slight oozing through the bandage, which, becoming dry, indicated that the bleeding was subsiding. The patient was sedulously watched, and plied with small and 183 often-repeated doses of brandy, ammonia, and juice of beef. Warmth was kept up on the surface by blankets, and heated bricks to the feet, and in the course of some hours feeble signs of reaction began to manifest themselves. The roller bandage w^as allowed to remain for twelve hours, and then only partially removed, leaving that portion which had become dry and adherent over the wound unmolested. This was replaced later by one applied more loosely around the head. The bandage was noAv removed daily, Avithout dis- turbing either the sponge or adherent portion of the original bandage, and the parts cleaned of the grumous bloody serum which continued to ooze from the wound. On the fourth day the sponge and first dressing had become loosened from suppuration. This became detached on the fifth day, leaving the wound in a granulating condition. By the use of strips of adhesive plaster, so as to bring the edges of the wound together, and slightly stimula- ting Avashes, the healing process went on gradually, and in a month the boy Avas discharged cured. It is very evident that if this patient had not received from the first the most unremitting care and attention, he must have suc- cumbed to the shock and collapse rendered persistent by the hemorrhagic diathesis, and the consequent obstinacy of the bleeding. Among the various systemic peculiarities enumerated, the nervous tem- perament exercises the greatest influence. Under ordinary circumstances some men are exceedingly mercurial and impressible, and are so constituted as to be thrown into a state of perturbation by the odor of certain flowers, or the sight of some familiar animal, such as a cat; and in other instances the sight of blood trickling from a wound, however trivial, will produce syncope. Vivid and prolonged emotion in such cases will induce a state of chronic excitability resembling the hysteria of women, rendering them morbidly impressionable to the most indifferent causes, and consequently more sus- ceptible to the immediate effects of severe lesions. Where this psychical impressibility to outward causes exists, severe physical pain originating from external injury will also affect the nervous system more acutely, and derange the molecular disposition or relations of the nervous cells to a greater degree, than in those of a torpid and lymphatic temperament. In cases of railway accidents and gunshot wTounds, an indefinable dread or panic takes posses- 184 sion of the so-called nervous persons, which tends to modify and maintain the effects of shock following severe injuries to a greater extent than in those of phlegmatic natures. It may also be observed that the mental condition of such persons at the time Avhen a severe lesion is received will influence the effect of the shock. The aphorism of Celsus, dolor medicina dolor is, seems to be exemplified in some cases by the temporary or partial suspension, and in the less intense manifestation, of the more grave immediate effects of shock under the influence of strong mental excitement, or the depressing agency of a great pre-existing emotion. Such immunity, however, is likely to be tran- sient and deceptive; the influence of the latest lesion is only deferred, and Avill before long become revealed. In fact, the grave effects of the lesion thus temporarily arrested or averted may thereafter become more intensely devel- oped by the consequent reactionary mental exhaustion naturally resulting, and superadded to the effects of the original injury. Influence of Sex upon Shock.—During certain periods of existence the reproductive system is quiescent, and does not exercise any particular influ- ence over the general economy; the advent of puberty, however, changes the girl into the woman, the psychical elements of character are developed into greater activity, and the nervous apparatus becomes more susceptible to external impressions. Apart from the influence of this new series of sym- pathies, the nervous system of the female under similar circumstances is not more impressible or sentient to impressions resulting from external lesions than that of the adult male. During the early part of my pupilage with Professor Valentine Mott, at a period of his career when he was in active practice, and performing daily important operations, prior to the gen- eral introduction of anaesthetic agents, he was often in the habit of calling the attention of his assistants to the greater endurance of women over the other sex during the ordeal of severe suffering under the knife. From my own observation I am led to the conclusion that, independent of the phys- iological and pathological sympathies connected Avith and radiated from the uterine system, the female nervous organization is less sentient to the influence of external agencies than that of the male. This may be attributed to the smaller dimensions of the nervous apparatus in the female, and to 185 the consequent diminished capacity of the afferent nervous cords and then more feeble effect upon the ganglionic centres, which relatively are also of a smaller size. The cerebral mass ordinarily is greater in the full-grown male foetus than in the female, as is learned from the statistical fact that the majority of difficult labors occur Avith male children, owing to the larger measurements of the head. It must not be overlooked that the education and early training of the female child inculcate the suppression of outAvard manifestation of the feelings and emotions, and that great suffering is often endured by them without complaint. The constitutional commotion Avhich accompanies the molimen mensium of commencing puberty, and the perturba- tion wiiich the system undergoes previous to and during the menstrual period, unfit the system to tolerate or resist at such a time the influence of external injuries as well as when the organism is in a more equally balanced physiolog- ical condition. During the whole period of the evolution of the ovum in the uterus the female system is unfavorably placed to bear the additional effects of intercurrent medical diseases or of external injuries. In cases of severity both mother and foetus are likely to be destroyed, as in variola; while in accidents, such as severe burns or railway injuries, premature labor is al- most a certain result, and in many instances both mother and ovum perish. On this account, when surgical operations on the female are required, the uterine condition should ahvays be consulted, and if it be unfavorable, the operation should be deferred until a more fitting time, unless the exigency of the occasion is so imperative as to require it to be done at once. Influence of Age upon Shock.—It is often stated in works of operative surgery that injuries received by the very young and the aged are not sup- ported as Avell as those received by persons in the middle periods of life. This general statement conveys the supposition that the child in its early infancy possesses less vitality and is endowed with a more acute and im- pressible nervous system than the adult, and is consequently more liable to be overwhelmed by the effects of severe external agencies. Age certainly modifies the physiological condition of the individual, and exercises an im- portant influence upon the pathological processes which occur in medical and surgical operations. Apart from the abrupt and severe effects of external 186 injuries, each period of life presents conditions that predispose to particular maladies. In infancy, the acute diseases of the head are more frequent;. in youth, those of the chest predominate; in ripe age, those of the abdomen; while in old age the chronic affections of the head and those of the hypogas- trium prevail. Physiologists variously divide the different epochs of exist- ence that the organization passes through dming the period of time which extends from birth until the natural cessation of life. Regarding the duration of infancy as limited to seven years, and taking septennial periodicity as a guiding rule, the epochs of life are divided by some into ten, by others into twelve or fifteen periods; others, disposed to attribute an equal duration to all the ages of life, divide existence, not after a fixed term based upon the length of embryonic life or of infancy, but after conventional numbers, and maintain the equal length of each age Avhile varying the number of the pe- riods of life. Daignan reckons fifteen ages of seven years each; Linnaeus enumerates tAvelve; Mende admits six, and Varron proposes five of fifteen years; Philites four of eighteen years; Pythagoras four of twenty years; Schmidt three of twenty-five; and Virey three of thirty years, the last-men- tioned starting upon the principle that all that is finite should be divided into a commencement, a middle, and an end.* These periods are to a certain degree artificial, and arbitrarily laid down, and do not correspond with the peculiar phenomena that are manifested during the several epochs of life. The division of life into youth, maturity, and old age is sufficiently precise for general consideration; but when viewed in relation to pathological condi- tions, it is not broad enough in detail. The changes and peculiarities which belong to each, and which are characteristic, do not occur abruptly or Avith precision. For the better study of disease the farther subdiAision is required of each age into two, from AAiiich results the division of the ages into the period of infancy and of youth, of adolescence and maturity, of old age and decrepitude. The question as to the greater or less endurance of the sys- tem at particular epochs must be answered by the consideration of the stages of development of the nervous system and of the various organs and func- tions during the several periods of infra-uterine and extra-uterine life. * ATide Longet,.Traite" de Physiologic Paris. "~ 187 The ultimate sources of shock are sentiency, or the susceptibility to re- ceive impressions, and an organism so constituted as to transmit and, at times, to reflect them. The effects of shock will be more or less intensely perceived or manifested by the individual according to the perfection of the organization and its susceptibility to be impressed. The less perfect the development, the less intense Avill be the impressibility. The relative toler- ance of shock depends on the greater or less capacity of the system to receive impressions, and also on the amount of vitality and viability which it possesses. From this we learn, other things being equal, that as the devel- opment of the nervous system has not reached perfection in the infant, the impression and direct effect of shock in early age aa ill be less felt; and that the viability being stronger, the power of recuperation and of tolerating or enduring injurious impressions will be greater. This statement is necessarily relative. The infant of a given age whose body contains twenty ounces of blood cannot part Avith half of that quantity with the same immunity as the adult can Avho is possessed of two hundred ounces in the system; yet the same infant will bear the loss of five ounces of blood better than the adult will that of fifty ounces, the amount lost in each case being the fourth part of the circulation; and also, an infant whose surface may be supposed to be equal to four square feet will support the effect of a severe burn extending over a portion of the body the size of half a foot square better than the adult of sixteen square feet of surface will bear a burn of equal severity of the ex- tent of tAvo square feet, each suffering from injury to an eighth part of the surface. Comparative anatomy teaches us that the human embryo in its groAvth passes successively through a series of gradations of rudimentary forms, each one of which, to a certain degree, represents the full development of a class of animals placed lower than itself in the zoological scale; and that as the creatures representing the inferior types of the animal creation are approach- ed, sentiency is found to be less perfect, while viability is more energetic and persistent. If this be conceded, and the inference carried forward, the influence of shock upon the system will be accordingly more or less mod- ified by age, from the period of the full development of the embryo at birth, 188 through the several stages of the first and second infancy, of youth, and of adolescence, up to the age of maturity, Avhen the extreme perfection of human development is reached. Here the equilibrium of the functions becomes es- tablished; repair and wTaste, assimilation and disassimilation, progress Avith equal pace; the nisusformativus is at a stand-still, and the system during this physiological pause maintains a negative position between progressive and receding vitality under the action of extraneous influences. Heretofore the impression has prevailed, and been advanced by many, that at maturity the system is better constituted to bear the effects of shock ; but I am satis- fied that such is not the case, precisely because the mind has so much to do with the result in accidents or injuries, and that at mature age sentiency is greater, Avhile viability is less than in early life. Without coinciding altogether with the doctrine laid down by Meckel, Serrcs, and Geoffroy St. Hilaire, that the human foetus passes through condi- tions of transition at each of which the definitive constitution of the different beings Avhich are inferior to it in the zoological series is represented, it is apparent that the human organogeny, in the different epochs of its progress, is an abridged illustration of transitional comparative anatomy. Thus M. Serres asserts that the monads among the inferior animals are represented in cmbryogeny by the vesicle of Purkinje; that the gones, the volvoces, etc., find their representatives in the primitive embryonic state. There is an apparent identity amongst the embryos before they are organically charac- terized, as there is, also, an apparent similitude or identity at the early period of development among the ova of all animals. The organization of the fish, of the reptile, of the bird, of the mammifer, and of man is, at the early or initial phase of embryonic life, the most simple expression of the type common to all. As soon as any visible trace of animal organization is manifested upon the blastoderm, this trace offers at once a characteristic and different type for all the individuals of each of the four grand divisions of the animal kingdom. In the vertebrata, to which man belongs, it con- sists of the appearance of a primitive line, and as soon as the ovum has reached in its development the period of the blastodermic membrane stage, and this line is indicated, it can be assumed that a vertebrate will spring 189 from this egg. Thus the first embryonic lineaments and organic dispositions of the nervous, the vascular, and the digestive systems are entirely analogous in all the embryos of the vertebrated class—the fishes, the birds, the reptiles, and the mammifers, including man. The analogy can be traced among the several embryonic organizations embraced in the different divisions, classes, orders, and genera of the animal kingdom. From what has just been stated it Avill be seen that the laws of development, and the peculiarities in reference to sensibility and viability belonging to the inferior individualities of the ani- mal creation, afford a physiological basis for a surgical law or deduction by Avhich we may estimate the relative tolerance and vitality of the system at the different ages under the influence of severe impressions, whether resulting from accidental injuries or from important lesions, such as those necessarily required during capital operations. While impressibility in some of the lower types of the animal creation is but small, vitality is so great that the capacity for self-restoration is manifested after a portion of the body has been removed by accident or design. Some even have the fissiparous power, by scission, of reproducing an entire living being similar to itself from sections made of the primitive animal. In general, the power of recuperation, and of repairing and reproducing lost parts, in the animal economy, increases in- versely as we descend from the higher to the lower parts of the animal scale. In man, and in the higher and Avarm-blooded vertebrata, the power of restoring lost component parts and organs is totally or almost entirely want- ing. The stratified tissues, however—the epithelium, the epidermis, the hair, and the nails—are reproduced continually; and even Avhen there is loss of sub- stance in the fibrous, osseous, and other tissues, the loss, when not too exten- sive, is often repaired in a longer or shorter time. Thus the cicatrices of the skin, of the fibrous and nervous tissues, and the callus of the osseous system, are regenerations in a great degree analogous to the structures Avhich they are intended to repair. It has been asserted that in certain mammifers the crystalline lens has been reproduced when the posterior part of the capsule has remained intact, and also that in man even a partial regeneration of the lens has taken place after the operation for cataract by depression.* * Burdacu, Traiti de Physiologie. Paris, 1837. 26 190 If from the superior vertebrata we descend in the scale to the reptiles, avc find there the capacity for regeneration much more energetic. With them the mutilated trunk reproduces the entire organs which it has lost. There is almost indefinite regeneration of the fangs of venomous serpents, and it is known that lizards, orvets, seps, and geckoes often break off the tail, and that the loss is soon repaired: " II est peu de lezards qui n'aient eprouve cet ac- cident ; et on en recommit les traces a la brievete, a la couleur plus terne, aux ecailles plus petitcs, a la forme plus rapidement conique de la portion reproduite, qui pourtant, a la longue, devient presque absolument semblable a une queue normale. A linteriem, on y trouve peau, muscles, vaisseaux, prolongement nerveux, enveloppe d'un etui solide; mais cet etui n'est jamais divise en vcrtebrcs, ni meme parfaitement ossifie; c'est un cylindre de carti- lage auqucl est incorpore un peu de phosphate de chaux."* With young frogs and toads the pattcs are reproduced. In the sala- mander this faculty of reproduction by scission is still more remarkable. With these animals, after mutilation, not only one foot is replaced, but all the four. In some experiments, after the tail was excised, a neAV one, Avith all its parts—skin, muscles, bones, vessels, nerves, and spinal inarroAV—was reproduced. Spallanzani has also observed the regeneration of the tail in the tadpole, and even that of the inferior jaw in the salamander.f Upon the authority of BonnetJ and of Blumenbach§ it has been stated that the eye of the salamander will be reneAved within the space of a year, if during re- moval the optic nerve has been preserved, and a portion of the membranes of the eye have been allowed to remain in the bottom of the orbit. In ex- periments with fishes, the fins, when cut off, have been reproduced, after se\^- eral stages of growth, in about eight months. The phenomena of reproduction in the articulata, the Crustacea, the in- sects, and the arachnides are even more marked. Examples are common of the shedding of the teguments of the larvae of insects, and of the regeneration * Duges, Traite de Physiologie comparee de VHomme et des Animaux. Montpellier, 1839. t Spallanzani, Prodromo