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Recueil de Memoires de Medecine Militaire.

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RECUEIL DE MEMOIRES DE MEDECINE, DE CHIRURGIE, ET DE PHARMACIE MILITAIRES. Vol. LXII. Octavo, pp. 400. Paris, 1846.

In availing ourselves of the contents of the successive volumes of this "Recueil," issued under the superintendence of a Committee of the Council of Health of the French Army, which selects from the various documents forwarded by the medical officers of the service those that it deems most fitting for publication, we have often regretted that our own military medical authorities have not, in a similar manner, contributed to the diffusion of the ample and valuable materials which have been, from time to time, deposited in such abundance in the archives of the war department. Something of the kind has been done of late by the publication of the Army and Navy Medical Statistical Reports; and it is to be hoped that the universal approbation bestowed upon these valuable works will incite those in power to continued analogous undertakings.

The present volume contains some interesting papers, which we proceed to notice.

1. FRAGMENTS FROM THE SURGICAL CLINIC OF M. Sedillot, Senior Surgeon to the Hospital of Instruction at Strasburg.

1. Purulent Infection.-M. Sedillot believes that authors have too generally regarded this affection as constantly fatal in consequence of their only taking into consideration extreme cases. He establishes a distinction between purulent infection and metastatic abscesses. As long as the disease is confined to the former condition it may be cured; if there are abscesses only of small size, or few in number, all hope is not extinct; death only being inevitable when these are very numerous or large, or open into the pleura, the articulations, &c. The effects vary much also, not only according to the quantity of pus mingled with the blood, but also according to its qualities-the pus from a phlegmon producing much less deleterious effect than a sanious pus. Wounds of the perineum, in which there is a mixture of pus and urine, produce, even when the suppuration is not very abundant, fatal effects in a very brief space of time. It may be replied to the statement that the less advanced cases of purulent affection recover, that such were not examples of the disease at all; but M. Sedillot believes the pathological changes induced in man and animals from this cause are the same, and numerous experiments upon these last have proved to him1. That a small quantity of pus injected into the veins only produces slight effects. 2. If the injection be repeated for several successive days, thirst, shivering, &c. are produced; but the animal continues to live if they are then discontinued-so that we must kill it in order to observe the pathological alterations at this period, such as patches in the lungs, emphysema, &c. 3. If a new portion of pus be daily injected, death takes place, always producing the same changes.

The lungs are the organs in which pus is found to be most frequently

NEW SERIES, NO. XI.-VI.

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deposited in this affection; then follow the pleura, the joints, the liver, and the muscles. Although veins are constantly found leading from the source of pus, in a great number of cases no trace of phlebitis is visible. After amputations, in deep-seated phlegmons, in chronic suppuration, caries, &c., it is always by means of the divided or eroded veins that a direct communication between the purulent centre and the circulation is established, and the mixture of pus with blood which this gives rise to is one of the best ascertained phenomena of the disease. The constant obliteration of the veins by coagula, even in the cases in which they are inflamed, is, contrary to the statement of most authors, an exceptional occurrence. The coagulum, when it exists, does not adhere to the walls of the vein, but floats in the pus, having an elongated, fusiform, shape. If it is interrupted from place to place, the blood remains fluid in the intervals, having lost its red colour, and become converted into a sanies by admixture with pus.

Recognizing different stages of this affection, and its curability in some of these, M. Sedillot enumerates the following indications of treatment. 1. Combating the inflammatory symptoms, if intense, by bleeding, especially local. 2. Modifying the surface secreting the pus, in the case of a wound. This is to be done by stimulant lotions or baths, or injections of aromatic wine. In this way the vitality of the tissues becomes modified, and the pus changed in qualities, or its secretion arrested. 3. Furnishing ample exit for pus by prompt incisions if necessary. 4. The frequent renewal of dressings. 5. The use of the actual cautery. This is often very efficacious. 6. If purulent infection seems threatened after attempting union by the first intention, the commencing cicatrix is to be broken, and the edges of the solution of continuity irritated. 7. A revulsive action of the secretory organs is to be maintained, especially by the use of purgatives. 8. Cold fluids should be drank in abundance, to maintain the venous system in a state of repletion, and diminish its absorbing powers as much as possible. 9. Counter-irritants should be applied in the vicinity of any organs suffering from derangement of function. 10. Tonics are not indicated until the febrile action has declined, and true prostration set in. 11. In the case of symptoms of infection occurring in a carious limb, amputation offers the best resource if its performance be not too long delayed.

2. Union by the First Intention.-In a section upon extirpation of the cervical glands, M. Sedillot takes occasion to express his opinion upon the union of wounds by the first intention. He is not an advocate in general for attempting this, as, in the hands of himself and the other surgeons of Strasburg, it seldom succeeds. When it is incomplete, the inconveniences it gives rise to are not compensated by its advantages, and the wound is healed more certainly, and nearly as rapidly, by dressing it with a barred compress and lint. When immediate union occurs, sometimes the integuments are alone agglutinated, the deeper portions of the wound not having undergone reparation. By the other method, the healing takes place from within outwards. In determining the question, climate must be taken into consideration. In the high temperature and dry air of Egypt union by the first intention produces wonderful results, and M. Serres has ob

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served the same thing to some extent at Montpellier: but in cold and damp climates, like those of Paris and Strasburg, such a mode of union is only the exceptional case. Alluding to the same subject, when treating of amputation of the thigh, M. Sedillot adds :

"The most exact approximation cannot prevent an excavation which serves as a reservoir for the fluids exuding from the wound. A pultaceous, greyish matter, a species of false membrane formed of the fibrous portion of the blood, which should be eliminated, is retained within the wound, and converted into a purulent and fetid sanies, which may give rise to severe consequences, such as phlebitis, purulent infection, &c. The bone, macerated in the pus, becomes denuded of the periosteum and necrosed. All this while adhesion of the skin, which is easily produced, masks what is going on in deep-seated parts until tension, tumefaction, and heat reveal it. Unless incisions are practised, or the cicatrization torn open, collections of matter are formed, and the morale of the patient, who believing himself nearly cured finds that all is well nigh to suffer again, becomes injuriously influenced.

"More security attends a different practice. After the ligature of the vessels the blood is to be carefully staunched, and the wound is neither to be closed by strapping or crammed with lint. A barred compress spread with cerate, and a few pieces of fine lint, are alone to be applied, the muscles of the limb being supported by a roller. During the first days the surface of the wound becomes covered with a greyish, pultaceous crust, which however is soon detached, leaving red, healthy granulations-the precursors of cicatrization. The fears of the patient of the first dressing have been especially objected to his plan: but such objection is only valid when the dressing is performed prior to the complete establishment of suppuration, and ceases to be so if this be delayed to the fourth or fifth day, when the compresses are nearly detached by the suppuration, and their removal gives relief instead of pain to the patient. After this the wound should be dressed daily, for frequent dressings are the best means for the prevention of danger from the sojourn of pus."

For the union of wounds by means of pins, needles, or the twisted suture, M. Sedillot gives the following precepts.

"When the solution of continuity is not very considerable, two or three points of suture are sufficient, as strips of plaster may be applied along the rest of its course. Surgical incisions or accidental wounds of more than certain extent require a greater number. In this case we should apply the first one at about the middle of the incision, as we can in this way judge much better of the disposition of the two lips of the wound, and remedy any imperfections or defects of relation. Before passing the needle we must smear its point with grease, taking especial care to free our fingers from this afterwards. When we wish to withdraw it, we should carefully free its point from all matters which can impede its exit, support the edges of the wound by our fingers while removing it, and leave in the threads for some days longer. The third or fourth day is generally the proper period for the removal of the needles, unless severe pain, tension, redness of the edges of the wound, or inflammation accompanied by fever, occur. In these cases we must remove them at once, and combat the accidents by ap propriate measures."

3. Extirpation of the Amygdala.-The humid climate of Strasburg seems very favourable for the production of angina and consequent tonsillar hypertrophy, for in one year M. Sedillot performed the operation of extirpation no less than thirty times. The operation may be performed by means of Fahnestock's amygdalotome, or by the bistoury. The former,

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requiring the aid of no other instrument, simplifies the operation, frightens the patients much less, and causes less pain: but it is a bad instrument, as only a part of the structure is removed, and resolution very rarely follows. The straight, probe-pointed, narrow-bladed bistoury, protected by a piece of linen to within a certain distance from its extremity, is the best one, requiring however the assistance of a hook or forceps. The section should be made from below upwards, with the double object of not covering with blood the parts yet to be divided, and being able, in case of need, to suspend the operation before complete section, the divided portion still held by its upper segment not being then liable to produce mischief by falling back upon the glottis. In operating upon children, a difficulty presents itself in keeping the mouth open. Cork is usually used for this purpose; but if it is too small it is easily displaced, and if too large it takes up too much space. M. Sedillot employs with advantage gold or silver thimbles, by which an assistant guards his fingers, and is then easily enabled to keep the mouth open as widely as may be required.

II. SEVERAL CASES OF CONGELATION. By Dr. Shrimpton,

An episode in the Algerian Campaign of 1845-6 furnishes the material for this paper. During the retreat of a column of the army (its numbers are not stated) from Bou-Thaleb in January, its progress became arrested by heavy snows for two or three days, and, provisions falling short, above 200 men died on the route. The particular detachment which Dr. S. accompanied lost no one, nor did any one in it suffer en route from congelation, which results, he attributes, to the beneficial effect of a few drops of brandy which he was twice enabled to distribute with some bread, and to the circumstance of the men when lying down keeping huddled close together. Although a strong north wind blew the cold was by no means intense enough to account for the large mortality. Prior to the retreat, too, the labours of the soldiers had not been excessive, nor had they been subjected to any privations. The great scarcity of food, and the fact of some of the most robust perishing, seem to indicate that defective alimentation was the cause of these results; man requiring an energetic nutrition to resist the influence of low temperatures. The phenomena accompanying death by congelation, Dr. S. thus describes :

"I have frequently been a witness of the symptoms which precede death from congelation. The persons experience a general sense of stiffness or numbness, accompanied sometimes with pains in the limbs and groins. Muscular contraction is performed with difficulty. The face becomes red and swollen, the lips blueish, the eyes projecting, and the hands red and tumid. The pulse is small and feeble and the respiration slow. All these symptoms rapidly increase. The eyes then take on a wandering expression, the step is uncertain and vacillating, and at last the man falls down. The skin of the hands cracks and frequently gives issue to from two to four ounces of blood. The patient preserves his senses, but has all the appearance of a drunken man. If he is raised up falls down again, and he cannot be kept in a litter without being tied to it." Upon the arrival of the column at Setif, 532 patients were admitted into the hospital on account of the effects of congelation. Of these, 186

he

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were cases in which phlyctenæ or slight ulcerations followed congestion of the feet or hands, 60 in which the loss of one or more of the nails occurred, and 221 in which superficial gangrene took place without implicating the bones or joints. In 52 cases, in which these latter parts became affected, amputation was performed, three of the patients only dying after the operation, although the wounds for some days put on a very flabby aspect, and were in some parts disposed to slough. Eleven cases perished from sphacelus of the extremeties, or consecutive internal lesions. The feet, as might be expected, from their constant exposure to melting snow, suffered in the vast majority of cases; and thus, of 532 cases, in only 26 was there congelation of the hands. The local effects of congelation are strikingly identical with those produced by burning in its various degrees; so much so, indeed, that the one case could not by mere inspection have been distinguished from the other. In the fatal cases, marked pulmonary and cerebral congestions, or even inflammation, were found, and, as in severe cases of burns, gastro-intestinal irritation was set up, which sometimes proceeded to ulceration of the ileum and colon. The local inflammatory re-action after congelation was, however, less prompt and marked than after burns, and was often absent, giving rise to extensive lesions after the fall of the eschars. On the other hand, parts which were even blue, or black, from local asphyxia, sometimes promptly recovered their normal condition under the influence of this re-action.

In respect to treatment, the patients who seemed in danger of asphyxia, were enveloped in bed-covering, while some hot broth was given them. Very soon after this they fell asleep, and a mild re-action generally became established. In some cases detailed, fatal inflammation of the lungs or membranes of the brain was developed. The milder local effects were generally cured in from four to eighteen days, pains however persisting in the joints of the hands and feet for one or several months. The wounds were simply dressed and the limbs enveloped in flannel moistened with camphorated oil. The benumbed parts were gently rubbed until re-action became established. The phlyctenæ were preserved as long as possible, especially in the slighter cases, and, when the parts were much engorged, incisions were practised in order to prevent the spread of gangrene. Warm fomentations and poultices were also employed during the first days. All those who were enabled to leave their beds were encouraged to do so and go into the airing courts, while the wards, bedding, &c. were thoroughly cleansed and ventilated-a precaution rendered essential by the crowded state of the hospital, 528 patients occupying a space intended only for 200. Substantial diet and, as soon as possible, wine were prescribed.

III. ON THE EARLY USE OF INJECTIONS IN GONORRHEA. By

Dr. Poullain.

The employment of injections as an abortive mode of treating gonorrhoea, a practice never received with much favour in this country, has recently re-excited great attention in France. M. Poullain, from his position of Surgeon to the Military Hospital at Lyons, has had great opportunities