are especially prone to fatal collapse under ordinarily very inadequate exciting causes. It is also important to remember that, owing to internal disease, death may occur during a quarrel, although no blow may have been given. One such example is noted3o in a case where two women were in a violent altercation, when one was seen suddenly to fall dead. On examination she was found to have died of congestion of the brain. Yet, but for the witnesses of her mode of death, her adversary might have been suspected of dealing her a fatal blow. Wounds inflicted on pregnant women obviously render the prognosis graver in that they affect the life of two individuals, and also, by interfering with the normal course of the pregnancy, endanger the life of the mother. Under such circumstances wounds which involve the abdomen, especially those which do violence to the uterus, are of extreme gravity. The amount of violence necessary for the production of abortion, or of death to either mother or child, is of great variation. An instance is cited of a woman gored by a bull, the uterus being ripped open so that the child escaped through the tear in the abdominal wall; and yet both mother and child were saved ;31 but such cases must be most exceptional. 227. Indirect sources of danger; infection. Of the indirect sources of danger from wounds, by all odds the most important is that of infection with pathogenic organisms. On the entrance of these organisms depends the local suppuration in the wound and the general symptoms due to the absorption of the products of these germs, or the distribution of the germs themselves throughout the body. So that we see, as results of wound infection, many different types of disease, from the virulent sepsis or blood poisoning of the streptococcus pyogenes, to the slow and lasting infection with the unidentified virus of syphilis. As the common varieties of infection may be mentioned sepsis and pyemia, or general blood poisoning, tetanus or lockjaw, erysipelas, hospital gangrene, diphtheria, tuberculosis, syphilis, anthrax, and hydrophobia.32 Each type of infection depends upon the specific germ inoculated, and runs its own 26. Prager, Viertljhrs., Vol. LXVI., p. 1 See Pigue, Arch. Gén. de Méd., July, 1836, and also Thatcher, Edinb. Monthly Journ. Med. Sci., July, 1850, p. 88. For the relation of infection to trauma, especially tuberculosis, see: Salis, Dissertation, Bern, 1881, Die Beziehun gen der Tuberculöse zu Traumen des Schädels; Lacher, Friedreich's Blätter, 1891, p. 321; Grasser, Wiener med. Presse, 1893, No. 42, Unfall als Ursache von Enzündungen und Gewächsen; and Guder, Ueber den Zusammenhang zwischen Traumen und Tuberculöse, Vierteljahrsch. f. gericht. Med., 1894, VIII., 1 and 2. characteristic course, for the description of which reference should be made to any authoritative text-book on surgery. Under any ordinary circumstances outside of surgical operations, the responsibility for such an infection can not be laid upon the one who inflicts the wound, as the disease germs are widely spread throughout the air, earth, water, and other substances that come in contact with the wound under normal circumstances. Intentional infection of a wound is such a barbarity that it is not deemed honorable even in wars between nations, and could be brought about only in exceptional cases without access to scientific laboratories, or without at least scientific knowledge. 228. Fat embolism.- Fat embolism38 is a rather infrequent sequel of injury to some fatty tissue, most frequently the marrow of a bone after fracture, also after heart, kidney, and arterial disease, in suffocation and burns. In these cases bone injuries which in themselves do not seem in any way to threaten life may become mortal wounds, in that small particles of fat get into the blood vessels and are carried to the smaller vessels, where they lodge and obstruct the blood supply to that part. As these fat masses usually lodge in the lungs, their lodgment interferes with respiration, and not infrequently causes sudden death. This outcome is so far from the usual one following a fracture that it can not be said to be an expected conse quence. 229. Surgical interference. The dangers involved in the surgical treatment of major injuries often cannot be differentiated from those arising from the wound itself. The difficulty is not so great where the original wound has been trifling, chiefly because its comparatively innocuous character can be clearly shown. Thus, for instance, if the hand has been wounded and one of the arteries divided, compression may be necessary to arrest the hemorrhage. But if a surgeon, with this view, should apply a bandage so firmly, or leave it on so long as to cause mortification of the part, and death should ensue in consequence, it would be evident that the treatment had not only been unskilful, but that it had really been the cause of death, since the wound of the hand was neither, in itself, mortal, nor would it have produced death in the manner described. But, in severe injuries, in which various complications arise and require the exercise of the greatest skill that learning and experience can give, it cannot be expected that some will not terminate fatally, which, perhaps, under See Friedreich's Blätter f. gericht. Med. 1898,-an article by Carrara. more favorable circumstances, or a better plan of treatment, might have had a fortunate issue. The most humble surgeon may chance to receive the charge of an injury which calls for the enlightened tact and experience of a highly educated man; if his treatment should not prove successful, he should be prepared to show, if required, that his patient had the best care which he was able to afford him, and, if possible, that he consulted with one or more colleagues respecting the treatment. In the language of Judge Woodward: "The implied contract of a physician or surgeon is not to cure,-to restore (e. g.) a fractured limb to its natural perfectness, but to treat the case with diligence and skill. . He deals not with insensate matter, like the stonemason or bricklayer, who can choose their materials and adjust them according to mathematical lines, but he has a suffering human being to treat, a nervous system to tranquillize, and a will to regulate and control." 34 229a. Methoȧ.-Death, indeed, sometimes takes place during or immediately after surgical operations undertaken for the relief of the wounded person. The question of responsibility in this case belongs to the legal portion of the subject. It may not, however, be out of place to remark that the surgeon can seldom foresee, with confidence, the issue of capital operations, for there are many individual peculiarities and causes beyond his control, which may make it unfavorable. It is customary for the surgeon, before undertaking any major operation, to inform either the patient or his friends of the usual mortality of such operations, and the probable outcome of this particular one, as he estimates it. Such a preliminary statement, if cautiously made, prepares the patient for the accident which cannot be foreseen, and leads to harmony rather than lawsuits that arise out of misunderstandings. The uncertainty of outcome is present in any plan of treatment, whether it involves a serious operation or not. The question may arise, whether the surgical treatment employed was the best that could be devised, and whether, had some other course been pursued, a favorable result might not have been obtained. Or, it may be alleged that the treatment was so unskilful, or the patient so much neglected, as to be the occasion of the fatal termination of the injury. That these facts should be established beyond dispute, it ought to be shown that the treatment was marked by the omission of something universally recognized as of primary importance. But, as every surgeon has some peculiarities in his practice, and as the mode of treatment of bodily injuries, from the progressive nature of "McCandless v. McWha, 22 Pa. 261. the medical art, is various, this omission should be looked for only in those points which betray an ignorance of the fundamental principles of surgery. However much the opinions of competent persons may differ respecting the choice of remedial means, they will generally, we think, be found united upon the principles which should govern their application. Still, occasionally, the plan of treatment may be so singular, although apparently founded upon correct notions of the curative process, as to call for reprobation. Thus, in a case which occurred in Saxony,35 a surgeon was deprived of the liberty of practising his profession in that country for having attempted to promote bony union between the fragments of a fractured patella, by the novel expedient of firing a pistol between them. Although no permanent injury was done to the patient, who, indeed, a few months after the operation, declared that his leg was nearly as good as the other one, and that he was even able to dance and to walk long distances, yet the medical commission charged with the case very properly considered the operation as likely to prove a dangerous precedent if it were not condemned. 229b. Anesthesia. In the administration of general anesthetics for surgical work there is always a certain amount of danger from the anesthetic itself. In speaking of chloroform anesthesias in the International Text-book of Surgery,36 the statement is made that "No blame, in many instances, can be attached to the quality of the agent or to the method of administration. The accident has occurred in the hands of the most careful and experienced of men: Sir James Y. Simpson, the father of chloroform anesthesia, Erichson, Billroth, Volkmann, Syme, Hunter McGuire, Willard Parker, T. H. Hamilton, and many other competent and reliable physicians." The statistics as to the comparative dangers of the different anesthetics vary a great deal; but, in general, the mortality from chloroform may be taken at about one in two thousand, of ether about one in fifteen thousand, and of nitrous oxid, or laughing gas, about one in two hundred thousand. But the choice of anesthetic depends upon so many factors that it is not fair to say that the one which has the lowest mortality numerically should be used in all instances. Nitrous oxid has many disadvantages for general surgical work, ether, also, is distinctly contraindicated in certain other cases, and, on the other hand, chloroform has many distinct advantages. The recent introduction of local anesthesia has brought forward the possibility of Casper's Vierteljhrschr., 1852, Bd. 1, H. 1. "International Text-Book of Surgery, Warren-Gould, 1900, p. 445. doing away with the general anesthetic in many instances, even in some major operations. Within the last few years, too, the injection of cocaine into the spinal canal has been used in cases where the safety of a general anesthetic is very doubtful, but the technique of this injection is still in process of modification to such an extent that, in general, it cannot be considered as safe for persons in good health as is even the most dangerous of the established general anesthetics. 229c. Complications. After operations, too, in a certain number of cases there is an unaccounted-for confusional insanity, which is, as a rule, of but a temporary character, and needs merely to be mentioned. Of a similar character is the traumatic delirium that follows in a certain number of instances,-likewise a temporary condition. As another complication of operations, or more often of wounds that produce much laceration of tissue, and yet are kept clean and aseptic, is the temporary traumatic fever,-rarely of a severe grade,—not significant except as a complication which might give rise to some misinterpretation of the results of an operation or wound if it were not recognized as of its true character. 230. Remote sources of danger, in general.— Besides these direct and indirect results of injury there are a number of remote effects dependent upon the traumatism for their beginning. Among these may be mentioned the cases of traumatic epilepsy or diabetes following injuries to the regions of the brain or spinal cord and paralysis due to injury of the nerves going to the helpless muscles. 231. Spinal paralysis.- Spinal cord or nerve injuries leading to paralysis of the parts of the body supplied by those nerves are common. Destruction or even compression of the spinal cord regularly produces paralysis of all the voluntary muscles below the level of the injury. For the exact extent of the paralyses reference should be made to any of the standard text-books on nervous diseases, under the heading of paraplegia or transverse myelitis.3 37 232. Epilepsy.- Epilepsy may be a sequel of injury to the skull, or, in rarer instances, to injuries in different regions of the body, in which cases the irritation of the scar or the disturbance of the nervous equilibrium in the remote part of the body produces a reflex nervous discharge in the form of an epileptic attack. One very interesting instance of reflex epilepsy is recorded by Briggs,38 in which a girl had both a depressed fracture of the skull and disease of the leg. "See Starr's Organic Nervous Dis eases. "Briggs' case is quoted in the Amer ican Text-Book of Surgery, 4th ed., 1903, p. 608. |