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in a single lung. Multiplicity is one of their characteristics; but in some cases a dozen, or even less, have been found in the lungs. There is no absolute rule; but in general, when they are very numerous, they are also very small. In respect to the agency of capillary phlebitis in the production of these abscesses, M. Sedillot observes :

"We must have no playing upon words here; for it is evident that no parenchyma can be attacked with phlogosis without the capillaries participating. But if it is understood, by this phlebitis, an isolated inflammation of the small vessels amidst intact cellular texture; and if it is supposed that pus is formed and recognisable in the venous ramuscules, observation does not confirm this hypothesis, and we may fearlessly deny the existence of the phlebitis." (p. 470.)

Abscesses, when fully formed, may evacuate their contents into neighbouring cavities, or externally like other purulent collections; but at other times these contents are resorbed, the pus being at first replaced by a clear serous fluid ("the liquefaction of pus"), and all traces of this afterwards disappearing.

It is to purulent effusion into the pleura that attention has been chiefly directed, this being far more common than effusions into the peritoneum or arachnoid, which, indeed, are rare. The author has never observed such pleuritic effusion without coexisting pulmonary alterations, which, indeed, he regards as a necessary correlation. Sometimes there are only partial pleurisies; and at others, pseudo-membranes in various stages of organization. The most remarkable cases are those of consecutive pleurisy, consequent upon an abscess of the lung having made its way into the pleura. Purulent effusions into the joints are of frequent occurrence.

"When a bone has been sawn across in amputation, and a fatal purulent infection has resulted, it is common enough to find pus in the joint above. Here the cause is evident; the inflammation being propagated by the medullary canal, in which we may generally discover sanies and pus. But, in many cases, joints far removed from the source of primary suppuration become the seats of such effusion; and in explaining this, we must invoke not only the presence of the globules of the pus, but also the facility with which the synovial membranes reflect all general perturbatory causes. We can offer only doubtful explanation of the sudden disappearance of articular swelling and effusion, and we confine ourselves to indicating them." (p. 478.)

As the author has endeavoured to point out the symptomatic distinctions between purulent infection, and its complication with a putrid element (septico pyamia); so he also believes that their pathological characters are sufficiently distinctive. As purulence is the distinguishing trait of pyæmia, so is gangrene of putrid infection; and hence we find in purulent infection, complicated with putridity, "blackish, brown, or gray projections on the lungs, having soft walls, and being true gangrenous phlyctenæ filled by an altered and spumous blood. The affected tissues are easily torn through, offering irregular, eroded, grayish surfaces. Suppuration is tedious, and takes place at the circumference of the mortified parts, and petechiæ are observed in different parts of the body."

Prognosis. Although ordinarily the progress of this disease be from worse to worse, and that with rapidity, in other cases it is of slower procedure the mean duration of the disease being from four to eight days, according, at least, to M. Sedillot's own experience. The disease has generally been regarded as incurable, but the author long since published proofs of the incorrectness of this opinion, and the present work contains

both in the experiments and cases detailed, its ample refutation. Still we believe the author speaks too sanguinely upon this point, or he must include cases not usually comprehended under this term. Thus he says:

"MM. Vidal, Blandin, Velpeau, Nelaton, and others have published some successful cures. We may reassure practitioners by telling them that such ought to be the ordinary result of well-directed treatment. Pyæmia is of infinitely more frequent occurrence than is generally admitted, and for the most part terminates successfully. Incurability is the exception; and far from proclaiming the powerlessness of art, we believe it possible to throw farther back thie limits of its applicability, and yet extend its resources." (p. 452.)

The danger in pyæmia is in direct proportion to the amount of pus poured into the circulation. Where large quantities rapidly obtain admission, the progress of the disease may be so rapid (pyæmie foudroyante) that the formation of the metastatic abscesses has been even prevented, it being an error to suppose that the existence of such abscesses is essential to constitute a case of pyæmia. Emphysematous patches and numerous points of ecchymosis are found on the lungs, and the signs of asphyxia in other parts of the body; and the patients succumb by reason of the defective hæmatosis. In such a case the danger is extreme, and death almost inevitable. In other cases the quantity of pus mingled with the blood is less at a given time, but is continually augmented by the arrival of new parcels, presenting a very dangerous form of acute pyæmia, which must become incurable if the source of the pus cannot be arrested. If this is accomplished by amputation, or other means, the patient will then be saved or lost, according to his condition of vitality, and to the degree of alterations that have been already produced. When pus is introduced in small quantities and with intermissions, a state of chronic pyæmia is induced. The consequent organic changes are inconsiderable, of slow development, and of easy resolution if the source of pus be dried up. The qualities of the pus also influence the result. Thus a thick pus, abounding in globules, is more dangerous than a serous pus; and an inodorous, laudable pus causes fewer accidents than does an altered and fetid pus. The conditions in which the patients may be placed are highly important in the consideration of the prognosis. Thus, as regards constitution, a person of a lymphatic temperament, with soft flesh and hurried breathing, whose vessels are of small calibre, and in whom moderate exertion induces dyspnoea and palpitation, ill resists the invasion of a pyæmia. As regards age, the author's observations lead him to believe that youthfulness is favorable to the cure. The great cause of the fatal termination of surgical cases being faulty hygienic circumstances, the existence of such materially influences the prognosis. Hemorrhages not only predispose to pyæmia, but render its cure more difficult, owing probably to the depressed morale of the patient, and the greater tendency to suppuration in enfeebled constitutions. Upon this point M. Sedillot makes the following incidental observation :

"I have formerly heard men of undoubted authority declare that tying the principal artery of a limb would be a very efficacious means of arresting the progress of an inflammation by a suspension of the supply of arterial blood; but experience has shown me the error of this supposition. I have observed many examples of abundant and inexhaustible suppurations occurring in organs in which the circulation of red blood had been in part suspended by the ligature of the arteries. The

most vigorous men are the least liable to suppurations. Facts like this should greatly modify ill-founded opinions." (p. 488.)

Treatment. After adverting to the vague, empirical, and desponding views which have prevailed upon this subject, M. Sedillot lays down the following plan of procedure: 1. The prevention of the causes (prophylaxis). This would be best effected by the suspension of the formation of pus, but although this is often impossible, yet, as all suppurating wounds do not induce pyæmia, we should investigate the additional circumstances upon which it especially depends, and these seem especially to be faulty hygienic conditions and retention of pus in the wounds. The author mentions the fact that formerly a moat filled with stagnant water existed near the Strasburg Hospital, and that then few patients were saved after operations, whereas since it has been filled up, success has been as great. Still he regards as a chief cause of pyæmia, the retention of pus in the wounds, which induces inflammations and erosions, and consequent phlebitis. If union by the first intention could certainly be obtained, it would operate as our best preventive; but unfortunately this is not the case, and he reprehends the attempts as deceptive.

"It is principally in reference to amputations that so much controversy has prevailed upon this subject, and for my part I have a strong feeling against attempting union by the first intention. I have performed or seen performed hundreds of amputations at Paris, Metz, Strasburg, and in Poland, Germany, and Africa, and I have never yet been witness of one case of the complete success of this mode of dressing the stump. I know, however, such do exist; but how often have not patients been considered as cured whose partially cicatrized stumps yet presented fistulous apertures, from which daily escaped a certain quantity of pus? I have found such patients in a yet more precarious position, one, two, or three, and even six months later, their health having become deteriorated, and a fatal pyæmia being set up. In union by the first intention, the integuments adhere together easily enough, but the blood, lymph, and pus remain accumulated beneath around the extremity of the bone, ferment there, and acquire fetidity; the deeper textures become altered, the bone is denuded, and pyæmia is imminent." (p. 496.)

All inflammatory strangulation of the soft parts concerned in wounds must be guarded against, whether by local bleeding, the cautery, or debridement. The traumatic surfaces should be maintained in their vitality by moderately stimulating applications. M. Sedillot refers to the injudicious preference given to the bistoury in recent times, in several operative procedures, where caustics would act much better, as exciting obturative or obliterating inflammation.

The second indication is, in the case of pyæmia becoming declared, to arrest the penetration of pus into the blood. This is endeavoured to be accomplished in five modes: 1 The opening of a free issue for the pus. 2. The conversion of a pyogenic membrane into an eschar, and thus suppressing suppuration from its surface. M. Bonnet passes the actual cautery over the whole of the suppurating surface for this purpose; but M. Sedillot prefers proceeding more cautiously unless the surface is very limited, fearing otherwise that by acting only upon the superficial layers, pus might be imprisoned by the eschar, and strangulation produced. 3. Obliteration of the veins by intercurrent applications of the actual cautery effectually impedes the conveyance of pus by substituting an obturative to a suppurative phlebitis. 4. The actual cautery is the most valuable means we have of also modifying an unhealthy, fetid condition

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of the wound, conditions which may produce septico-pyæmia. other astringent and caustic topical applications are of much use to this end. 5. Ablation of the suppurating parts is of course a means of great efficacy, but requires much consideration before deciding in favour of it.

The third indication relates to the treatment of the local inflammations due to the presence of the pus-globules; but under this head we find nothing worthy of notice.

Having thus brought the principal points of M. Sedillot's work under our readers' notice, we may observe, that although we consider it a valuable contribution to the literature of the subject, its value appears to us to consist rather in the number of facts it contains, than in the reasoning by which these are explained. In the first place we believe, as already stated, that certain miasmatic poisons are capable of producing the train of symptoms he has indicated, and, in fact, we cannot doubt that they did so in some of the cases where he has attributed this agency to pus; and, indeed, when we consider the numberless cases in which pus may obtain access to the blood, and yet does not give rise to purulent infection, we may well suppose that some co-operating cause is essential to its production. His theory is excellent for the explanation of the production of the metastatic abscesses; but we cannot regard these as other than a mere part of the affection; for if sufficient pus is thrown into the circulation, death results long before these can become developed. Then again his acknowledgment of the toxical effects of putrid matters introduced into the blood, even separated from the obstructing globules, seems fatal to his theory; especially since the fatal effects of such agents proved far more rapid than those caused by mere pus, and are often exhibited before any of the gangrenous results on which he bases the distinction could be developed.

It can scarcely be questioned that purulent fluids have a peculiar tendency to undergo decomposition; and we believe that the facts of the case will be better met by supposing that in this condition pus may act as a "ferment," in common with other putrescent substances, than by considering that it has any special agency, otherwise than possibly that of mechanically obstructing the capillary circulation.

ART. IV.

A Short Sketch of the Life and Writings of the late Joseph Clarke, Esq., M.D., V.P.R.I.A., and formerly Master of the Dublin Lying-in Hospital, &c. &c.; containing Minute Results of his Private Practice, extending over a Series of Forty-four Years, including Three Thousand Eight Hundred and Seventy-eight Births. By ROBERT COLLINS, M.D., President of the King's and Queen's College of Physicians in Ireland, &c. &c.-London, 1849. 8vo, pp. 88.

THIS is an interesting and important publication. It contains an obstetric record which, in some respects, is without a parallel. It is one perfectly to be depended on, and comprises no less than 3847 cases of labour, representing 3878 births, personally attended and registered by one of the most distinguished obstetricians of his age, and occurring amongst the higher ranks of society. It is the rich legacy of an active

professional life, extending over forty-four years, which has been made an available addition to the science of midwifery by Dr. Collins. It will be received by all whom experience has taught to appreciate the records of an honest and discriminating mind with interest and respect.

A short sketch of the principal events of Dr. Joseph Clarke's life, written by himself, and extended by a more detailed account of his history, writings, and private practice, by Dr. Collins, forms another feature of this publication. In this part, however, we have been disappointed. The life of a practising physician is almost necessarily scanty in incident; but we hardly could anticipate such a meagreness of personal history in one who had filled so conspicuous a position in a large capital, and for so long a time, as Dr. Clarke. Those who, like ourselves, did not know Dr. Clarke, can learn but little of him from this biography. And yet the large expressions which Dr. Collins, with such a warmth of feeling and veneration, employs in reference to him, excite a strong desire to learn more of his individual character, and of what he said and did. The outline is broad, but there is no filling up. We feel, too, that Dr. Collins's long and intimate acquaintance with Dr. Clarke might have supplied a most useful and instructive account of his midwifery consultations; a kind of knowledge which is much wanted, and which might well be gleaned from such a life as Dr. Clarke's.

It appears that, after a good general education, Dr. Clarke studied medicine at Edinburgh, where he graduated with ease to himself and some reputation. He afterwards travelled on the continent with a patient; and before returning to Dublin, spent some time in London, which enabled him to attend Dr. William Hunter's course of lectures, including those on the gravid uterus. He had previously determined to practise as a physician in Derry; but by the advice of his friends, and particularly Dr. Cleghorn, he resolved to settle as an accoucheur in Dublin, a fair prospect of success being opened by the death of his grand-uncle, Dr. Maconchy. He then entered as a pupil of the Lying-in hospital, with something short of £300 of money, and in about eighteen months afterwards he was appointed assistant to the master, for each of which appointments he paid 100 guineas. He subsequently travelled with an invalid gentleman, from which, he says, he "acquired much valuable information from visiting the London and continental hospitals, gratified a great deal of curiosity, diminished somewhat his youth (which is adverse to professsional success), and saved of his allowance £240." He married, in 1786, Isabella Cleghorn, niece to Dr. George Cleghorn, with whom he received a fortune of £1500; and on the 3d of November of the same year he became master of the Lying-in hospital. Dr. Cleghorn was the founder of the Anatomical School in Trinity College; and in this school Dr. Clarke was called upon to assist him as a lecturer for about two years.

During the time that Dr. Clarke was pupil and assistant-physician to the Lying-in hospital, his attention was directed to the frightful mortality amongst the infants, from what the women called nine-day fits, which destroyed no less than one in six. Dr. Clarke referred them to a defect in the ventilation of the hospital, which, at his urgent suggestion, was remedied. There was constantly provided an easy and free passage of fresh air through the wards; the number of beds was reduced; and the wards kept more clean. The mortality from this time diminished; and

8-IV.

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