is a bad epithet for the condition which arises from septic infection, because it implies putridity of the blood, in the sense of putridity outside the body; and thus a word wrongly applied has led to more argument about the word than about the condition which it is supposed to describe. The word does not convey to pathologists the idea of putridity of the blood, but of blood poisoned by a certain substance derived from a putrid material. In my remarks on fermentation I pointed out that the fermentation of certain organic fluids gave rise, as a result, to a poison called septic poison; we have now to consider the means by which this poison may be introduced into the blood, and the results which may follow its introduction. It has been shown that where bacteria exist this poison is liable to be produced, therefore if a suitable soil for the maintenance of the life of the bacteria and their progeny is maintained in any portion of the body where entrance to the blood stream can be obtained, the system is in danger of the septic poison. Now such soils for the growth of bacteria exist in wounds, some forms of ulcers, anthraces, and the uterus of a recently delivered woman; the presence of bacteria in such stations is a mere matter of observation, and does not depend on opinion. It may, however, be affirmed that if the septic poison be produced by the action of bacteria apart from the infected body, that that poison is also capable of producing septicemia. Certain accidents which happened to myself seem to illustrate this point. In the autumn of the year 1860, when resident pupil at Steevens' Hospital, and acting as dresser to Mr. Cusack, I accidently cut myself with an ordinary knife at breakfast; after breakfast I proceeded to the wards (having placed a piece of ordinary plaster firmly over the wound) and went round with the medical staff. At about eleven o'clock I commenced dressing Mr. Cusack's patients, of whom there were a considerable number to attend to, having among them a recent amputation, a case of extravasation of urine with extensive sloughing, and a bad compound fracture. I had concluded my work about one o'clock, and went to my home in Molesworth-street, distant about two miles, walking without fatigue; dined at five, but felt disinclined to eat, and about six o'clock proceeded back to the hospital. Before I arrived there I felt exceedingly ill, and scarcely able to walk. Being too ill to work I went to bed; did not sleep; felt feverish and shivery all night. In a few hours felt my arm painful, and when daylight came I found red streaks passing from the site of the wound of the previous morning up to the axilla,

where the glands became swollen and tender; the wound itself was not painful. The symptoms subsided in a few days, and in a week I was well. I had received a comparatively small but direct dose of septic poison. I have on several occasions since suffered from post mortem wounds, and once from a wound caused by a careless assistant who was helping to dress a case of cut-throat. In none of these cases, however, did I feel the effect for several days, whereas in the former instance I suffered immediately. Viewing these phenomena by the light of our present knowledge, I am led to the belief that in the first instance I was affected by the septic poison which had been already produced by the bacteria and their progeny in the open sores of the patients. In the latter cases it was only bacteria which had entered my wounds; and had they been destroyed before developing their poison, I should have escaped; as it was, they spent the few days elaborating their venom. When the septic poison is introduced into the blood of animals the effects are rigors, debility, gastro-intestinal irritation, vomiting, and purging (the discharges often being of a bloody character), and the temperature rises to two or three degrees above the normal. If the dose be not sufficiently large the symptoms subside, and the animal recovers. If the animal die the post mortem appearances are-extravasations of blood found on the internal surfaces of the cavities of the heart, especially the left ventricle under the lining membrane, also upon the serous surface of the pleura and pericardium; the spleen is enlarged, and the mucous membrane of the stomach and small intestine intensely congested, and the epithelium detached; all the other abdominal viscera also congested-in fact, all the conditions present indicate capillary congestion and stasis of the blood. Not only do these conditions present themselves, but a careful microscopical and physical examination of the blood shows that it itself has become materially altered. It is not putrid in the ordinary sense of the word, but nevertheless some of its essential constituents are decomposed. Thus the blood of an animal dead of septic poison is of a darker colour, and on minute examination it is found that many of the red corpuscles have disappeared, been broken up and disintegrated, some have even been completely removed from the body with the blood-stained discharges from the bowels, and where the blood is allowed to settle it is found that the supernatant fluid remaining after the subsidence of such corpuscles as are intact is stained by the colouring matter of the disintegrated corpuscles. The conditions

which arise from septic infection in man, differ in many particulars from those produced experimentally on animals, but are nevertheless of the same nature, and produce similar results. The following definition of septicemia, used by Dr. Sanderson in his recent lectures on the infective processes of disease, may be accepted as complete and concise:-" Septicemia is a constitutional disorder of limited duration, produced by the entrance into the blood stream of a certain quantity of septic material." Dr. Sanderson further remarks in the same connexion-" It must therefore be looked upon not so much as a disease as a complication-differing from pyæmia not only in the fact that it has no necessary connexion with any local process, either primary or secondary, but also in the important particular that it has no development." "Pyæmia is a malignant process which goes on to its fatal end." It may be considered proved that the conditions which follow the introduction of the septic poison-namely, debility, local congestion, and fever, depend upon the disintegration of the blood corpuscles. This proof rests upon the fact that if healthy blood, drawn from an animal, be so treated as to break up the corpuscles, such blood introduced into the circulation of the same animal will produce symptoms exactly similar to those following the introduction of the septic poison. It has been ascertained that the corpuscles contain an element which is the cause of the coagulation of the blood, and in order that this element may act it must be liberated by the breaking up of the corpuscles-hence the dangerous effects by the re-introduction, into the arterial system, of blood containing broken corpuscles. The stasis in the capillaries is caused by minute coagula, and this condition will also arise in consequence of the introduction of the septic poison. The two conditions are very similar, but not identical, for the sepite poison seems to possess other properties besides disintegrating blood corpuscles. The points which I particularly wish to emphasise are:-1st. That the septic poison may be produced outside, and not even in contact with the body which it affects. 2nd. That it may be produced within the same body, provided a suitable soil for the growth of bacteria and their progeny exist therein. 3rd. That the septic poison is incapable of self-multiplication. Bacteria or their germs may enter the system by the lacteals, by the lungs, or through wounds. Healthy blood never contains bacteria or their germs, but it is proved that healthy organs do contain bacteria, therefore the

British Medical Journal. 1877 and 1878.

bacteria and their germs are capable of being destroyed by the vital processes; indeed if it were not so life would be impossible. If, however, septic germs be introduced into the circulation of an animal suffering from inflammation produced by an injury, such as the operation of bistournage, the germs will lodge in the inflamed part and produce diffuse inflammation, which quickly extends. In a similar manner germs from the intestine may make their way to a suitable soil in an inflamed peritoneum, and produce similar and fatal results. These poisoned soils become thus centres of true septic poison. We can here see how an inflamed or irritated peritoneum may become the means of diffusing fatal infection.

ART. II.-On Amputation in Spreading Traumatic Gangrene. By EDW. WOLFENDEN COLLINS, M.D., F.R.C.S.I.; Surgeon to Jervis-street Hospital, &c., &c.

THE propriety of immediate amputation in traumatic gangrene, when rapidly spreading without any line of demarcation, is still a subject on which civil surgeons are far from being agreed. The expectant treatment formerly pursued in these cases, before the writings and practice of Larrey demonstrated the advantage of early operative measures in military surgery, has still its advocates. I, therefore, submit the following series of cases, which have occurred comparatively recently in Jervis-street Hospital, under my own care and that of my colleagues, with the intent that their consideration may contribute, in some degree, towards the solution of the vexed question-how far amputation may be resorted to with success in civil practice in the treatment of this truly formidable disease. CASE I.-Laceration of Arm by Machinery-Gangrene and Secondary Hamorrhage-Amputation near Shoulder-joint-Recovery.

John Doyle, aged fourteen years, was admitted under the care of Mr. Banon, on December 2, 1857, having sustained a severe lacerated and contused wound above the elbow, which extended round the limb. While engaged in a paper mill, near Dublin, attending to the felt as it passed between the rollers, he had unconsciously laid his hand on this substance when the machinery was revolving with great rapidity, so that the limb had been forcibly dragged between the rollers up to the elbow. The soft parts in this region were, therefore, much more bruised than in the forearm near the wrist, owing to the pressure of the rollers increasing with the bulk of the forearm. The mill was immediately stopped, and the

arm extricated from the grasp of the rollers. The boy was then taken to the nearest surgeon at Tallaght, and was subsequently sent in to Jervisstreet Hospital. It was found that the injury was confined to the soft parts, and that the bones of the arm and forearm were unbroken.

Next morning the parts presented a very unfavourable appearance. The lips of the wound looked swollen and unhealthy; and the skin, extending downwards over the joint, showed signs of commencing gangrene. Large bullæ, containing the usual discoloured fluid, had formed in the neighbourhood of the joint and down the forearm, which was oedematous and swollen. The temperature of the parts was much reduced, and the boy complained of intense pain. In the course of a few hours, under the influence of opium in full doses, the pain subsided, and the boy got some sleep. Considerable hæmorrhage, however, took place from the part of the wound immediately above the olecranon process. This was restrained by the application of a tourniquet over the brachial artery, and, when it recurred some hours subsequently, by the introduction gently into the wound of strips of lint, steeped in a saturated solution of gallic acid.

By the following day, the third after the accident, the gangrene had greatly extended over the forearm, the back of which was in a state of sphacelus. The boy still complained of intense pain, and the constitutional disturbance was very great. Owing to the rapidity of the destruction of the parts from the period of the accident, the occurrence of hæmorrhage, and the alarming nature of the constitutional symptoms, the idea of saving the limb was now abandoned. Amputation of the arm was decided on, and forthwith performed by Mr. Banon. Although the limb was removed very high up, close under the shoulder, it was found that the soft parts in the line of the incision had not altogether escaped injury. Small coagula of blood were observed, and only one artery, the brachial, required to be tied-evidences that the parts were much contused.

The stump suppurated freely. Ultimately, the boy made a satisfactory, though tedious, recovery, after a stay in hospital of five months. CASE II.-Gunshot Injury of Forearm-Gangrene-Amputation at Shoulderjoint-Death from rapid recurrence of Gangrene in Stump.

James Waters, a strong muscular blacksmith, aged thirty-six years, was admitted under the care of Mr. Meldon, on September 15, 1867. Four days previously he had received a gunshot wound in the forearm, just below the inner condyle of the humerus. The shot had not lodged, but had carried away the soft parts, leaving the bones of the forearın bare, but unbroken.

On the second day after the accident gangrene set in. The man at this time resolutely refused his assent to amputation. The gangrene