the actual limit varying with the nature of the calculi — and for those that require the fenestrated bladed lithotrite. For such lithotomy should be employed."

The dangers of lithotrity, which are dependent mainly upon the injury liable to be incurred by the vesical mucous membrane in consequence of the prolonged presence of fragments, appear so great to the experienced authorities quoted above as to lead them, in cases where the stone exceeds certain quite narrow limits, to prefer lithotomy with all its well-known perils. It seems to me, however, that when the size of the stone or the age or feebleness of the patient are unfavorable to lithotrity, they must also weigh with great force against the cutting operation, which, as the lately published experience of Sir Henry Thompson shows, is attended in the most skillful hands by a mortality exceeding thirty-seven per cent. when practiced upon adults in cases unfit for lithotrity. Inasmuch as the risks of injury to the bladder from retained fragments are wholly avoided by their immediate and complete removal, the operation devised by Dr. Bigelow seems not unlikely to take the place of lithotomy with advantage in cases where the treatment by multiple sittings of lithotrity appears to be counterindicated. It should not be forgotten that the great aim of the surgeon. is to get rid of the stone in the shortest time with the least damage to the patient. That this result can be accomplished by means of "rapid lithotrity with evacuation" the cases already published suffice to show.

GUN-SHOT FRACTURE OF SKULL.

BY J. O. WHITNEY, M. D., PAWTUCKET, R. I.

LOVECA ROOT MALEY, aged twenty-three years, died on April 7th, forty-seven hours after a fatal wound from a misshot by another actress, a victim to the dangerous sport of having an apple shot from her head. The range was but nine feet, with an elevation upwards at the rate of one and a quarter inches to the foot. The ball (No. 22, conical) entered a little to the left of the centre and fairly within the hair, her head being erect. It struck the skull at a very acute angle, shattering it, and knocking a hole in it, and passed onward and out of the scalp about an inch and a half from the place of entrance. Both scalp wounds were circular; the flesh at the anterior one turned in, and the other turned out, and about the latter the hair was filled with powdered bone and bits of "fibre," no doubt a part of the diploë. A few scales of bone were found also, one clearly from the internal table. There was not the least doubt that the longitudinal sinus was opened, for she was deluged with venous blood, and the brain was exuding from the anterior scalp wound. The violence of the bleeding ceased in a short time,

but again returned in four or five hours. It seemed that she would die at once from shock. The pulse was nearly gone; pupils normal; convulsive movements in all the extremities, but most on the left side. In twelve hours reaction was fair, and she was removed from the operahouse, where the affair had taken place, to her hotel. She had urinated unconsciously. She showed no signs of intelligence farther than swallowing water from a teaspoon, although the attendants say emphatically that she made responsive expressions to inquiries. At first the pupils responded to the stimulus of light. At the end of twenty hours the pulse was strong, full, and becoming irregular. The breathing also was a little irregular, and the pupils began to dilate, but were equal.

There was no notable change in these symptoms, but a gradual increase of them till death, which was abrupt, and entirely unexpected at the moment, although not the least encouragement of recovery had been given to the friends.

The town authorities came to the conclusion, tardily, to hold a coroner's inquest; the body being ready for transportation to Western New York, and the friends very much opposed to a post-mortem examination, it was not ordered.

RECENT PROGRESS IN MILITARY SURGERY.1

BY G. A. OTIS, M. D.

PROCEEDING from this point, the commission insists, from well-established facts and clinical experiments and hospital observations on the process of putrefaction, concerning the influence of the different relations of putrid matter with the air, that in every wound there is nothing harmful save the condition of want of free access of air, which produces the most pernicious form of putrefaction. On the other hand, the free admission of the air, as well as its absolute exclusion or hermetism, is invariably favorable to healing and the prevention of complications. The hurtful influence of porous bodies, as bandages, threads, and the like, becomes easy to understand. To avoid the harmful causes of the want of open ingress of air and to combine exclusively the favorable conditions of the treatment were two distinct practical problems to solve, the fundamental principle being postulated. The commission contends that the general method of aeration for treating wounds and granulating surfaces, tested by three years' discussion and experiment, satisfies by the simplest precepts the requirements of these two problems, and for the simplicity of its application, rational and strict precision in dealing with the wound and patient, facility in supervising the wound, and rapidity and economy of treatment commends the method to surgeons and administrators. Looking at the natural healing of wounds in man and the lower animals without medical intervention, the commission urges that one is amazed at the abundance of means that the living organism uses in struggling with external agents of the decom

1 Concluded from page 535.

position of dead matter. The almost invariable absence of signs of gangrene in an open wound is not less striking, though regularly appearing in wounds covered with porous dressings. In every lesion of continuity, whatever its depth, is observed a liquid, at first limpid, then more or less sanguinolent, then purulent, forming over all the surface of the wound, driving the air from different crevices, and covering the whole with a continuous layer through which it remains in contact with the ambient air. That the superficial layer of the effused liquid dries in a crust, or the crust forms at the edges only, according to the depth or extent of the wound, is indifferent; healing is unimpeded, and no complication supervenes. Such a free contact of the wound with the air meets precisely the conditions of free access of air, which exclude between the air and wound every space that might permit the confinement of air; and observation proves that these relations are natural and adapted to the favorable progress of wounds, and demonstrates that whatever the means by which the natural situations of healing are attained, whether by increasing the quantity of liquid that fills the wound, or accelerating the formation of a crust, or by forming a dry eschar by the aid of caustics, - the favorable progress of the wound is promoted as the important terms are not infringed. Just the opposite is observed when there are formed within the surface of the wound and the ambient air free spaces and crannies, which are not in immediate relation with the ambient air. Whether these circumstances are found either in the wound itself or in the porous dressings applied to it, when signs of putrefaction and phenomena of irritation, hyperæmia, and inflammation become palpable; whether putrefaction makes rapid progress in such predicaments and its marked physiological effects are hastened; or whether, because of the fortuitous invasion of most potent putrid agents, the formation of poisonous products immediately it is certain that the privation of the free access of air is the condition that interferes with the natural relations above mentioned, and constitutes the principal source of grave septic complications so justly called the Scourge of surgical wards. Consequently" the commission holds that "the fundamental rules of the aeration method consist in avoiding in every way the causes of the free access of air; in not permitting of any porous body on the surface or in the depths of a wound; in seeking to place the wound in the favorable conditions above mentioned; lastly, in cases of urgent necessity for the toleration of some kind of porous bodies, by having recourse to the most energetic means of rendering them harmless, that is, by destroying their porousness and by disinfecting them."

commences,

66

The second part of the report of the Russian commission is devoted to minute details of the practical application of the aeration method: (1) the treatment of wounds by first intention, including amputation and other incised wounds; (2) the treatment of suppurating wounds; (3) shot wounds; (4) compound fractures; (5) resection wounds; (6) granulating surfaces. We have not space to enter upon any of these details. The wood-cut on the following page will give an idea of the numerous illustrations contained in the report for treating operative and other wounds without further intervention than metallic sutures, catgut ligatures, and absolutely essential means of support and protection.

The statistical facts on which the commission rely as demonstrating that under the aeration method amputation wounds result more successfully by fifty per cent. than in the open treatment of Dr. Rose, of Zürich, and that the antiseptic or Lister treatment is not incompatible with the aeration method, are still"in press" and inaccessible.

It had been my purpose to review the experience of antiseptic treatment in military surgery, especially in actual field practice, but want of space forbids. The readers of the JOURNAL are familiar with the papers of Dr. Goss and Dr. R. White.1 Assistant-Surgeon A. C. Girard's report to Surgeon-General Barnes on his personal observations of this treatment in the hands of its author and of Surgeon-General Nussbaum of the Bavarian army is reprinted in the Medical Record, 1877, vol. xii., page 721. Dr. Girard last winter received a letter from Professor Lister 2 on the use of the method for shot wounds of the knee-joint in actual field practice by a Russian military surgeon. Dr. Girard last year made suggestions for facilitating the antiseptic dressing by the use of worn-out mosquito bars prepared as antiseptic gauze, as described in the foot-note. Excellent suggestions for diminishing the costliness of the antisep1 White (R., Jr.), Personal Observations of Lister's Antiseptic Treatment, in Boston Medical and Surgical Journal, 1877, vol. xcvii., page 235.

2 Assistant-Surgeon A. C. Girard, U. S. Army, received, at Fort Randall, Dakota, November 28, 1877, the following letter from Professor Lister on the successful use of the antiseptic dressing of shot wounds of the knee-joint by a Russian military surgeon:

12 PARK CRESCENT, REGENT'S PARK, LONDON, October 24, 1877. MY DEAR SIR,- Your kind letter and inclosed report have reached me to-day, and I hasten to tell you how much pleasure they have given me. The kind reception I met with while in America last year prepared me to learn before long that antiseptic treatment was taking root and bearing fruit there. What you say about the worst enemies of the system being those who profess to adopt it but fail to carry it out efficiently is perfectly true. It may interest you to learn that I received a few days ago a letter from a Russian surgeon who is in chief position with the Russian army in Asia Minor, and who, having learned antiseptic treatment in Edinburgh, had introduced it into his university clinic at Dorpat, and thence had transported it to the seat of war, taking with him the apparatus for preparing antiseptic gauze, showing that "where there's a will there's a way." And the results he is getting are certainly, as he expresses it," herrlich." Thus seven successive cases of gun-shot wound of the knee-joint, almost all complicated with fracture, are recovering without inflammatory disturbance! I confess it was very gratifying to me to learn that the antiseptic treatment can really be effectually carried out in military practice. Thanking you again for your kind communication, I remain (signed) JOSEPH LISTER.

Yours very sincerely,

3 The following is an extract from Assistant-Surgeon A. C. Girard's letter, dated Fort Randall, July 8, 1877: "During my sojourn abroad last winter I had occasion to satisfy myself of the wonderful success of wound treatment under Lister's system, and, since my arrival at this post, I have endeavored to carry out the same with the limited means at my disposal. The only objection to the system is the cost of dressings, and this I have tried to overcome and, I believe, have succeeded. The purpose of this letter is to submit suggestions which, if followed, will enable every surgeon to prepare his own dressings with a minimum expense to the department. The supply list enables me to keep on hand the different carbolized solutions, carbolized oil, the spray (with the steam atomizer, which, though furnishing a weak stream, is better than the 'local anesthesia apparatus'), the solution of chloride of zinc, the 'protective' (oiled silk dipped in carbolized starch and dried), the mackintosh (our rubber cloth), the antiseptic sponges and silk.' The only articles not supplied, or at

tic treatment are also brought forward by Mr. J. Chiene.1 After the publication of Dr. Weir's valuable papers,2 with a figure and description of the steamspray apparatus manufactured by Tiemann & Co. under his supervision, the purveyor was enabled to supply the medical officers of the army with serviceable and comparatively inexpensive appliances for the antiseptic treatment.

6

I had designed also to advert to the contributions on M. Guérin's cottonwool dressings, to which many of the French military surgeons have largely resorted, and which is well described in the JOURNAL from personal observations by Dr. T. B. Curtis, and had wished particularly to call attention to the good results that military surgeons have had in treating lacerated wounds of the extremities by continuous immersion in tepid baths, as recommended by Professors Hamilton,5 Langenbeck, and Spence. But I have room only to urge the briefest comments on the antiseptic and open or aeration method of treating wounds. Of the former there remains, as Dr. Emmert has well said, the question whether the success of the Lister treatment should be ascribed to the antiseptic powers of the carbolic acid and its mode of application, or to minute preservation of cleanliness in the entire sphere of the wound, the careful ligation of the vessel, the removal of all blood coagula, the provision for the escape of wound secretions, the careful approximation and occlusion of the wound, thus excluding all possible mechanical irritation, etc., in short, the rigid observance of completely rational rules of wound treatment. The majority of practical surgeons, viewing the good results of Professor Thiersch least not in sufficient quantity, are the 'gauze' and the carbolized catgut. The latter is easily prepared if Lister's rules are strictly observed. The gauze offers more difficulties, which, however, I have succeeded in overcoming. Being at a loss what dressing of those on hand to select, I chose at first the patent lint, the most porous, but found that it lost by the preparation all its absorbent power. Having on hand a number of old unbleached musquito bars, which, being somewhat torn, had to be condemned, I thought them a good substitute, and, after preparation, used them in the dressing of an amputation in the metatarsus, with complete success, for on removal of the gauze not the slightest smell could be perceived in the discharge. Nearly every army hospital has a few of these mosquito bars on hand awaiting the action of an inspector, and by preparing from them antiseptic gauze they would be put to better use than conversion to mop rags. The following is the mode of preparation which I found most convenient and suitable: They should first be ripped; then steeped in lye for twenty-four hours, to remove not only noxious substances, but to improve the absorbent power of the fibre by removing fatty matters. Then steep them in Lister's mixture of crystallized carbolic acid one, common resin five, paraffin seven parts. This mixture is best obtained by dissolving the resin

...

and paraffin in a tin bucket on the stove and adding the carbolic acid when the solution is made. I obtained the best results by steeping and heating the gauze in the solution on the stove, as thus it does not harden so quickly when the surplus is pressed out. To effect the latter I found the most convenient mode to be to pass the gauze through a clothes-wringer, of which there is a specimen at nearly every post. The instrument is not injured thereby, and can easily be cleaned with hot water and a cloth. After pressing out all the surplus liquid and cooling the stuff, it should be stretched into shape, rolled up, and kept in some air-tight receptacle, like a tin bucket or boiler, until needed for use."

1 Chiene (J.), The Antiseptic Dressing of Wounds, in Edinburgh Medical Journal, 1877, No. cclxx., page 509,

2 Weir (R. F.), On the Antiseptic Treatment of Wounds and its Results, in New York Medical Journal, December, 1877, and January, 1878, vol. xxvi., page 561, vol. xxvii., page 30, and republished in pamphlet form.

3 Fiaux (M. L.), Note sur l'Application du Pansement ouaté de M. A. Guérin, in Recueil de Mém. de Méd., etc., 1872, 3eme ser., tome xxviii., page 366. Cassedebat, Étude comparée des divers Modes de Pansement des grandes plaies, in Arch. gén. de Méd., Février, 1878, tome xxxvi., page 154.

4 Curtis (T. B.), Cotton-Wool Dressings for Wounds, in Boston Medical and Surgical Journal, 1874, vol. xci., page 197.

5 Hamilton (F. H.), Use of Warm and Hot Water in Surgery, in New York Medical Record, May 15, 1874. Langenbeck (B.), Das permanente warm Wasserbad zur Behandlung grösserer Wunden, insbesondere der Amputationsstumpfe, in Deutsche Klinik, 1855, No. 37, page 409. Spence (J.), Address in Surgery at the Forty Third Meeting of the British Medical Association, Edinburgh, August, 1875; On the Treatment of Wounds and Surgical Dressings, in British Medical Journal, 1875, vol. ii., page 197.

* Emmert (C.), Ueber moderne Methoden der Wundbehandlung, in Archiv für klin. Chir, 1874, Bd. xvi. page 102.