report on surgery to the santa clara county medical society. by j. bradford cox, m. d. _read march 2d, 1880._ san jose: mercury steam print. 1880. report on surgery. in presenting this report i will not attempt to give any historical data connected with the subject of surgery, since that has been ably done in the report of last year. i shall assume, and that without hesitation, that surgery is a science, properly so-called. that it is an art, is also true. but what is science? what is art? science is knowledge. art the application of that knowledge. to be more explicit, science is the knowledge we possess of nature and her laws; or, more properly speaking, god and his laws. when we say that oxygen and iron unite and form ferric oxide, we express a law of matter: that is, that these elements have an _affinity_ for each other. a collection of similar facts and their systematic arrangement, we call chemistry. or we might say, chemistry is the science or knowledge of the elementary substances and their laws of combination. when we say that about one-eighth of the entire weight of the human body is a fluid, and is continually in motion within certain channels called blood vessels, we express a law of life, or a vital process. when we say this fluid is composed of certain anatomical elements, as the plasma, red corpuscles, leucocytes and granules, we go a step further in the problem of vitality. when we say that certain nutritious principles are taken into this circulating fluid by means of digestion and absorption, and that by assimilation they are converted into the various tissues of the body, we think we have solved the problem, and know just the essence of life itself. but what makes the blood hold these nutritious principles in solution until the very instant they come in contact with the tissue they are designed to renovate, and then, as it were, precipitate them as new tissue? you say they are in chemical solution, and the substance of contact acts as a re-agent, and thus the deposit of new tissue is only in accordance with the laws of chemistry. perhaps this is so. let us see as to the proofs. in the analysis of the blood plasma, we find chlorides of sodium, potassium and ammonium, carbonates of potassa, soda, lime and magnesia, phosphates of lime, magnesia, potassa, and probably iron; also basic phosphates and neutral phosphates of soda, and sulphates of potassa and soda. now in the analysis of those tissues composed principally of inorganic substances or compounds, it will be seen that these same salts are found in the tissues themselves. so also the organic compounds lactate of soda, lactate of lime, pneumate of soda, margarate of soda, stearate of soda, butyrate of soda, oleine, margarine, stearine, lecethine, glucose, inosite, plasmine, serine, peptones, etc., are found alike in the tissues and in the blood plasma. that they are in solution in the plasma is well known,--that they are in a solid or precipitated form in the tissues is also true,--and that the tissues are supplied from the blood is also evident,--because the blood is the only part that receives supplies of material direct from the food taken and digested. that carbonate of lime and phosphate of lime are precipitated or assimilated from the plasma to form bone, is admitted by all physiologists. that the carbonates and phosphates already deposited act as the re-agent to precipitate fresh supplies from the plasma is not a demonstrated fact, but may be inferred. so also with the other tissues. should this be admitted without positive evidence we would not then be at the end of our problem;--for the question may be asked as to what causes the first or initial deposit. here we must stop and acknowledge our ignorance. but you may now ask what all this physiology and chemistry of the plasma has to do with a report on surgery. i propose to use it for the purpose of explaining some peculiarities in the process of repair in surgical cases. a few months ago i had a case of delayed union in a fracture of the tibia, at the hospital, and spent more time in waiting for nature, unassisted, to accomplish a cure, than i should ever spend again. one week after putting the patient on the use of ten grain doses of hypophosphite of lime, i had the pleasure of seeing bony union commencing. and why? simply because the quantity of phosphate of lime in solution in the plasma was not sufficient to supply the waste of bone tissue in all parts of the body, and at the same time furnish a supply for the provisional callus which is thrown out in the repair of fractures. in september, 1878, august g----, aged 18 years, single, a native of switzerland, was admitted to the santa clara county hospital with incipient spinal disease. he was of that peculiar temperament which indicates a scrofulous cachexia. the fifth dorsal vertebra was sufficiently prominent to indicate the sight where the attack was being made by the enemy. there was considerable tenderness on pressure; slightly accelerated pulse, and elevated temperature;--in other words, a well defined case;--one which would have resulted in caries and deformity within a few months. by the administration of ten grain doses of hypophosphite of lime for several weeks, i had the pleasure of seeing recovery take place. reasoning by analogy, i am led to conclude that the nature of the wound should, to a great extent, govern the kind of food given the patient during the treatment. in many cases of surgery, medicines are not necessary. but in some exceptional cases, as in similar ones to those above noticed, medicine is demanded. and in all cases of flesh wounds, i believe the patient will be benefited by a liberal diet of animal food; that is, after the first inflammatory condition has subsided. why this is so, is simply because those very materials are furnished to the system which are required for the repair of the tissues injured, viz., the organic compounds. in flesh wounds of weak and debilitated persons which are slow in healing, a diet of beef tea, eggs, oysters, etc., will often bring about a rapid improvement. thus, we see that chemistry, organic and inorganic, has something to do with surgery. i will now present the following cases which have seemed of special interest to me: case first.--in 1874, while in the mountains on the trinity river, dr. ---was kicked by a mule in such a manner as to rupture the ligamentum patellae. the tendon of the quadriceps femoris, at once drew the patella at least two inches above its normal position. of course he was unable to walk, but was taken to a house near by. with some assistance from a brother physician the patella was brought down to its place, but it would not remain. i suggested the use of a gutta percha mould or covering for the knee. without much difficulty, a piece one-fourth of an inch thick, softened in hot water, was applied, and kept in place by means of compresses and bandages until it hardened. this made a perfect and firm, splint fitting all the inequalities of the knee, covering all but the posterior part of the leg, and extending three or four inches above and below the patella. with this bound moderately tight to the leg by a roller bandage, it was simply an impossibility for the patella to move from its proper position. at the end of about a week the patient left the bed, and could walk about, but, of course, with a stiff leg. he wore this splint or cap for the knee for about four weeks, when i found he could leave it off at night without much pain. continued to wear it during the day for perhaps a fortnight, when i found he could leave it off entirely. i mention this case partly for the purpose of calling the attention of the members of the society to the use of gutta percha as a material for splints. it is not adapted to all cases of fracture; but in very many cases i find nothing else so satisfactory. i have thought that in fracture of the patella it would be peculiarly valuable, as it is so readily adjusted to all the inequalities of the knee joint. case second.--jerome de----, aged fifty-four years, native of france, single, was admitted to the santa clara county hospital, july 20th, 1878. he was suffering from rheumatism, or at least complained of pains in various parts of the body, more particularly the long bones of the arms and legs. these pains were worse at night, pulse varying between 80 and 90, temperature natural. suspecting a specific origin for this malady, i put him on the use of iodide potassium, with increasing doses. he slowly improved with the exception of a pain in the left humerus, anteriorily, and in the upper part of the middle third. this became localized to a spot no larger than a twenty-five cent piece. at times the pain was intense and excruciating: and about a week from admission this spot seemed quite tender to the touch. after the use of a blister and tincture of iodine for a week, he was somewhat relieved. not entirely, however, for at times the pain was very severe. on aug. 7th, he left the hospital thinking he could do some work. the next day, while attempting to climb a fence, and while in the act of raising the body by the arms, the left humerus was fractured transversely at the exact point of his previous suffering. he was again admitted to the hospital, and the fracture dressed in the usual manner. after five or six days a gutta percha splint was used which encircled the arm. bony union was slow in taking place. however, on oct. 3d, nearly two months from the date of the fracture, he left the hospital, the union being complete, and he being entirely relieved from his pain; in fact, he was relieved from the moment of the fracture. this case presents a question in pathology which is of interest. was there a localized periostitis at this point? if so, why was it not entirely relieved by the treatment which consisted of blisters and iodine, externally, and mercury and iodide potassium internally? was there a deficiency of nutrition at this point? or anemia from some change in the nutrient artery,--the result of the periostitis of the long bones? or was it incipient necrosis? prof. hamilton gives the record of a case of fracture of the humerus, from muscular action, taking place three several times in the same individual, each time in a different place. case third.--dec. 29th, 1878, was called to see mr. ----, male, married, aged about 40 years. has led an out-door, active life. has always been healthy. no venerial taint. nervous temperament, spare built, and weighs about 140 pounds. present condition: has been sick two or three days; the attack commenced with a chill, followed by fever; has had fever ever since the chill; complains of pains in the back and legs; has vomited considerable; bowels costive; tongue coated; severe pain in right side corresponding to lower part of the lung, which i found solidified; there is considerable cough. ordered a cathartic; to be followed by an anti-pyretic of acetate of ammonia and aconite, and a blister over the lower part of the right lung. continued this treatment for three or four days, when the pneumonia began to subside, and at the end of about ten days i considered my patient convalescent. about this time i was sent for in great haste after night. the patient, who is a very intelligent man, said he had felt worse during the day, and in the evening, his knee, which had been somewhat painful for two or three days, had become exceedingly painful. i gave morphine, hypodermically, and went home, leaving some morphine for the night. the next day i saw him. the pain had been relieved by the morphine, still occasionally it was quite severe. there was no redness or heat, or even tenderness; nothing unnatural about the knee except pain, which was aggravated by any attempt to move the leg. ordered quinine as a tonic, and pill "c. c." as a cathartic. bandaged the leg pretty tightly from the toes to above the knee. the urine was natural; pulse and temperature only slightly elevated. after six or seven days of these symptoms, the knee began to feel hot and became very slightly swollen. ordered a small blister over the inside of the knee as the greatest amount of pain seemed to be here. dressed it with tartar-emetic ointment until the skin was very sore; using iodine on other puts of the knee. used iodide potassium and colchicum, internally. this treatment for five days seemed to do no good. on jan. 17th, twenty-two days from the beginning of his illness, and about twelve days from the first appearance of symptoms denoting any local trouble at the knee, a consultation was held, the result of which was a blister over the whole of the knee, to be dressed with unguentuin hydrargiri. the inflammation was but little influenced by this or any other treatment. the knee continued to slowly and surely enlarge. and this extended upward without first producing any great distention of the synovial sack under the patella. there seemed to be simply enlargement of all the tissues of the lower part of the thigh. this continued until about the 1st of feb. when, from the general appearance of the patient, viz: a typhoid condition, feeble pulse, coated tongue, emaciation, loss of appetite, as well as from the local appearance of the inside of the knee, i suspected pus within the joint. accordingly, i introduced an exploring needle into the inner part of the joint just above and anterior to the insertion of the tendon of the semimembranosis muscle. finding pus, i made an incision only about half an inch long, and squeezed out perhaps an ounce of pus. closed this up and again bandaged the leg. there was but very little pus discharged from this opening afterward, not, however, for want of drainage, since the cut was kept open by introducing the probe occasionally. about the 9th or 10th of feb. fluctuation became quite apparent along the outer and lower part of the thigh. on feb. 12th, consultation was again had, when fluctuation being very well marked over a considerable portion of the thigh in its lower and middle thirds, after giving the patient chloroform, an incision was made three inches long on the outer and posterior part of the thigh, from the junction of the lower with the middle third, downward through the posterior part of the vastus externus muscle. about two quarts of laudable pus was discharged. by introducing the finger upward and downward, the periostium could be felt smooth except within the knee joint, for this could be distinctly felt, the finger passing readily between the ends of the femur and tibia, and beneath the patella; the crucial and lateral ligaments seemed to be gone, and the cartilages somewhat roughened. a drainage tube was put in, the leg bandaged from the toes to the trochanter major, with compresses so arranged as to obliterate the sack, if possible. the patient, up to this time, had been slowly losing flesh, and was now very much emaciated. a general typhoid condition existed, the temperature ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor appetite, and in short, the patient in a very critical condition. the use of chloroform, and the shock from the evacuation of the pus, added to the gravity of all the symptoms, and for about two weeks the patient was in great danger of death from asthenia. however, by liberal use of whisky, quinia, beef tea, cod liver oil, etc., he slowly rallied. two smaller abscesses formed below the knee, but those gave no great anxiety, not so much as some bed sores on the back and hips. the sack or pouch became gradually obliterated, down as far as the knee. the cavity of the joint, however, did not seem to be well drained from the opening in the thigh, notwithstanding it had been kept open freely by tents. about three weeks from this last operation, the sinus or pouch within the knee-joint being so imperfectly drained as above indicated, i made an opening directly into the joint at the outer and posterior part, one inch long, through which i could introduce the probe between the ends of the femur and tibia, without any difficulty, through all parts of the joint. however, i discovered no necrosed bone by so doing. put a tent into this opening, and let the one above heal up, which it did in about two weeks. this latter opening into the joint i kept open by means of tents until the joint became anchilosed and ceased to discharge pus. the patient made a slow and steady recovery, and about the middle of april was able to get out doors again. the special points of interest in this case seem to be the obscure and insidious mode of attack; the slow progress of the inflammation, it being rather sub-acute than acute; and the fact of its being a sequela of pneumonia. prof. gross, in his excellent work on surgery, says, "synovitis, in the great majority of cases, arises from the effects of rheumatism, gout, eruptive fevers, syphilis, scrofula, and the inordinate use of mercury." prof. hamilton, in "principles and practice of surgery," says, "synovitis may be caused by exposure to cold, or may occur as a consequence of a rheumatic, strumous, or syphilitic cachexia, as a gonorrhoeal complication, as a sequela of fevers, and from many other causes, whose relation to the disease in question may not always be easily determined." since there was no local injury to the knee in this case which could have caused the disease, we must seek some other cause for it. i have thought that its origin might be accounted for on the principle of metastasis of morbid material. the patient had pneumonia which passed through its several stages somewhat rapidly, resolution taking place about the end of the second week. the symptoms of this were well marked, viz: a chill followed by fever, cough, brick-dust sputa, delirium, pain over lower half of right lung, which was solidified, and afterward gave the crepitant and sub-crepitant roles. could not the morbid material, which entered the circulation from the re-absorption of the deposit in the solidified lung, have been carried to the synovial membrane of the knee, and there found a lodgment, and set up the inflammation which resulted in the formation of so much pus? if not, why not? notwithstanding a tedious illness, and an anchilosed knee, was not this result better than to have had suppuration of the lung tissue and destruction of the whole of the right lung, and perhaps eventually the left also? however, we are not certain that such a result would have followed, although the patient's general appearance at the time of the attack, and the typhoid condition which followed, as also the low grade of inflammation bordering on the scrofulous, made such a thing probable. case fourth.--on jan. 31st, 1879, mr. r----, italian, aged 35 yrs., while chopping wood near almaden mines, was injured by a falling tree. the lower part of the body was very much bruised, both posteriorly and anteriorly. the only place where the skin was broken was a smooth cut about four inches long and nearly half an inch deep, following the fold or crease between the right testicle and thigh, and extending from the anterior part of the testicle to the perineum in a straight line just where the scrotal integument joins that of the thigh. the main injury was in the lumbar region over the upper lumbar vertebrã¦. the spinous process of the lower dorsal vertebra seemed to be unusually prominent, leading to the supposition that the spinous process of the upper lumbar vertebra might be fractured and depressed. however, i was unable to detect mobility or crepitus in any of the processes, spinous or transverse, either of the dorsal or lumbar vertebrã¦. there was considerable tenderness over the lumbar region. i would here state that the examination was made about twenty hours after the receipt of the injury. there was but little discoloration of the skin, not very much pain, no paralysis of any part, the bladder evacuating itself naturally, and a cathartic producing its ordinary effect in the usual time. the patient did well; complained of but little pain; did not use opiates. on wednesday and thursday following, the patient felt well enough to walk about the wards, eating well and having no constitutional disturbance, pulse never higher than eighty per minute, and the temperature not above 99 degrees f. on friday morning the nurse remarked that this patient had complained of pain in the back during the previous night, and that there seemed to be a soft spot on his rump. by examining, i found below the bandage which i had put around the patient, a fluctuating mass, immediately beneath the skin and superficial fascia, extending from the tenth dorsal vertebra above, to the coccyx below, and from the crest of the right ilium to that of the left. i was at a loss to know how to account for this fluid, for there was at least a quart. i removed the bandage and examined more carefully. there was no inflammation to amount to anything, nor had there been. here it is only the seventh day from the receipt of the injury, and it surely cannot be pus. however, to satisfy myself, i used an exploring needle; and not very much to my surprise, i discovered light colored arterial blood! could i be mistaken? i twisted the needle about, pressed it to one side, until nearly a drachm of the blood had escaped. fully convinced now that i had a secondary hemorrhage to deal with, the question arose what to do. i supposed that it came from one of the lumbar or inter-costal arteries that had been injured by the supposed fracture of the process of the vertebra. if so, it comes from an artery inclosed in a bony cavity, and one that cannot contract and close spontaneously, and since its origin is so close to the aorta, it will continue to bleed until the patient dies of hemorrhage. while i was thus examining the fluctuating mass, and conjecturing as to origin and results, i fancied that the quantity of fluid was sensibly increasing. however, i will not be positive that my imagination did not assist in this accumulation. but what shall i do? cut down into this sinus, and hunt the bleeding artery, and tie it? could i find it? and could i tie it if i did find it? probably not; and more especially if it is a lumbar artery, and injured in the foramen through which it passes from the vertebra. but the man will probably bleed to death; and must i do nothing to prevent it? i concluded to use pressure with a bandage for the present, and ask for the advice of my brethren. accordingly, compresses were placed along the spine, and the body bandaged snugly. on returning to town, i stated the case to doctors brown and thorne, giving my theory for the hemorrhage,--that it was secondary, and probably from a lumbar artery. they were of opinion that it would be almost an impossibility to find the artery and tie it, and without seeing each other, concluded that pressure was the remedy to be used. i would state that at the last visit the pulse was 74, and temperature 99. this was at about 9 a. m. i visited him again about 5 p. m., and found the pulse and temperature the same. there was by this time considerable increase in the quantity of fluid. i re-adjusted my compresses and bandaged again. on saturday morning i found the quantity of fluid about the same, perhaps slightly increased. there was now considerable inflammation of the integument, over a large part of the sinus, the skin appearing tense, and the small blood vessels distinct and purple. the patient had a slight chill last night, pulse 100, temp. 102; did not remove the compresses. saturday evening, feb. 7th, condition worse, pulse 112, temp. 103, tongue furred ash-colored, countenance typhoid in expression, loss of appetite, no abdominal symptoms, mind clear. sunday, feb 8th. pulse 120, temp. 105.4, tongue same as yesterday, had a chill last night. the skin over the sinus is inflamed somewhat more than it was yesterday. with the advice and assistance of doctors brown, thorne, benj. cory and kelly, sixty-eight ounces of blood was removed from the sinus, by aspiration. one hour after this operation, the pulse was 140 and the temp. 104. the specific gravity of the blood removed was 1030, and after standing for two or three hours, a grey or ash-colored sediment settled, the proportion of this being about 20 per cent. of the whole amount of the blood. this sediment consisted of corpuscles that seemed to be undergoing decomposition; they were a little larger than the red corpuscles; contained granules or spots, from three to four and seven and eight in each corpuscle. some of them seemed to be simply swollen red blood corpuscles, ready to burst, or as it were, suppurate. if there be such a thing as inflammation of the blood,--and i believe there is,--then this change must effect the red corpuscles themselves, as to size, temperature and perhaps pain, thus supplying three of the well known characteristics of inflammation, expressed so tersely by the old latin formula, _rubor, tumor, calor cum dolore_. owing to the color of the blood, the rubor, or redness, is not produced by inflammation here as it already exists. but to return to the patient. after the blood was withdrawn, compresses were carefully applied, and the body bandaged from the lower ribs as low down as the bandage could be applied with the legs flexed at right angles to the body. the patient stood on all fours, as it is called, while the bandage was applied. monday, feb. 9th, 9:30 a. m., pulse 100, temp. 103.8. there appeared to be about one-half a pint of fluid in the sack. monday, feb. 9th, 6:30 p. m., pulse 100, temp. 102. tuesday, feb. 10th, 9:30 a. m.,--the fluid in the sack has increased--perhaps a pint now in it, pulse 110, temp. 104. wednesday, feb 11th, 9:30 a. m.,--pulse 90, temp. not taken. condition good. ordered a laxative. friday, feb 13th,--considerable inflammation over the left iliac crest, in the centre of which, a spot as large as the thumb nail, looks gangrenous. the inflammation extends over a surface as large as the two hands. some bullae or blebs have formed in the vicinity of the gangrenous spot. ordered a large flaxseed poultice applied, expecting an abscess would form at this place. the cathartic moved the bowels two or three times. i will here state that the patient, after the withdrawal of the blood on sunday, was ordered iron, quinine and whisky; twenty minims of tr. ferri muriat., three grs quinia, in a tablespoonful of glycerine and a little whisky. i afterward had the quinia made into pill and left off the iron, as the latter seemed to disagree with the stomach. saturday, feb. 14th, 5 p. m.,--pulse 112, temp. 102.4. the inflammation over the left ilium is much better; but there is now as much inflammation over the right ilium as there was over the left. the fluid in the sinus has increased gradually since the evacuation of it with the aspirator. the inflammation that has now existed for two or three days over these parts of the sinus, led me to conclude that the blood which was left and that which had accumulated, had undergone decomposition and was now pus. i used an exploring needle and found this to be the case. i then introduced a trocar and canula, and drew off fifty ounces of pus, slightly tinged with blood. i re-adjusted the compresses and bandage over the sinus, hoping that a part of it at least would become obliterated before it became necessary to open it more freely. feb. 15th, 5 p. m.,--pulse 112, temp. 102.5. the inflammation over that part of the sinus to the right of the spine is still about the same as yesterday; also that over the left ilium. the fluid has increased during the last twenty-four hours so that there is now nearly as much as was drawn off through the canula yesterday. i concluded that further delay to a free opening was useless; consequently with the patient lying on his right side, and near the edge of the bed, i made an opening one inch long in the lower portion of the abscess,--for i now considered it one,--near the spot where the needle of the aspirator and the trocar had been previously introduced. after the discharge of about a pint of bloody pus, the stream was checked by a clot of blood coming into the opening. i enlarged the opening, making it about two inches long, when a clot the size of a hen's egg came through, followed by about a pint more of bloody pus. after syringing the cavity with a five per cent. solution of carbolic acid in distilled water, and introducing a tent about four inches long, i applied compresses and bandages. ordered the quinia continued, and whisky and beef tea. feb. 16th, 9 a. m.,--pulse 100, but feeble; temp. 97.8. removed dressings which were saturated with pus and blood. the latter had excited the anxiety of the superintendent during the night, and he applied an additional bandage. there was perhaps five or six ounces of thick, flaky, yellow pus discharged. no hemorrhage; syringed the cavity with a five per cent. solution as before, and introduced a clean tent. on examining the inflamed spot over the left ilium, i detected fluctuation over the anterior part of the crest of the ilium, near the gangrenous spot, and extending down over the abdomen. however, it seemed to be superficial, at least, not deeper than the connective tissue between the external and internal oblique muscles, and not more than one inch by two in size. this i opened, and squeezed out about half a ounce of pus. introduced a tent and applied oakum over both tents, for the purpose of absorbing the pus, and applied a compress over the main sinus or pouch, and a bandage over the whole lower part of the body. feb. 17th, 9 a. m.,--pulse 96, temp. 99. ordered a laxative of carbonate of magnesia. both openings discharging very freely. the gangrenous spot over the left ilium is separating from the surrounding tissues. removed considerable dead flesh from this spot, leaving an opening or pouch one inch in diameter, leading down to the pubis, just beneath the oblique muscles. feb. 19th, 9 a. m.,--pulse 106, temp. 99.5. both sinuses discharging very freely. made an opening in the lower part of the pouch to the left of the pubis for better drainage, as the patient usually lies on the right side. laxative has operated. after washing out both sinuses with a five per cent. solution of carbolic acid, i inject the smaller sinus with liquid vasaline. feb. 20th, 9 a. m.,--pulse 112, temp. 103.5. there is a great amount of pus being discharged from the large sinus on the back, not so much from the small one. patient had a chill last night. after the usual washing out of the sinuses with the carbolic solution, i inject both of them in with liquid vasaline. this i do, a well as the washing out, by means of a no. 10 catheter, attached to the end of a davidson's syringe. the sinus on the back extends from the coccyx to the ribs, and from one ilium to the other. the skin and fascia of the external wall being so thin that the catheter can be seen over the entire extent, as i push it from one part to another for the purpose of washing out all parts of the sack. patient has been complaining of pain and want of sleep; had a chill last night. he still takes beef tea twice a day, and eggs and other food twice a day, making four meals a day; also, continues the quinine and whisky. feb. 21st, 9:30 a. m.,--pulse 98, temp. 101. feels more comfortable. discharge of pus much less than yesterday. wash out the sinuses and inject liquid vasaline. feb. 23d, 9:30 a. m.,--pulse 98, temp. 101. complains of being "very sick." speaks english but poorly. considerable discharge of laudable pus, but not so much as before the use of the liquid vasaline. there is one point near the left hand side of the large sinus on the back, where the walls are adherent. i wash them out with a five per cent. solution of carbolic acid in water, and again inject the liquid vasaline. by gentle pressure made over the upper part of the pouch, i force everything out of it at the opening below, bringing the walls of the sack together over the greater part of the surface. hoping that the adhesion between the walls, which has commenced, will continue, and soon obliterate, at least, all the upper part of the pouch. put on the usual compresses; this time using oakum instead of folded cloths. feb. 24th, 9:30 a. m.,--pulse 108, temp. 101. did not wash out the upper or left hand part of the pouch on the back, for fear of disturbing adhesions that are taking place. washed out the lower part and injected vasaline. a small spot, as large as a ten cent piece, has sloughed, making a hole into the pouch over the lower lumbar vertebra. another spot immediately above this, and about the same size, looks as if it would slough. feb. 25th, 9:30 a. m.,--pulse 100, temp. 100. feb. 27th, 9:30 a. m.,--pulse 115, temp. 99.2. adhesion is taking place between the walls of the sinus, on the left of the vertebrã¦. feb. 29th, 9:30, a. m.,--pulse 104, temp. 100. the sacks, or sinuses, have been washed out regularly every day, and dressed with vasaline. this case presents several features of interest. the first is the very large amount of secondary hemorrhage, and its location, there being sixty-eight ounces removed at one time and fifty at another, and perhaps thirty or forty at another, from just beneath the skin and superficial fascia of the lower part of the back. the second point of interest would be to know from what vessel this hemorrhage took place. the third interesting feature of the case is its progress and treatment. at the time of the aspiration the patient was in a critical condition; temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia. this danger was avoided by drawing off the decomposing blood, and giving the patient a new lease of life. this was but temporary, for six days afterward the same danger presented itself again. this was also avoided by opening the sinus freely, by an incision two inches long, which could not have been done sooner for fear of adding to the hemorrhage. at the end of six days from this last critical period, the temperature again went up to 103.5, and the pulse and condition of the patient indicated great danger of death from exhaustion--the result of the formation of so much pus. this was avoided by preventing the excessive formation of pus by washing out the sinus with liquid vasaline. the patient is still under treatment in the hospital now under the care of my esteemed friend, dr. benj. cory. the patient will probably recover. it will be simply a question of endurance with him. that is, if the supply of nourishment can be kept up, and the waste prevented, which must result from the formation of such a large quantity of pus, there is no reason why he should not recover.[a] [a] on march 25th, date of publication of this report, the patient is considered convalescent. at the time of putting him under the care of dr. cory, he was taking nine grains of quinia daily, about six ounces of whisky, beef tea twice a day, and eggs twice, with such other food as he might relish; taking four meals a day. thus you see i was carrying out the theory mentioned in the first part of this paper:--that of supplying the system with all the flesh producing food the stomach would digest, and using whisky and quinia to prevent disassimilation or waste; also vasaline locally for a similar reason. with this case i conclude my report; only adding that perhaps the thought of a poet, who evidently knows much of human nature, is applicable to this hastily written paper. this poet says: "a fool will pass for such through one mistake, while a philosopher will pass for such, through said mistakes being ventured in the gross and heaped up to a system." thus i, as one or the other of the personages here mentioned, offer this, my mite, to the literature of surgery, leaving you to decide which of the titles i deserve. produced from images generously made available by the kentuckiana digital library) pioneer surgery in kentucky: a sketch. by david w. yandell, m. d., professor of clinical surgery in the university of louisville, ky; president of the american surgical association. louisville: printed by john p. morton & company. 1890 the president's address: delivered at the regular annual meeting of the american surgical association, washington, d.c., may 13, 1890. pioneer surgery in kentucky. a sketch. fellows of the association: in the endeavor to chronicle the lives and achievements of kentucky pioneers in surgery, i shall not attempt the resurrection of village hampdens or mute inglorious miltons. the men with whom i deal were men of deeds, not men of fruitless promise. it may with truth be said that from hippocrates to gross few in our profession who have done enduring work have lacked biographers to pay liberal tribute to their worth. in justice to the unremembered few, i turn back the records of medicine for a century, and put my finger upon two names that in the bustling march of science have been overlooked, while i try to set in fuller light two other names of workers in that day, which have and will hold an exalted place in history. the worthies to whom these names belong were pioneers in civilization as well as in surgery. i shall introduce them in the order of their work. 1806. the earliest original surgical work of any magnitude done in kentucky, by one of her own sons, was an amputation at the hip-joint. it proved to be the first operation of the kind in the united states. the undertaking was made necessary because of extensive fracture of the thigh with great laceration of the soft parts. the subject was a mulatto boy, seventeen years of age, a slave of the monks of st. joseph's college. the time was august, 1806; the place, bardstown; the surgeon, dr. walter brashear; the assistants, dr. burr harrison and dr. john goodtell; the result, a complete success. the operator divided his work into two stages. the first consisted in amputating the thigh through its middle third in the usual way, and in tying all bleeding vessels. the second consisted of a long incision on the outside of the limb, exposing the remainder of the bone, which, being freed from its muscular attachments, was then disarticulated at its socket. far-seeing as the eye of the frontiersman was, he could not have discerned that the procedure by which he executed the most formidable operation in surgery came so near perfection that it would successfully challenge improvement for more than fourscore years. hundreds of hips have since been amputated after some forty different methods; but that which he introduced has passed into general use, and (though now known under the name of furneaux jordan's) remains the simplest, the least dangerous, the best. the first genuine hip-joint amputation executed on living parts was done by kerr, of northampton, england, 1774. the first done for shot wounds was by larrey, in 1793. i feel safe in saying that brashear had no knowledge of either of these operations. he therefore set about his work without help from precedent, placing his trust in himself, in the clearness of his own head, in the skill of his own hands, in the courage of his own heart. the result shows that he had not overestimated what was in him. but whether or not brashear had ever heard or read a description of what had been accomplished in this direction by surgeons elsewhere, the young kentuckian was the first to amputate at the hip-joint in america, and the first to do the real thing successfully in the world. dr. brashear seems to have set no high estimate on his achievement, and never published an account of the case. had he done so, the art of surgery would thereby have been much advanced, his own fame have been made one of the precious heritages of his country, and, what is better, many valuable lives would have been saved. eighteen years after the jesuits' slave had survived the loss of his limb, the report of the much-eulogized case of dr. mott appeared. dr. brashear came of an old and wealthy catholic family of maryland. he was born in february, 1776. his father journeyed to kentucky eight years later, and cleared a farm near shepherdsville, in bullitt county. walter was his seventh son, and was therefore set apart for the medical profession. when a youth he was enrolled in the literary department of transylvania university, where it is said he ranked high as a scholar in latin. at the age of twenty he began the study of medicine, in lexington, with dr. frederick ridgely, a very cultivated physician and popular man, who had won distinction in the medical staff of the continental army. after two years spent in this way, he rode on horseback to philadelphia, and attended upon a course of lectures in the university of pennsylvania. at this time rush, barton, and physick were teachers in that venerable seat of learning. his was a restless nature, and after a year spent in philadelphia he shipped to china as surgeon of a vessel. while among the celestials he amputated a woman's breast, probably the first exploit of the kind by one from the antipodes. unfortunately for science, he there learned the method used by the chinese for clarifying ginseng, and thinking, on his return home, that he saw in this an easy way to wealth, he abandoned the profession in which he had exhibited such originality, judgment, and skill, and engaged in merchandising. twelve years of commerce and its hazards left him a bankrupt in fortune, but brought him back to the calling in which he was so well fitted to shine. he moved, in 1813, from bardstown to lexington, where he at once secured a large practice, especially in diseases of the bones and joints. he was thought to excel in the treatment of fractures of the skull, for the better management of which a trephine was made in philadelphia, under his direction, which, in his judgment, was superior to any then in use. the same temper which led him to leave philadelphia without his medical degree, sail to china, and afterward enter commerce, again asserted itself, and he forsook for the second time his vocation. with his family he now moved to st. mary's parish, louisiana, and engaged in sugar-planting. during his residence in the south he served his adopted state in the senate of the united states. he employed much time in the study of the flora of the west. "during the winter of 1843-4, when henry clay was on a visit to new orleans" (says a writer in the new orleans medical and surgical journal), "we had the pleasure, together with some twenty-five physicians, of spending the evening with him at the house of a medical friend. while at the table one of the company proposed the health of the venerable dr. brashear, 'the first and only surgeon in louisiana who had successfully performed amputation at the hip-joint.' mr. clay, who sat next to dr. brashear, with characteristic good humor, immediately observed, 'he has you on the hip, doctor,' to the great amusement of brashear and the rest of the company." dr. brashear was a man of fine literary taste and many and varied accomplishments. in conversation he was always entertaining, often brilliant. his voice was pleasant, his manners affable. in stature he was short; in movement, quick and nervous. but in the make-up of the man one essential of true greatness--fixedness of purpose--had been omitted. he lacked the staying qualities. he was "variable and fond of change." "his full nature, like that river of which alexander broke the strength, spent itself in channels which led to no great name on earth." by a single exploit, at the age of thirty, he carved his name at high-water mark among the elect in surgery. most of his life thereafter he wasted in desultory labors. as the learned grotius said of his own life, he consumed it in levities and strenuous inanities. he died at an advanced age at his home in louisiana. 1809. three years after brashear had won his unparalleled success at bardstown, a practitioner already of wide repute as a surgeon, living in danville, a neighboring village, did the second piece of original surgical work in kentucky. it consisted in removing an ovarian tumor. the deed, unexampled in surgery, is destined to leave an ineffaceable imprint on the coming ages. in doing it ephraim mcdowell became a prime factor in the life of woman; in the life of the human race. by it he raised himself to a place in the world's history, alongside of jenner, as a benefactor of his kind; nay, it may be questioned if his place be not higher than jenner's, since he opened the way for the largest addition ever yet made to the sum total of human life. so much has been written of this, mcdowell's chief work, that i feel it needless to dwell upon it. all students of our art are familiar with it as presented by abler hands than mine. what i shall say of him, therefore, will relate rather to his life and general work than to the one operation by which his name has come to be the most resounding in all surgery. this is a much more difficult task than at first it might seem to be, for mcdowell made no sketch of himself, nor have his brothers or his children left us any record of his life. even his early biographers failed to gather from his surviving friends those personal recollections of the man which would now be of such exceeding interest to us all. an authentic life-size portrait of ephraim mcdowell, as he was seen in his daily walk among men, can not now be made. the materials are too scant; the time to collect them has gone by. a profile, a mere outline drawing, is all that is possible to-day. the picture i have attempted, therefore, will be found deficient in many details which have passed into general acceptance. it is known that he came of a sturdy stock, his blood being especially rich in two of the best crosses--the scotch-irish. his great-grandfather rebelled against the hierarchy of his time, and enlisted as a covenanter under the banner of james i. after honorable service, he laid down his arms, gathered his family together, and came to america. it was in honor of this ancestor that the subject of the present sketch was named. the maiden name of his mother was mcclung. she was a member of a distinguished family of virginia. mcdowell was born in rockbridge county, virginia, on november 11, 1771. he was the ninth of twelve children. his father, samuel mcdowell, was a man of note and influence in the state, and was honored with many positions of trust. in 1773 he removed with his family to kentucky, settling near danville. he was made judge of the district court of kentucky, and took part in organizing the first court ever formed in the state. he lived to see his son confessedly the foremost surgeon south of the blue ridge. but it was not given to eyes of that day to see that the achievements of the village operator had illuminated all the work which has since been done in the abdominal cavity, that one had grown up and toiled in their midst, "whose influence ineffable is borne round the great globe to cheerless souls that yearned in darkness for this answer to their needs." ephraim's early education was gotten at the school of the town in which he lived. he completed his school studies at an institution of somewhat higher pretentions, situated in a county near by. no anecdotes are preserved of his childhood. during his school-age he clearly preferred the out-door sports of his companions to the in-door tasks of his teachers. on quitting school he crossed the alleghanies and became an office pupil of dr. humphreys, of staunton, va. after reading under this preceptor for two years, he repaired to the university of edinburgh. the scotch metropolis was then styled the "modern athens." it afforded opportunities at that time for acquiring a medical education the best in all the world. it was then to the medical profession what leyden had been in the days of sir thomas browne, what paris became when velpeau and louis taught there. he entered the private class of john bell, whose forceful teachings and native eloquence made a lasting impression on the mind of his youthful hearer. it has been said that mcdowell conceived the thought of ovariotomy from some suggestions thrown out by this great man. the only distinction he is known to have won while in edinburgh was that of having been chosen by his classmates to carry the colors of the college in a foot-race against a professional. in this it appears he was an easy first. he came away without a diploma. but what was of far greater value than a degree, he brought back the anatomical and surgical knowledge which was to place him in the front of his profession. he returned to kentucky in 1795, and settled among the people who had known him from boyhood. his success was immediate, and yet dr. samuel brown, who knew him in virginia, and was his classmate in scotland, had said, when asked of him: "pish! he left home a gosling and came back a goose." in a little while he commanded all the surgical operations of importance for hundreds of miles around him, and this continued till, some years later, dudley returned from europe to share with him the empire in surgery. in 1802, fully established in his profession, and with an income which rendered him independent, he married sarah, daughter of governor isaac shelby. in 1809 he did his first ovariotomy. he believed the operation to be without precedent in the annals of surgery, yet he kept no note of it or of his subsequent work. he prepared no account of it until 1817. this appeared in the eclectic repertory. it was so meagre and so startling that surgeons hesitated to credit its truth. he had not mastered his mother tongue. the paper was thought to bear internal evidence of its author's having "relied upon his ledger for his dates and upon his memory for the facts." the critics from far and near fell upon him. the profession at home cast doubt upon the narrative. the profession abroad ridiculed it. for all that, mcdowell kept his temper and his course, and when he finally laid down his knife he had a score of thirteen operations done for diseased ovaria, with eight recoveries, four deaths, and one failure to complete the operation because of adhesions. it would be neither fitting nor becoming on this occasion, and in this presence, to speak in detail of the technic observed by mcdowell in his work. that has long since passed into history. i may, however, be permitted the remark that the procedure, in many of its features, is necessarily that of to-day. the incision was longer than that now usually made, and the ends of the pedicle ligature were left hanging from the lower angle of the wound. but the pedicle itself was dropped back into the abdomen. the patient was turned on her side to allow the blood and other fluids to drain away. the wound was closed with interrupted sutures. this marvel of work was done without the help of anesthetics or trained assistants, or the many improved instruments of to-day, which have done so much to simplify and make the operation easy. mcdowell had never heard of antisepsis, nor dreamed of germicides or germs; but water, distilled from nature's unpolluted cisterns by the sun, and dropped from heaven's condensers in the clean blue sky, with air winnowed through the leaves of the primeval forest which deepened into a wilderness about him on every hand, gave him and his patients aseptic facility and environment which the most favored living laparotomist well might envy. these served him well, and six out of seven of his first cases recovered. he removed the first tumor in twenty-five minutes, a time not since much shortened by the average operator. it was not alone, however, in this hitherto unexplored field of surgery that mcdowell showed himself a master. his skill was exhibited equally in other capital operations. he acquired at an early day distinction as a lithotomist, which brought to him patients from other states. he operated by the lateral method, and for many years used the gorget in opening the bladder. at a later period he employed the scalpel throughout. he performed lithotomy thirty-two times without a death. among those who came to him to be cut for stone was a pale, slender boy, who had traveled all the way from north carolina. this youth proved to be mcdowell's most noted patient. he was james k. polk, afterward president of the united states. dr. mcdowell's "heart was fully open to the lesson of charity, which more than all men we should feel," and he dispensed it with constant remembrance of the sacred trust imposed upon us. yet he had a proper appreciation of what was due his guild from those whose means allowed them to make remuneration for professional services. he charged $500 for an ovariotomy that he went to nashville, tenn., to do. the husband of the patient gave him a check, as he supposed, for that sum. on presenting it, the doctor discovered that it was drawn for $1,500 instead of $500, whereupon he returned the check, thinking a mistake had been made. the grateful gentleman replied that it was correct, and added that the services much outweighed the sum paid. when the fact is borne in mind that the purchasable value of money was much greater in the first than in this the last decade of the century, it will be seen that the "father of ovariotomy," at least, set his successors in the field a good example. this is made conspicuous by the fact that sir spencer wells has seldom charged a larger sum, and has declared â£100 to be a sufficient fee for the operation. in person dr. mcdowell was commanding. he was tall, broad-shouldered, stout-limbed. his head was large, his nose prominent and full of character, his chin broad, his lips full and expressive of determination, his complexion florid, his eyes dark-black. his voice was clear and manly; he often exercised it in recitations from scotch dialogues, when he would roll the scotch idiom upon his tongue with the readiness of a native. he was fond of music, especially comic pieces, which he sang with fine effect, accompanying his voice sometimes with the violin. he was a man of the times, taking an active interest in the affairs of the community in which he lived. he had many books for that day. cullen and sydenham were his chief authorities in medicine; burns and scott in literature. he was fond of reading, yet he was inclined to action rather than study. he placed great reliance on surgery and its possibilities; he placed little trust in drugs. he counselled against their too liberal use. in truth, he did not like the practice of medicine, and turned over most of his non-surgical cases to his associate in business. in manner he was courteous, frank, considerate, and natural. he was a simple, ingenuous man. his great deeds had given him no arrogance. his was a clean, strong, vigorous life. his spirit remained sweet and true and modest to the last. he lived a god-fearing man, and died on june 25, 1830, in the communion of the episcopal church. 1813. while mcdowell was so busily engaged in his special line of surgery, his colaborers elsewhere in the state were not idle. four years after his first ovariotomy, the first complete extirpation of the clavicle ever done was accomplished by dr. charles mccreary, living in hartford, ohio county, ky., two hundred miles, as the crow would fly, farther into the wilderness. the patient was a lad named irvin. the disease for which the operation was done was said to be scrofulous. recovery was slow but complete. the use of the arm remained unimpaired, and the patient lived, in good health, to be forty-nine years old. in 1829, sixteen years after the back-woods surgeon had achieved his success, professor mott repeated the operation, also on a youth, with a like fortunate result, and, believing he was first in the field, claimed the honor of the procedure for the united states, for new york, and for himself. he termed it his "waterloo operation," not, however, because it surpassed, as he declared, in tediousness, difficulty, and danger any thing he had ever witnessed or performed, but because, as it appears, it fell on the 18th of june, the anniversary of the battle of waterloo. mott's operation required nearly four hours for its execution, and the tying of forty vessels; but after all it proved to be not a complete extirpation; for the autopsy, made many years later, showed three quarters of an inch of the bone at the acromial end still in its place. yet the case passed quickly into the annals of surgery and added much to the already great renown of the operator. to this day it is referred to by surgical writers as "mott's celebrated case," and the description of his procedure is often given in his own words. mccreary removed the entire collar bone, and that while a young practitioner, living in a village composed of a few scattering houses, situated in a new and sparsely settled country, where opportunities for cultivating surgical science were necessarily rare, and the means for acquiring anatomical knowledge necessarily small. the only published report of mccreary's case is from the pen of dr. johnson, in the new orleans medical and surgical journal for january, 1850. the account, though all too brief, clearly establishes the date of the operation, its successful issue, and the removal of the entire bone. it is greatly to be regretted that more is not known of mccreary's personal and professional character. he is said, by one who met him often, to have been a serious, thoughtful man, given to study, devoted to his calling, and fatally fond of drink, to which he fell a victim when but thirty-seven years of age. 1814. a younger man than either of those i have attempted to sketch, dr. benjamin winslow dudley, now came upon the stage. he, too, was the son of a pioneer. his early training was much like that of his contemporaries. like brashear, he had instruction in the office of dr. ridgely. like him, he had attended lectures in the university of pennsylvania. unlike him, he carried away its diploma. this he did in 1806, just two weeks before he was twenty-one years old. he came home, opened an office, and offered his services to the public. the public gave him little business. he was deficient either in the knowledge or in the self-trust necessary to professional success. mcdowell was located in a village hard by--was applying himself mainly to surgery, and was already in full practice. dudley resolved to still better qualify himself for the work he was ambitious to do. he longed to go into the hospitals and follow the great teachers of europe, but lacked the means. to get these he made a venture in trade. he purchased a flat-boat, loaded it with produce, headed it for new orleans, and floated down the kentucky, the ohio, and the mississippi rivers to the desired port. he invested the proceeds of his cargo in flour. this he billed to gibraltar, which he reached some time in 1810; there and at lisbon he disposed of it at a large advance. the opportunities he had sought were now near at hand. he hastened through spain to paris. while there he heard baron larrey recite his wonderful military experience. he made the acquaintance of caulaincourt, "the emperor's trusted minister." through him he was present with talma and john howard payne in the chamber of deputies when napoleon entered the building at the close of his disastrous russian campaign. he saw the emperor mount the tribune. he heard him begin his report with these portentous words: "the grand army of the empire has been annihilated." remaining in paris nearly three years, he crossed the channel to observe surgery as practiced in london. while there he listened to abernethy as he dwelt with all his wonted enthusiasm on his peculiar doctrine. he heard him reason it; he saw him act it, dramatize it, and came away believing him to be "the highest authority on all points relating to surgery, as at once the observant student of nature, the profound thinker, and the sound medical philosopher." he always referred to him as the greatest of surgeons. he saw sir astley cooper operate, and habitually designated him as the most skilled and graceful man in his work he had ever known. he returned to lexington in the summer of 1814, "in manners a frenchman, but in medical doctrine and practice thoroughly english." the public was quick to detect that he had improved his time while away. "his profession had become the engrossing object of his thought, and he applied himself to it with undeviating fidelity. he made himself its slave." one who knew him well wrote of him: "he had no holidays. he sought no recreation; no sports interested him. his thoughts, he had been heard to say, were always on his cases, and not on the objects and amusements around him." he found lexington in the midst of an epidemic of typhoid pneumonia, the same that had prevailed in the older states. this singularly fatal disease was followed by a "bilious fever, characterized, like the plague, by a tendency to local affections. abscesses formed among the muscles of the body, legs, and arms, and were so intractable that limbs were sometimes amputated to get rid of the evil." recalling the use he had seen made of the bandage, while abroad, in the treatment of ulcers of the leg, dudley applied this device to the burrowing abscesses he saw so frequently in the subjects of the fever. the true position and exceeding value of the roller bandage were not so generally recognized then as now. dr. dudley was no doubt himself surprised at the success which followed the practice. this success probably led him to urge that wide application of the bandage with which his name came in time to be so generally associated. the tide of practice now set full toward him. he had come home a thorough anatomist. with opportunity he exhibited surpassing skill in the use of the knife. his reputation soon became national. no medical school had at that time been founded west of the alleghanies. the need of such an institution was felt on every hand. transylvania university, already of established reputation, was in operation. it required only a school in medicine to make it complete in its several departments. the trustees met in 1817 and added this to its organization. dr. dudley was made its head and appointed to fill the chairs of anatomy and surgery. a small class of students assembled in the autumn. at the commencement exercises held the following spring, w. l. sutton was admitted to the doctorate--the first physician given that distinction by an institution in the west. troubles arose in the faculty. resignations were sent in and accepted. dr. richardson, one of the corps, challenged dr. dudley. a meeting followed. richardson left the field with a pistol wound in his thigh which made him halt in his gait for the rest of his life. the year following a second organization was effected, which included the two belligerent teachers. the history of the medical department of transylvania university--its rise, its success, its decline, its disappearance from the list of medical colleges--would practically cover dr. dudley's career, and would form a most interesting chapter in the development of medical teaching in the southwest. but it must suffice me here to say that dr. dudley created the medical department of the institution and directed its policy. its students regarded him from the beginning as the foremost man in the faculty. that he had colleagues whose mental endowments were superior to his he himself at all times freely admitted. he is said to have laid no claim to either oratorical power or professional erudition. he was not a logician, he was not brilliant, and his deliverances were spiced with neither humor nor wit. and yet, says one of his biographers, in ability to enchain the students' attention, to impress them with the value of his instructions and his greatness as a teacher, he bore off the palm from all the gifted men who, at various periods, taught by his side. a friend and once a colleague described his manner while lecturing as singularly imposing and impressive. "he was magisterial, oracular, conveying the idea always that the mind of the speaker was troubled with no doubt. his deportment before his classes was such as further to enhance his standing. he was always, in the presence of his students, not the model teacher only, but the dignified, urbane gentleman; conciliating regard by his gentleness, but repelling any approach to familiarity; and never for the sake of raising a laugh or eliciting a little momentary applause descending to coarseness in expression or thought. so that to his pupils he was always and everywhere great. as an operator they thought he had distanced competition. as a teacher they thought he gave them not what was in the books, but what the writers of the books had never understood. they were persuaded that there was much they must learn from his lips or learn not at all." his hold upon the public was as great as that upon his classes. "patients came to him from afar because it was believed that he did better what others could do than any one else, and that he did much which no one else in reach could do." during the larger part of dr. dudley's life few physicians in any part of america devoted themselves exclusively to surgery. the most eminent surgeons were general practitioners--all-round men. in this class dr. dudley was equal to the best. in one respect, at least, he took advance ground--he condemned blood-letting. he was often heard to declare that every bleeding shortened the subject's life by a year. admiring abernethy more than any of his teachers, his opinions were naturally colored by the views of this eccentric englishman. like him he believed in the constitutional origin of local diseases, but his practice varied somewhat from that of his master. like him he gave his patients blue pill at night but omitted the black draught in the morning. he thought an emetic better, and secured it by tartarized antimony. between the puke and the purge his patients were fed on stale bread, skim milk, and water-gruel. and this heroic practice he pursued day after day, for weeks and months together, in spinal caries, hip caries, tuberculosis, urethral stricture and other diseases. i said that as a physician he was equal to the best. as we see things to-day this would not, perhaps, be saying much; but in fact he was better than the best. negatively, if not positively, he improved upon the barbaric treatment of disease then in universal favor. he wholly discarded one of the most effective means by which the doctors succeeded in shortening the life of man. this was just before those biological dawnings which were soon to break into the full light of physiological medicine and the rational system of therapeutics based thereupon. and it is not improbable that as a watcher in that night of therapeutical darkness, where the doings of the best strike us with horror, his prophetic eye caught some glimpses of the coming day which in old age it was given him to see. though engaged chiefly with the great things in surgery, he deserves a place in the list of therapeutic reformers. much of the renown acquired for kentucky by her surgeons was in the treatment of calculous diseases. this state is believed to have furnished almost as many cases of stone as all the rest of the union. dr. dudley stands the confessed leader of american lithotomists, heading the list with two hundred and twenty-five cases. of these he presents an unbroken series of one hundred consecutive successful operations. he used the gorget in all. he preferred the instrument invented by mr. cline, of london. "in one case, when his patient was on the table, he discovered that his accustomed operation was impracticable from deformity of the pelvis, and while his assistants were taking their positions resolved to make the external incision transverse, which was executed before any one else present had remarked the difficulty." through this incision he removed a stone three and a half inches in the long diameter, two and a half inches in the short, by eleven inches in circumference. the patient recovered. in an article contributed to the transylvania journal of medicine by dr. dudley, in 1828, he thus wrote of the trephine: "the experience which time and circumstances have afforded me in injuries of the head induced me to depart from the commonly received principles by which surgeons are governed in the use of the trephine. in skillful hands the operation, beyond the atmosphere of large cities, is neither dangerous in its consequences nor difficult in the execution." in this remark dr. dudley bore early testimony to the efficacy of aseptic surgery. he urged the trephine in the treatment of epilepsy and applied it in six cases--in four of which the disease was cured. the result in the two remaining cases is unknown, because the patients were lost sight of. dr. dudley believed himself to be the first surgeon who ever attempted to treat _fungus cerebri_ by gentle and sustained pressure made with dry sponge aided by the roller. of the first cases in which he used it, he wrote: "by imbibing the secretions of the part, the pressure on the protruded brain regularly and insensibly increased until the sponge became completely saturated. on removing it the decisive influence and efficacy of the agent remained no longer a matter of doubt." he noted the difficulty experienced in removing the sponge because of its being extensively penetrated by blood-vessels springing from the surface of the brain. this inconvenience he afterward obviated by putting a thin piece of muslin between the fungus and the sponge. he saw in this property of the sponge what no doubt others had seen before, the phenomenon of sponge-grafting, but like them he failed to utilize it in practice. dr. dudley was not a student of books. he had no taste for literature. he wrote but little, and that only for the transylvania journal of medicine, edited by two of his colleagues, professors cooke and short. his first article did not appear until 1828, fourteen years after he had begun practice. it was on injuries of the head. it abounded in original views, and did much to shape surgical thought at the time. today it may be consulted with profit. his second paper was on hydrocele; in this he advocated the operation by incision and removal of the sac. he read so little that he fell into the error of believing that he was the originator of the procedure. there are writers in our own day who would be able to hold their own against him in this particular. a paper on the bandage, another on fractures, and one on the nature and treatment of calculous diseases, embrace all his contributions to medical literature. dr. dudley was the son of ambrose dudley, a distinguished baptist minister. he was born in spottsylvania county, va., april 25, 1785. when but a year old he was brought by his father to the then county of kentucky. the family settled in lexington, in which beautiful city the child became a man, and lived and wrought and died. the date of his death is january 25, 1870; his age was eighty-five years. dr. dudley was a man of affairs. his practice was always large and paid him well. he amassed a handsome fortune. his opinions were often sought in courts of justice on professional points, where his dignity, self-possession, and dry wit (which he seems to have suppressed at the lecturer's desk), commanded the respect of judge, juror, and advocate, while it made him the terror of the pettifogger. once, while giving expert testimony in a case involving a wound made by bird-shot delivered at short range, he described the behavior of projectiles, and the danger of bullet wounds. the opposing counsel interrupted him: "do you mean to say," said the lawyer, "do you mean to say, dr. dudley, that shot wounds are as dangerous as bullet wounds?" "shot are but little bullets," was the unhesitating reply. dr. dudley had also a proper sense of the value of his professional services. he was called on one occasion to a town near lexington to attend a patient in labor, who was the wife of a man made rich by marriage. the husband was too wise to engage a "night rider," and too purse-proud to call the village doctor. at that time most of the one hundred dollar notes in circulation in kentucky were issued by the northern bank, at lexington. on the reverse side of the bill was the letter c in roman capital. this letter was so round in figure that it looked like a "bull's-eye," and in local slang was so called. the visit being over, and the doctor ready to leave, the young father handed him one of these notes. eyeing it for a moment, dr. dudley said: "another 'bull's-eye,' mr. x., if you please." in person dr. dudley was of medium size. his features were refined, the forehead wide and high, the nose large and somewhat thick, the lips thin, the eyes bluish-gray. his hair was thin, light, and of a sandy tint. he was a graceful man. his voice was pleasing; his manners courtly; his bearing gracious. he married miss short, daughter of major peyton short, in 1821. he delivered his last lecture in 1850, and the last entry on his ledger bears the date of april 28, 1853. * * * * * i can not give these remarks more fitting close than by describing briefly the surroundings which set their impress upon the character of the men whose lives i have attempted to portray. the picture is full of meaning, dignity, and simplicity. in this time "canetuckee" was still a part of virginia. the grounds on which, as boys, they played were held by their fathers under what is known as a "tomahawk claim." "beyond lay endless leagues of shadowy forest." "the illinois" had not been admitted into the sisterhood of the states. the vast domain west of the mississippi river was unexplored. the city of st. louis was but an outpost for traders. the name "chicago" had not been coined. fort dearborn, occupied by two companies of united states troops, marked a roll in the prairie among the sloughs where stands to-day the queen and mistress of the lakes. cincinnati had no place on the map, but was known as fort washington. general pakenham had not attempted the rape of new orleans, and general jackson, who was to drive him with his myrmidons fleeing to his ships, was unknown to fame. wars with indians were frequent. massacres by indians were common. the prow of a steamboat had never cut the waters of a western river. railroads were unknown in the world. there were but two avenues by which kentucky could be reached from the east. one was the water-way, furnished by the ohio river. the other was the "wilderness road," "blazed" by daniel boone. the former was covered in keel-boats, flat-boats, and canoes. the latter was traveled on horseback or on foot. no wheel had broken it or been broken by it. the fathers of the subjects of this narrative followed this road after crossing the alleghanies. they were a clear-eyed, a bold, an adventurous people. they wrested the land from the savage, made it secure by their arms, and by the toil of their hands fitted it for its present civilization. among these, and such as these, these heroes in the bloody exploits of surgery were reared. from such ancestors they drew that dauntless courage which was so often tried in their achievements--achievements the fame of which will not lapse with the lapse of time. boone had opened the way to the wilderness around them. he "blazed" a path through its unbroken depths, along which the stream of civilization quickly flowed. they blazed a path through the unexplored regions of their art along which surgeons continue to tread. his name is written in the history of his adopted state and embalmed in the traditions of its people. their names are written in the chronicles of their beloved calling and upon the hearts of myriads of sufferers whom their beneficent labors have relieved. they may or may not have felt that their work was durable. but durable it is, and it hands down to posterity a _monumentum ã¦re perennius_, the absolute worth of which passes computation. no present or future modification of this work can rob its authors of that glory which crowns the head of the original workman. like their kinsmen in genius, these toilers devised measures and dealt with issues in advance of their time. like them they enjoyed but scant recompense for labors the far-reaching significance of which they did not comprehend. let us who are reaping in the harvest which they sowed forget not how much we are beholden to these immortal husbandmen. and as we contemplate the shining record of their deeds, let it counsel us to "bend ourselves to a better future." not that we may hope to rival their sublime achievements, but that each in his walk, however humble it may be, may strive to enlarge the sphere of his usefulness by making surgery the better for his having practiced it. bibliography. gross's report on kentucky surgery. gross's medical biography. l. p. yandell's report on the medical literature of kentucky. l. p. yandell's life of benjamin w. dudley. transcriber's note: page 27 the dot above the "i" in _fungus cerebri_ is not evident in the original publication. use of the dead to the living. from the westminster review. _albany_: printed by websters and skinners. 1827. advertisement. the following pages contain an article extracted from the westminster review, an english periodical of considerable reputation. on its appearance in great britain, it excited great attention; and, indeed, has been there reprinted in a cheap form for general distribution. the author (dr. southwood smith) deserves the thanks of the community for the talents he has displayed, and the lucid and powerful manner in which he has investigated the important subject under consideration. the editors believe that they are discharging a duty to the community in presenting it to them for perusal and consideration. they will not conceal their wishes, that it may have a favorable effect on a bill now pending before the legislature. both in a general point of view, as well as with reference to the particular institution to be benefitted, the arguments are particularly applicable; nor will an enlightened body of men be deterred from doing what they may deem their duty by the unparalleled impudence of those who _now_ cry out against monopoly, when they have risen into importance by monopoly, and have, always, while it suited their views, been its most persecuting and vindictive advocates. it is due to truth to state, that the suggestion of the republication of this article, originated with a member of the senate of this state, and who does not belong to the profession. _february, 1827._ use of the dead to the living. from the westminster review. _an appeal to the public and to the legislature, on the necessity of affording dead bodies to the schools of anatomy, by legislative enactment._ by william mackenzie. glasgow. 1824. every one desires to live as long as he can. every one values health "above all gold and treasure." every one knows that as far as his own individual good is concerned, protracted life and a frame of body sound and strong, free from the thousand pains that flesh is heir to, are unspeakably more important than all other objects, because life and health must be secured before any possible result of any possible circumstance can be of consequence to him. in the improvement of the art which has for its object the preservation of health and life, every individual is, therefore, deeply interested. an enlightened physician and a skilful surgeon, are in the daily habit of administering to their fellow men more real and unquestionable good, than is communicated, or communicable by any other class of human beings to another. ignorant physicians and surgeons are the most deadly enemies of the community: the plague itself is not so destructive; its ravages are at distant intervals, and are accompanied with open and alarming notice of its purpose and power; theirs are constant, silent, secret; and it is while they are looked up to as saviours, with the confidence of hope, that they give speed to the progress of disease and certainty to the stroke of death. it is deeply to be lamented that the community, in general, are so entirely ignorant of all that relates to the art and the science of medicine. an explanation of the functions of the animal economy; of their most common and important deviations from the healthy state; of the remedies best adapted to restore them to a sound condition, and of the mode in which they operate, as far as that is known, ought to form a part of every course of liberal education. the profound ignorance of the people on all these subjects, is attended with many disadvantages to themselves, and operates unfavorably on the medical character. in consequence of this want of information, persons neither know what are the attainments of the man in whose hands they place their life, nor what they ought to be; they can neither form an opinion of the course of education which it is incumbent on him to follow, nor judge of the success with which he has availed himself of the means of knowledge which have been afforded him. there is one branch of medical education in particular, the foundation, in fact, on which the whole superstructure must be raised, the necessity of which is not commonly understood, but which requires only to be stated to be perceived. perhaps it is impossible to name any one subject which it is of more importance that the community should understand. it is one in which every man's life is deeply implicated: it is one on which every man's ignorance or information will have a considerable influence. we shall, therefore, enter into it with some detail: we shall show the kind of knowledge which it is indispensable that the physician and surgeon should possess; we shall illustrate, by a reference to particular cases, the reason why this kind of knowledge cannot be dispensed with: and we shall explain, by a statement of facts, the nature and extent of the obstacles which at present oppose the acquisition of this knowledge. we repeat, there is no subject in which every reader can be so immediately and deeply interested, and we trust that he will give us his calm and unprejudiced attention. the basis of all medical and surgical knowledge is anatomy. not a single step can be made either in medicine or surgery, considered either as an art or a science without it. this should seem self evident, and to need neither proof nor illustration: nevertheless, as it is useful occasionally to contemplate the evidence of important truth, we shall show why it is, that there can be no rational medicine, and no safe surgery, without a thorough knowledge of anatomy. disease, which it is the object of these arts to prevent and to cure, is denoted by disordered function: disordered function cannot be understood without a knowledge of healthy function; healthy function cannot be understood without a knowledge of structure; structure cannot be understood unless it be examined. the organs on which all the important functions of the human body depend, are concealed from the view. there is no possibility of ascertaining their situation and connections, much less their nature and operation, without inspecting the interior of this curious and complicated machine. the results of the mechanism are visible; the mechanism itself is concealed, and must be investigated to be perceived. the important operations of nature are seldom entirely hidden from the human eye; still less are they obtruded upon it, but over the most curious and wonderful operations of the animal economy so thick a veil is drawn, that they never could have been perceived without the most patient and minute research. the circulation of the blood, for example, never could have been discovered without dissection. notwithstanding the partial knowledge of anatomy which must have been acquired by the accidents to which the human body is exposed, by attention to wounded men, by the observance of bodies killed by violence; by the huntsman in using his prey; by the priest in immolating his victims; by the augur in pursuing his divinations; by the slaughter of animals; by the dissection of brutes; and even occasionally by the dissection of the human body, century after century passed away, without a suspicion having been excited of the real functions of the two great systems of vessels, arteries and veins. it was not until the beginning of the 17th century, when anatomy was ardently cultivated, and had made considerable progress, that the valves of the veins and of the heart were discovered, and subsequently that the great harvey, the pupil of the anatomist who discovered the latter, by inspecting the structure of these valves; by contemplating their disposition; by reasoning upon their use, was led to suspect the course of the blood, and afterwards to demonstrate it. several systems of vessels in which the most important functions of animal life are carried on--the absorbent system, for example, and even that portion of it which receives the food after it is digested, and which conveys it into the blood, are invisible to the naked eye, except under peculiar circumstances: whence it must be evident, not only that the interior of the human body must be laid open, in order that its organs may be seen; but that these organs must be minutely and patiently dissected, in order that their structure may be understood. the most important diseases have their seat in the organs of the body; an accurate acquaintance with their situation is, therefore, absolutely necessary, in order to ascertain the seats of disease; but for the reasons already assigned, their situation cannot be learnt, without the study of anatomy. in several regions, organs the most different in structure and function are placed close to each other. in what is termed the epigastric region, for example, are situated the stomach, the liver, the gall bladder, the first portion of the small intestine, (the duodenum) and a portion of the large intestine (the colon); each of these organs is essentially different in structure and in use, and is liable to distinct diseases. diseases the most diversified, therefore, requiring the most opposite treatment, may exist in the same region of the body; the discrimination of which is absolutely impossible, without that knowledge which the study of anatomy alone can impart. the seat of pain is often at a great distance from that of the affected organ. in disease of the liver, the pain is generally felt at the top of the right shoulder. the right phrenic nerve sends a branch to the liver: the third cervical nerve, from which the phrenic arises, distributes numerous branches to the neighborhood of the shoulder: thus is established a nervous communication between the shoulder and the liver. this is a fact which nothing but anatomy could teach, and affords the explanation of a symptom which nothing but anatomy could give. the knowledge of it would infallibly correct a mistake, into which a person who is ignorant of it, would be sure to fall: in fact, persons ignorant of it do constantly commit the error. we have know several instances in which organic disease of the liver has been considered, and treated as rheumatism of the shoulder. in each of these cases, disease in a most important organ might have been allowed to steal on insidiously, until it became incurable; while a person, acquainted with anatomy, would have detected it at once, and cured it without difficulty. many cases have occurred of persons who have been supposed to labor under disease of the liver, and who have been treated accordingly: on examination after death, the liver has been found perfectly healthy, but there has been discovered extensive disease of the brain. disease of the liver is often mistaken for disease of the lungs: on the other hand, the lungs have been found full of ulcers, when they were supposed to have been perfectly sound, and when every symptom was referred to disease of the liver. persons are constantly attacked with convulsions--children especially; convulsions are spasms: spasms, of course, are to be treated by antispasmodics. this is the notion amongst people ignorant of medicine: it is the notion amongst old medical men: it is the notion amongst half educated young ones. all this time these convulsions are merely a symptom; that symptom depends upon, and denotes, most important disease in the brain: the only chance of saving life, is the prompt and vigorous application of proper remedies to the brain; but the practitioner whose mind is occupied with the symptom, and who prescribes antispasmodics, not only loses the time in which alone any thing can be done to snatch the victim from death, but by his remedies absolutely adds fuel to the flame which is consuming his patient. in disease of the hip-joint pain is felt, not in the hip, but, in the early stage of the disease, at the knee. this also depends on nervous communication. the most dreadful consequences daily occur from an ignorance of this single fact. in all these cases error is inevitable, without a knowledge of anatomy: it is scarcely possible with it: in all these cases error is fatal: in all these cases anatomy alone can prevent the error--anatomy alone can correct it. experience, so far from leading to its detection, would only establish it in men's minds, and render its removal impossible. what is called experience is of no manner of use to an ignorant and unreflecting practitioner. in nothing does the adage, that it is the wise only who profit by experience, receive so complete an illustration as in medicine. a man who is ignorant of certain principles, and who is incapable of reasoning in a certain manner, may have daily before him for fifty years cases affording the most complete evidence of their truth, and of the importance of the deduction to which they lead, without observing the one, or deducing the other. hence the most profoundly ignorant of medicine, are often the oldest members of the profession, and those who have had the most extensive practice. a medical education, founded on a knowledge of anatomy, is, therefore, not only indispensable to prevent the most fatal errors, but to enable a person to obtain advantage from those sources of improvement which extensive practice may open to him. to the surgeon, anatomy is eminently what bacon has so beautifully said that knowledge in general is: it is power--it is power to lessen pain, to save life, and to eradicate diseases, which, without its aid, would be incurable and fatal. it is impossible to convey to the reader a clear conception of this truth, without a reference to particular cases; and the subject is one of such extreme importance, that it may be worth while to direct the attention for a moment to two or three of the capital diseases which the surgeon is daily called upon to treat. aneurism, for example, is a disease of an artery, and consists of a preternatural dilatation of its coats. this dilatation arises from the debility of the vessel, whence, unable to resist the impetus of the blood, it yields, and is dilated into a sac. when once the disease is induced, it commonly goes on to increase with a steady and uninterrupted progress, until at last it suddenly bursts, and the patient expires instantaneously from loss of blood. when left to itself, it almost uniformly proves fatal in this manner; yet, before the time of galen, no notice was taken of this terrible malady. the ancients, indeed, who believed that the arteries were air tubes, could not possibly have conceived the existence of an aneurism. were the number of individuals in europe, who are now annually cured of aneurism, by the interference of art, to be assumed as the basis of a calculation of the number of persons who must have perished by this disease, from the beginning of the world to the time of galen, it would convey some conception of the extent to which anatomical knowledge is the means of saving human life. the only way in which it is possible to cure this disease is, to produce an obliteration of the cavity of the artery. this is the object of the operation. the diseased artery is exposed, and a ligature is passed around it, above the dilatation, by means of which the blood is prevented from flowing into the sac, and inflammation is excited in the vessel; in consequence of which its sides adhere together, and its cavity becomes obliterated. the success of the operation depends entirely on the completeness of the adhesion of the sides of the vessel, and the consequent obliteration of its cavity. this adhesion will not take place unless the portion of the artery to which the ligature is applied be in a sound state. if it be diseased, as it almost always is near the seat of the aneurism, when the process of nature is completed by which the ligature is removed, hemorrhage takes place, and the patient dies just as if the aneurism had been left to itself. for a long time the ligature was applied as close as possible to the seat of the aneurism: the aneurismal sac was laid open in its whole extent, and the blood it contained was scooped out. the consequence was, that a large deep-seated sore, composed of parts in an unhealthy state, was formed: it was necessary to the cure that this sore should suppurate, granulate, and heal: a process which the constitution was frequently unable to support. moreover, there was a constant danger that the patient would perish from hemorrhage, through the want of adhesion of the sides of the artery. the profound knowledge of healthy and of diseased structure, and of the laws of the animal economy by which both are regulated, which john hunter had acquired from anatomy, suggested to this eminent man a mode of operating, the effect of which, in preserving human life, has placed him high in the rank of the benefactors of his race. this consummate anatomist saw, that the reason why death so often followed the common operation was, because that process which was essential to his success was prevented by the diseased condition of the artery. he perceived that the vessel, at some distance from the aneurism, was in a sound state; and conceived, that if the ligature were applied to this distant part, that is, to a sound instead of a diseased portion of the artery, this necessary process would not be counteracted. to this there was one capital objection, that it would often be necessary to apply the ligature around the main trunk of an artery, before it gives off its branches, in consequence of which the parts below the ligature would be deprived of their supply of blood, and would therefore mortify. so frequent and great are the communications between all the arteries of the body, however, that he thought it probable, that a sufficient supply would be borne to these parts through the medium of collateral branches. for an aneurism in the ham, he, therefore, boldly cut down upon the main trunk of the artery which supplies the lower extremity; and applied a ligature around it, where it is seated near the middle of the thigh, in the confident expectation that, though he thus deprived the limb of the supply of blood which it received through its direct channel, it would not perish. his knowledge of the processes of the animal economy, led him to expect that the force of the circulation being thus taken off from the aneurismal sac, the progress of the disease would be stopped; that the sac itself, with all its contents, would be absorbed; that by this means the whole tumor would be removed, and that an opening into it would be unnecessary. the most complete success followed this noble experiment, and the sensations which this philosopher experienced when he witnessed the event, must have been exquisite, and have constituted an appropriate reward for the application of profound knowledge to the mitigation of human suffering. after hunter followed abernethy, who, treading in the footsteps of his master, for an aneurism of the femoral, placed a ligature around the external iliac artery; lately the internal iliac itself has been taken up, and surgeons have tied arteries of such importance, that they have been themselves astonished at the extent and splendor of their success. every individual, on whom an operation of this kind has been successfully performed, is snatched by it from certain and inevitable death! the symptom by which an aneurism is distinguished from every other tumor is, chiefly its pulsating motion. but when an aneurism has become very large, it ceases to pulsate; and when an abscess is seated near an artery of great magnitude, it acquires a pulsating motion; because the pulsations of the artery are perceptible through the abscess. the real nature of cases of this kind cannot possibly be ascertained, without a most careful investigation, combined with an exact knowledge of the structure and relative position of all the parts in the neighborhood of the tumor. pelletan, one of the most distinguished surgeons of france, was one day called to a man who, after a long walk, was seized with a severe pain in the leg, over the seat of which appeared a tumor, which was attended with a pulsation so violent that it lifted up the hand of the examiner. there seemed every reason to suppose that the case was an aneurismal swelling. this acute observer, however, in comparing the affected with the sound limb, perceived in the latter a similar throbbing. on careful examination he discovered that, by a particular disposition in this individual, one of the main arteries of the leg (the anterior tibial) deviated from its usual course, and instead of plunging deep between the muscles, lay immediately under the skin and fascia. the truth was, that the man in the exertion of walking, had ruptured some muscular fibres, and the uncommon distribution of the artery gave to this accident these peculiar symptoms. the real nature of this case could not possibly have been ascertained but by an anatomist. the same surgeon has recorded the case of a man who, having fallen twice from his horse, and experienced for several years considerable uneasiness in his back, was afflicted with acute pain in the abdomen. at the same time an oval, irregularly circumscribed tumor made its appearance in the right flank. it presented a distinct fluctuation, and had all the appearance of a collection of matter depending on caries of the vertebrã¦. the pain was seated chiefly at the lower portion of that part of the spine which forms the back, which was, moreover, distorted; and this might have confirmed the opinion that the case was a lumbar abscess with caries. pelletan, however, who well knew that an aneurism, as it enlarges, may destroy any bone in its neighborhood, saw that the disease was an aneurism, and predicted that the patient must perish. on opening the body (for the man lived only ten days after pelletan first saw him) an aneurismal tumor was discovered, which nearly filled the cavity of the abdomen. if this case had been mistaken for lumbar abscess, and the tumor had been opened with a view of affording an exit to the matter, the man would have died in a few seconds. there is no surgeon of discernment or experience whose attention has not been awakened, and whose sagacity has not been put to the test, by the occurrence of similar cases in his own practice. the consequence of error is almost always instantaneously fatal. the catalogue of such disastrous events is long and melancholy. richerand has recorded, that ferrand, head surgeon of the hotel dieu, mistook an aneurism in the armpit for an abscess; plunged his knife into the swelling, and killed the patient. de haen speaks of a person who died in consequence of an opening which was made, contrary to the advice of boerhaave in a similar tumor at the knee. vesalius was consulted about a tumor in the back, which he pronounced to be an aneurism; but an ignorant practitioner having made an opening into it, the patient instantly bled to death. nothing can be more easy than to confound an aneurism of the artery of the neck with the swelling of the glands in its neighborhood: with a swelling of the cellular substance which surrounds the artery; with abscesses of various kinds; but if a surgeon were to fall into this error, and to open a carotid aneurism, his patient would certainly be dead in the space of a few moments. it must be evident, then, that a thorough knowledge of anatomy is not only indispensable to the proper treatment of cases of this description, but also to the prevention of the most fatal mistakes. there is nothing in surgery of more importance than the proper treatment of hemorrhage. of the confusion and terror occasioned by the sight of a human being from whom the blood is gushing in torrents, and whose condition none of the spectators is able to relieve, no one can form an adequate conception, but those who have witnessed it. in all such cases, there is one thing proper to be done, the prompt performance of which is generally as certainly successful, as the neglect of it is inevitably fatal. it is impossible to conceive of a more terrible situation than that of a medical man who knows not what to do on such an emergency. he is confused; he hesitates: while he is deciding what measures to adopt, the patient expires: he can never think of that man's death without horror, for he is conscious that, but for his ignorance, he might have averted his patient's fate. the ancient surgeons were constantly placed in this situation, and the dread inspired by it retarded the progress of surgery more than all other causes put together. not only were they terrified from interfering with the most painful and destructive diseases, which experience has proved to be capable of safe and easy removal, but they were afraid to cut even the most trivial tumor. when they ventured to remove a part, they attempted it only by means of the ligature, or by the application of burning irons. when they determined to amputate, they never thought of doing so until the limb had mortified, and the dead had separated from the living parts; for they were absolutely afraid to cut into the living flesh. they had no means of stopping hemorrhage, but by the application of astringents to the bleeding vessels, remedies which were inert; or of burning irons, or boiling turpentine, expedients which were not only inert but cruel. surgeons now know that the grand means of stopping hemorrhage is compression of the bleeding vessel. if pressure be made on the trunk of an artery, though blood be flowing from a thousand branches given off from it, the bleeding will cease. should the situation of the artery be such as to allow of effectual external pressure, nothing further is requisite: the pressure being applied, the bleeding is stopped at once: should the situation of the vessel place it beyond the reach of external pressure, it is necessary to cut down upon it, and to secure it by the application of a ligature. parã¨ may be pardoned for supposing that he was led to the discovery of this invaluable remedy by the inspiration of the deity. by means of it the most formidable operations may be undertaken with the utmost confidence, because the wounded vessels can be secured the moment they are cut: by the same means the most frightful hemorrhages may be most effectually stopped: and even when the bleeding is so violent as to threaten immediate death, it may often be averted by the simple expedient of placing the finger upon the wounded vessel, until there is time to tie it. but it is obvious that none of these expedients can be employed, and that these bleedings can neither be checked at the moment, nor permanently stopped, without such a knowledge of the course of the trunks and branches of vessels, as can be acquired only by the study of anatomy. the success of amputation is closely connected with the knowledge of the means of stopping hemorrhage. not to amputate is often to abandon the patient to a certain and miserable death. and all that the surgeon formerly did, was to watch the progress of that death: he had no power to stop or even to retard it. the fate of sir philip sidney is a melancholy illustration of this truth. this noble minded man, the light and glory of his age, was cut off in the bloom of manhood, and the midst of his usefulness, by the wound of a musket bullet in his left leg, a little above the knee, "when extraction of the ball, or amputation of the limb," says his biographer, "would have saved his inestimable life: but the surgeons and physicians were unwilling to practice the one, and knew not how to perform the other. he was variously tormented by a number of surgeons and physicians for three weeks." amputation indeed was never attempted, except where mortification had itself half performed the operation. the just apprehension of an hemorrhage which there was no adequate means of stopping, checked the hand of the boldest surgeon, and quailed the courage of the most daring patient--and if ever the operation was resorted to, it almost always proved fatal: the patient generally expired, according to the expression of celsus, "_in ipso opere_." how could it be otherwise? the surgeon cut through the flesh of his patient with a red hot knife: this was his only means of stopping the hemorrhage: by this expedient he sought to convert the whole surface of the stump into an eschar: but this operation, painful in its execution, and terrible in its consequences, when it even appeared to succeed, succeeded only for a few days; for the bleeding generally returned, and proved fatal as soon as the sloughs or dead parts became loose. plunging the stump into boiling oil, into boiling turpentine, into boiling pitch, for all these means were used, was attended with no happier result, and after unspeakable suffering, almost every patient perished. in the manner in which amputation is performed at present, not more than one person in twenty loses his life in consequence of the operation, even taking into the account all the cases in which it is practised in hospitals. in private practice, where many circumstances favor its success, it is computed that 95 persons out of 100 recover from it, when it is performed at a proper time, and in a proper manner. it seems impossible to exhibit a more striking illustration of the great value of anatomical knowledge. but if there be any disease, which, from the frequency of its occurrence, from the variety of its forms, from the difficulty of discriminating between it and other maladies, and from the danger attendant on almost all its varieties, requires a combination of the most minute investigation, with the most accurate anatomical knowledge, it is that of hernia. this disease consists of a protrusion of some of the viscera of the abdomen, from the cavity in which they are naturally contained, into a preternatural bag, composed of the portion of the peritoneum (the membrane which lines the abdomen) which is pushed before them. it is computed that one sixteenth of the human race are afflicted with this malady. it is sometimes merely an inconvenient complaint, attended with no evil consequences whatever; but there is no form of this disease, which is not liable to be suddenly changed, and by slight causes, from a perfectly innocent state, into a condition which may prove fatal in a few hours. the disease itself occurs in numerous situations; it may be confounded with various diseases; it may exist in the most diversified states; it may require, without the loss of a single moment, a most important and delicate operation; and it may appear to demand this operation, while the performance of it may really be not only useless, but highly pernicious. the danger of hernia depends on its passing into that state which is technically termed strangulation. when a protruded intestine suffers such a degree of pressure, as to occasion a total obstruction to the passage of its contents, it is said to be strangulated. the consequence of pressure thus producing strangulation is, the excitement of inflammation: this inflammation must inevitably prove fatal, unless the pressure be promptly removed. in most cases, this can be effected only by the operation. two things, then, are indispensable: first, the ability to ascertain that the symptoms are really produced by pressure, that is, to distinguish the disease from the affections which resemble it; and secondly, when this is effected, to perform the operation with promptitude and success. the distinction of strangulated hernia from affections which resemble it, often requires the most exact knowledge and the most minute investigation. the intestine included in a hernial sac, may be merely affected with colic, and thus give rise to the appearance of strangulation. it may be in a state of irritation, produced, for example, by unusual fatigue; and from this cause, may be attacked with the symptoms of inflammation. inflammation may be excited in the intestine, by the common causes of inflammation, which the hernia may have no share in inducing, and of which it may not even participate. were this case mistaken, and the operation performed, it would not only be useless, but pernicious: while the attention of the practitioner would be diverted from the real nature of the malady; the prompt and vigorous application of the remedies which alone could save the patient, would be neglected, and he would probably perish. on the other hand, a very small portion of intestine may become strangulated, and urgently require the operation. but there may be no tumor; all the symptoms may be those, and, on a superficial examination, only those, of inflammation of the bowels. were the real nature of this case mistaken, death would be inevitable. nothing is more common than fatal errors of this kind. it is only a few months ago, that a physician was called in haste to a person who was said to be dying of inflammation of the bowels. before he reached the house the man was dead. he had been ill only three days. on looking at the abdomen, there was a manifest hernia: the first glance was sufficient to ascertain the fact. the practitioner in attendance had known nothing of the matter; he had never suspected the real nature of the disease, and had made no inquiry which could have led to the detection of it. here was a case which might probably have been saved, but for the criminal ignorance and inattention of the practitioner. whenever there are symptoms of inflammation of the bowels, examination of the abdomen is indispensable: and the life of the patient will depend on the care and accuracy with which the investigation is made. but it is possible that inflammation may attack the parts included in the hernial sac, without arising from the hernia itself. the inflammation may be produced by the common causes of inflammation; there may be no pressure: there may be no strangulation: the swelling may be the seat, not the cause of the disease. in this case, too, the operation would be both useless and pernicious. now all these are diversities which it is of the highest importance to discriminate. in some of them, life depends on the clearness, accuracy, and promptitude, with which the discrimination is made. promptitude is of no less consequence than accuracy. if the decision be not formed and acted on at once, it will be of no avail. the rapidity of the progress of this disease is often frightful. we have mentioned a case in which it was fatal in three days, but it not unfrequently terminates fatally in less than twenty four hours. sir astley cooper mentions a case in which the patient was dead in eight hours after the commencement of the disease. larrey has recorded the case of a soldier in whom a hernia took place, which was strangulated immediately. he was brought to the "ambulance" instantly, and perished in two hours with gangrene of the part, and of the abdominal viscera. this was the second instance which had occurred to this surgeon of a rapidity thus appalling. what clearness of judgment, what accuracy of knowledge, what promptitude of decision, are necessary to treat such a disease with any chance of success! the moment that a case is ascertained to be strangulated hernia, an attempt must be made to liberate the parts from the stricture, and to replace them in their natural situation. this is first attempted by the hand, and the operation is technically termed the _taxis_. the patient must be placed in a particular position; pressure must be made in a particular direction; it is impossible to ascertain either, without an accurate knowledge of the parts. if pressure be made in a wrong direction, and in a rough and unscientific manner, the organs protruded instead of being urged through a proper opening, are bruised against the parts which oppose their return. many cases are on record, in which gangrene and even rupture of the intestine, have been occasioned in this manner. when the parts cannot be returned by the hand, assisted by those remedies which experience has proved to be beneficial, the operation must be performed without the delay of a moment. to its proper performance two things are necessary. first, a minute anatomical knowledge of the various and complicated parts which are implicated in it; and secondly, a steady, firm, and delicate command of the knife. in the first place, the integuments must be divided; the cellular substance which intervenes between the skin and the hernial sac must be removed layer by layer with the knife and the dissecting forceps; the sac itself must be opened: this part of the operation must be performed with the most extreme caution: the sac being laid open, the protruded organs are now exposed to view. the operator must next ascertain the exact point where the stricture exists; having discovered its seat, he must make his incision with a particular instrument--in a certain direction--to a definite extent. on account of the nature of the parts implicated in the operation, and the proximity of vessels, life depends on an exact knowledge and a precise and delicate attention to all these circumstances. how can this knowledge be obtained, how can this dexterity be acquired, without a profound acquaintance with anatomy, and how can this be acquired without frequent and laborious dissection? the eye must become familiar with the appearance of the integuments, with the appearance of the cellular substance beneath it, with the appearance of the hernial sac, and of the changes which it undergoes by disease; with the appearance of the various viscera contained in it, and of their changes: and the hand must pay that steady and prompt obedience to the judgment, which nothing but knowledge, and the consciousness of knowledge, can command. even this is not all. when the operation has been performed thus far with perfect skill and success, the most opposite measures are required according to the actual state of the organs contained in the sac. if they are agglutinated together--if portions of them are in a state of mortification, to return them into the cavity of the abdomen in that condition, would, in general, be certain death. preternatural adhesion must be removed; mortified portions must be cut away: but how can this possibly be done without an acquaintance with healthy and diseased structure, and how can this be obtained without dissecting the organs in a state of health and of disease? it has been stated that the progress of strangulated hernia to a fatal termination is often frightfully rapid; in certain cases to delay the operation, even for a very short period, is, therefore, to lose the only chance of success. but ignorant and half informed surgeons are afraid to operate. they are conscious that the operation is one of immense importance: they know that in the hands of an operator ignorant of anatomy, it is one of extreme hazard: they therefore put off the time as long as possible: they have recourse to every expedient: they resort to every thing but the only efficient remedy, and when at last they are compelled by a secret sense of shame to try that, it is too late. all the best practical surgeons express themselves in the strongest language on the importance of performing the operation early, if it be performed at all. on this point there is a perfect accordance between the most celebrated practitioners on the continent, and the great surgeons of our own country: all represent, in many parts of their writings, the dangerous and fatal effects of delay. mr. hey in his practical observations, states that when he first began to practice, he considered the operation as the last resource, and only to be employed when the danger appeared imminent. "by this dilatory mode of practice," says he, "i lost three patients in five, upon whom the operation was performed. having more experience of the urgency of the disease, i made it my custom, when called to a patient who had laboured two or three days under the disease, to wait only about two hours, that i might try the effect of bleeding (if that evacuation was not forbidden by some peculiar circumstance of the case) and the tobacco clyster. in this mode of practice, i lost about two patients in nine, upon whom i operated. this comparison is drawn from cases nearly similar, leaving out of the account those cases in which gangrene of the intestine had taken place. i have now, at the time of writing this, performed the operation thirty-five times; and have often had occasion to lament that i performed it too late, but never that i had performed it too soon." these observations are sufficient to show the importance of anatomy in certain surgical diseases. the state of medical opinion from the earliest ages to the present time, furnishes a most instructive proof of its necessity to the detection and cure of disease in general. the doctrines of the father of physic were in the highest degree vague and unmeaning. every thing is resolved by hippocrates into a general principle, which he terms nature; and to which he ascribes intelligence; which he clothes with the attributes of justice; and which he represents as possessing virtues and powers, which he says are her servants, and by means of which she performs all her operations in the bodies of animals, distributes the blood, spirits, and heat, through all the parts of the body, and imparts to them life and sensation. he states that the manner in which she acts, is by attracting what is good or agreeable to each species, and retaining, preparing, and changing it: or, on the other hand, by rejecting whatever is superfluous or hurtful, after she has separated it from the good. this is the foundation of the doctrine of depuration, concoction, and crisis in fevers, so much insisted on by him, and by other physicians after him; but when he explains what he means by nature, he resolves it into heat, which he says appears to have something immortal in it. the great opponent of hippocrates was asclepiades. he asserted that matter, considered in itself, is of an unchangeable nature: that all perceptible bodies are composed of a number of small ones, termed corpuscles, between which there are interspersed an infinity of small spaces totally devoid of matter: that the soul itself is composed of these corpuscles: that what is called nature is nothing more than matter and motion: that hippocrates knew not what he said when he spoke of nature as an intelligent being, and ascribed to her various qualities and virtues: that the corpuscles, of which all bodies are composed, are of different figures, and consist of different assemblages: that all bodies contain numerous pores, or interstices, which are of different sizes: that the human body, like all other bodies, possesses pores peculiar to itself: that these pores are larger or smaller, according as the corpuscles which pass through them differ in magnitude: that the blood consists of the largest, and the spirits and the heat of the smallest. on these principles, asclepiades founded his theory of medicine. he maintains, that as long as the corpuscles are freely received by the pores, the body remains in its natural state: that, on the contrary, as soon as any obstacle obstructs their passage, it begins to recede from that state: that, therefore, health depends on the just proportion between these pores and corpuscles: that, on the contrary, disease proceeds from a disproportion between them: that the most usual obstacle arises from a retention of some of the corpuscles in their ordinary passages, where they arrive in too large a number, or are of irregular figures, or move too fast or proceed too slow: that phrensies, lethargies, pleurises, burning fevers for example, are occasioned by these corpuscles stopping of their own accord: that pain is produced by the stagnation of the largest of all these corpuscles, of which the blood consists: that, on the contrary, deliriums, languors, extenuations, leanness and dropsies, derive their origin from a bad state of the pores, which are too much relaxed, or opened: that dropsy, in particular, proceeds from the flesh being perforated with various small holes, which convert the nourishment received into them into water: that hunger is occasioned by an opening of the large pores of the stomach and belly: that thirst arises from an opening of the small pores: that intermittent fevers have the same origin: that quotidian fever is produced by a retention of the largest corpuscles; tertian fever by a retention of corpuscles somewhat smaller; and quartan fever by a retention of the smallest corpuscles of all. galen maintained that the animal body is composed of three principles, namely, the solids, the humors, and the spirits. that the solid parts consist of similar and organic: that the humors are four in number, namely, the blood, the phlegm, the yellow bile, and the black bile: that the spirits are of three kinds, namely, the vital, the animal, and the natural: that the vital spirit is a subtle vapour which arises from the blood, and which derives its origin from the liver, the organ of sanguification: that the spirits thus formed, are conveyed to the heart, where, in conjunction with the air drawn into the lungs by respiration, they become the matter of the second species, namely, of the vital spirits: that in their turn, the vital spirits are changed into the animal in the brain, and so on. at last came paracelsus, who was believed to have discovered the elixir of life, and who is the very prince of charlatans. he delivered a course of lectures on the theory and practice of physic in the university of basle, which he commenced by burning the works of galen and avicenna in the presence of his auditory. he assured his hearers, that his shoe-latchets had more knowledge than both these illustrious authors put together: that all the academies in the world had not so much experience as his beard; and that the hair on the back of his neck was more learned than the whole tribe of authors. it was fitting that a person of such splendid pretensions should have a magnificent name. he, therefore, called himself philippus aureolus theophrastus paracelsus bombast von hohenheim. he was a great chemist, and like other chemists, he was a little too apt to carry into other sciences "the smoke and tarnish of the furnace." he conceived that the elements of the living system were the same as those of his laboratory, and that sulphur, salt, and quicksilver, were the constituents of organized bodies. he taught that these constituents were combined by chemical operations: that their relations were governed by archeus, a demon, who performed the part of alchemist in the stomach, who separated the poisonous from the nutritive part of the food, and who communicated the tincture by which the food became capable of assimilation: that this governor of the stomach, this _spiritus vitã¦_, this astral body of man, was the immediate cause of all diseases, and chief agent in their cure: that each member of the body had its peculiar stomach, by which the work of secretion was effected: that diseases were produced by certain influences, of which there were five in particular, viz. _ens estrale_, _ens veneni_, _ens naturale_, _ens spirituale_, and _ens deale_: that when archeus was sick, putrescence was occasioned, and that either _localiter_ or _emunctorialiter_, &c. &c. &c. it would be leading to a detail which is incompatible with our present purpose to follow these speculations, or to give an account of the doctrines of the mechanical physicians, who believed that every operation of the animal economy was explained by comparing it to a system of ropes, levers, and pulleys, united with a number of rigid tubes of different lengths and diameters, containing fluids which, from variations in their impelling causes, moved with different degrees of velocity: or of the chemical physicians, whose manner of theorizing and investigating would have qualified them better for the occupation of the brewer or of the distiller, than for that of the physician. all these speculations are idle fancies, without any evidence whatever to support them; and it has been argued that, for this very reason, they must have been without any practical result, and that, therefore, if they were productive of no benefit, they were, at least, innoxious. no opinion can be more false or pernicious. these wretched theories not only pre occupied the mind, prevented it from observing the real phenomena of health and of disease, and the actual effect of the remedies which were employed, and thus put an effectual stop to the progress of the science: but they were productive of the most direct and serious evils. it is no less true in medicine than in philosophy and morals, that there is no such thing as innoxious error; that men's opinions invariably influence their conduct; and that physicians, like other men, act as they think. asclepiades, whose mind was full of corpuscles and interstices, was intent on finding suitable remedies, which he discovered in gestation, friction, and the use of wine. by various exercises, he proposed to render the pores more open, and to make the juices and corpuscles, the retention of which causes disease, to pass more freely. hence he used gestation from the very beginning of the most burning fevers. he laid it down as a maxim, that one fever was to be cured by another; that the strength of the patient was to be exhausted by making him watch and endure thirst to such a degree, that for the first two days of the disorder he would not allow them to cool their mouths with a drop of water. abernethy's regulated diet is luxurious compared to his plan of abstinence. for the three first days he allowed his patients no aliment whatever; on the fourth, he so far relented as to give to some of them a small portion of food; but from others he absolutely withheld all nourishment till the seventh day. and this is the gentleman who laid it down as a maxim, that all diseases are to be cured "_tuto, celeriter et jucunde_." to be sure he was a believer in the doctrine of compensation; and in the latter stage of their diseases endeavored to recompense his patients for the privations he caused them to endure in the beginning of their illness. celsus observes, that though he treated his patients like a butcher during the first days of the disorder, he afterwards indulged them so far as to give directions for making their beds in the softest manner. he allowed them abundance of wine, which he gave freely in all fevers; he did not forbid it even to those afflicted with phrenzy: nay, he ordered them to drink it till they were intoxicated; for, said he, it is absolutely necessary that persons who labor under phrenzy should sleep, and wine has a narcotic quality. to lethargic patients, he prescribed it with great freedom, but with the opposite purpose of rousing them from their stupor. his great remedy in dropsy was friction, which, of course, he employed to open the pores. with the same view, he enjoined active exercise to the sick; but what is a little extraordinary, he denied it to those in health. eristratus, who was a great speculator, and whose theories had the most important influence on his practice, banished blood-letting altogether from medicine, for the following notable reasons: because, he says, we cannot always see the vein we intend to open; because we are not sure we may not open an artery instead of a vein; because we cannot ascertain the true quantity to be taken; because, if we take too little, the intention is not answered; if too much, we may destroy the patient; and because the evacuation of the venous blood is succeeded by that of the spirits, which thus pass from the arteries into the veins; wherefore, blood-letting ought never to be used as a remedy in disease. yet, though he was thus cautious in abstracting blood, it must not be supposed that he was not a sufficiently bold practitioner. in tumor of the liver, he hesitated not to cut open the abdomen, and to apply his medicines immediately to the diseased organ; but though he took such liberties with the liver, he regarded with the greatest apprehension the operation of tapping in dropsy of the abdomen: because, said he, the waters being evacuated, the liver which is inflamed and become hard like a stone, is more pressed by the adjacent parts, which the waters kept at a distance from it, whence the patient dies. one physician conceived that gout originated from an effervescence of the synovia of the joints with the vitriolated blood: whence he recommended alcohol for its cure: a remedy for which the court of aldermen ought to have voted him a medal. a more ancient practitioner, who believed that the finger of st. blasius was very efficacious "for removing a bone which sticks in the throat," maintained that gout was the "grand drier," and prescribed a remedy for it, which the patient was to use for a whole year, and to observe the following diet each month. in september, he must eat and drink milk; in october, he must eat garlic; in november, he is to abstain from bathing; in december, he must eat no cabbage; in january, he is to take a glass of pure wine in the morning; in february, to eat no beef; in march, to mix several things both in eatables and drinkables; in april, not to eat horse-radish; nor in may, the fish called polypus; in june, he is to drink cold water in a morning; in july, to avoid venery; and lastly, in august, to eat no mallows. a third physician deduced all diseases from inspissation of the fluids; hence he attached the highest importance to diluent drinks, and believed that tea, especially, is a sovereign remedy in almost every disease to which the human frame is subject; "tea," says bentekoe, who is loudest in his praises of this panacea, and who, as blumenbach observes, 'deserved to have been pensioned by the east india company for his services,' "tea is the best, nay, the only remedy for correcting viscidity of the blood, the source of all diseases, and for dissipating the acid of the stomach, as it contains a fine oleaginous volatile salt, and certain subtle spirits which are analogous in their nature to the animal spirits. tea fortifies the memory and all the intellectual faculties: it will therefore furnish the most effectual means of improving physical education. against fever there is no better remedy than forty or fifty cups of tea, swallowed immediately after one another, the slime of the pancreas is thus carried off." another physician derived all his diseases from a redundancy or deficiency of fire and water. he maintained that where the water predominated, the fluids became viscid, and that hence arose intermittent fevers and arthritic complaints. his remedies are in strict conformity to his theory. these diseases are to be cured by volatile salts, which abound with fiery particles; venesection in any case is highly pernicious; these fiery medicines are the only efficacious remedies, and are to be employed even in diseases of the most inflammatory nature. "life," says dr. brown, "is a forced state;" it is a flame kept alive by excitement; every thing stimulates; some substances too violently; others not sufficiently; there are thus two kinds of debility, indirect and direct, and to one or other of these causes must be referred the origin of all diseases. according to this doctrine, the mode of cure is simple: we have nothing to do but to supply, to moderate or to abstract stimuli. typhus fever, in this system, is a disease of extreme debility; we must therefore give the strongest stimulants. consumption and apoplexy, also, are diseases of debility; of course, the remedies are active stimulants. humanity shudders, and with reason, at the application of such doctrines to practice. and not less destitute of reason, and not less dangerous in practice, is the great doctrine of debility promulgated by cullen. this celebrated professor taught, that the circumstance which invariably characterised fever, that which constituted its essence, was debility. the inference was obvious, that, above all things, the strength must be supported. the consequence was, that blood-letting was neglected, and that bark and wine were given in immense quantities, in cases in which intense inflammation existed. the practice was in the highest degree mortal; the number of persons who have perished in consequence of this doctrine is incalculable. so far then is it from being true, that medical theories are of no practical importance, there is the closest possible connection between the speculations of the physician in his closet, and the measures which he adopts at the bed side of his patient. truth to him is a benignant power, which stops the progress of disease, protracts the duration of life, and mitigates the suffering it may be unable to remove: error is a fearfully active and tremendously potent principle. there is not a medical prejudice which has not slain its thousands, nor a false theory which has not immolated its tens of thousands. the system of medicine and surgery which is established in any country, has a greater influence over the lives of its inhabitants than the epidemic diseases produced by its climate, or the decisions of its government concerning peace and war. the devastations of the yellow fever will bear no comparison with the ravages committed by the brunonian system; and the slaughter of the field of waterloo counts not of victims, a tithe of the number of which the cullenian doctrine of debility can justly boast. anatomy alone will not teach a physician to think, much less to think justly; but it will give him the elements of thinking; it will furnish him with the means of correcting his errors; it will certainly save him from some delusions, and will afford to the public the best shield against his ignorance, which may be fatal, and against his presumption, which may be devastating. we have entered into this minute detail at the hazard, we are aware, of tiring the reader; but in the hope of leaving on his mind a more distinct impression of the importance of anatomical knowledge, than could possibly be produced by a mere allusion to the circumstances which have been explained. in all ages, formidable obstacles have opposed the prosecution of anatomical investigations. among these, without doubt, the most powerful has its source in a feeling which is natural to the heart of man. the sweetest, the most sacred associations are indissolubly connected with the person of those we love. it is with the corporeal frame that our senses have been familiar: it is that on which we have gazed with rapture; it is that which has so often been the medium of conveying to our hearts the thrill of exstacy. we cannot separate the idea of the peculiarities and actions of a friend from the idea of his person. it is for this reason that "every thing which has been associated with him acquires a value from that consideration; his ring, his watch, his books, and his habitation. the value of these as having been his, is not merely fictitious; they have an empire over my mind; they can make me happy or unhappy; they can torture and they can tranquilize; they can purify my sentiments, and make me similar to the man i love; they possess the virtue which the indian is said to attribute to the spoils of him he kills, and inspire me with the power, the feelings, and the heart of their preceding master." it is nothing, says the survivor, to tell me, when disease completed its work and death has seized its prey, that that body, with which are connected so many delightful sensations, is a senseless mass of matter: that it is no longer my friend; that the spirit which animated it, and rendered it lovely to my sight and dear to my affections, is gone. i know that it is gone, i know that i never more shall see the light of intelligence brighten that countenance, nor benevolence beam in that eye, nor the voice of affection sound from those lips: that which i loved, and which loved me, is not here: but here are still the features of my friend: this is his form, and the very particles of matter which compose this dull mass, a few hours ago were a real part of him, and i cannot separate them, in my imagination, from him. and i approach them with the profounder reverence; i gaze upon them with the deeper affection, because they are all that remain to me. i would give all that i possess to purchase the art of preserving the wholesome character and rosy hue of this form, that it might be my companion still: but this is impossible: i cannot detain it from the tomb: but when i have "cast a heap of mould upon the person of my friend, and taken the cold earth for its keeper," i visit the spot in which it is deposited with awe: it is sacred to my imagination: it is dear to my heart. there is a real and deep foundation for these feelings in human nature: they arise spontaneously in the bosom of man, and we see their expression and their power in the customs of all nations, savage as well as civilized, and in the conduct of all men, the most ignorant and uncultivated no less than the most intelligent and refined. it has been the policy of society to foster these sentiments. if has been conceived that the sanctity which attaches to the dead, is reflected back in a profounder feeling of respect for the living; that the solemnity with which death is regarded, elevates, in the general estimation, the value of life; and that he who cannot approach the mortal remains of a fellow creature without an emotion of awe, must regard with horror every thing which places in danger the life of a human being. religion has contributed indirectly, but powerfully, to the strength and perpetuity of these impressions; and superstition has availed herself of them to play her antics, and to accomplish her base and malignant purposes. it is not the eradication of these feelings that can be desired, but their control: it is not the extinction of these natural and useful emotions that is pleaded for, but they should give way to higher considerations when these exist. veneration for the dead is connected with the noblest and sweetest sympathies of our nature: but the promotion of the happiness of the living is a duty from which we can never be exonerated. in antient times the voice of reason could not be heard. superstition, and customs founded on superstition, excited an influence which was neither to be resisted nor evaded. dissection was then regarded with horror. in the warm countries of the east, the pursuit must have been highly offensive and even dangerous, and it was absolutely incompatible with the notions and ceremonies universally prevalent in those days. the jewish tenet of pollution must have formed an insuperable obstacle to the cultivation of anatomy amongst that people. by the egyptians, every one who cut open a dead body was regarded with inexpressible horror. the grecian philosophers so far overcame the prejudice, as occasionally to engage in the pursuit, and the first dissection on record was one made by democritus of abdera, the friend of hippocrates, in order to discover the course of the bile. the romans contributed nothing to the progress of the art: they were content with propitiating the deities who presided over health and disease. they erected on the palatine mount a temple to the goddess febris, whom they worshipped from a dread of her power. they also sacrificed to the goddess ossipaga, who, it seems, presided over the growth of the bones, and to another styled carna, who took care of the viscera, and to whom they offered bean broth and bacon, because these were the most nutritious articles of diet. the arabians adopted the jewish notion of pollution, and were thus prohibited by the tenets of their religion from practising dissection. abdollaliph, who flourished about the year 1200, a man of learning and a teacher of anatomy, never saw and never thought of a human dissection. in order to examine and demonstrate the bones, he took his students to burying grounds, and earnestly recommended them, instead of reading books, to adopt that method of study: yet he seemed to have no conception that the dissection of a recent subject might be a still better method of learning. christians were equally hostile to dissection. pope boniface the 8th issued a bull prohibiting even the maceration and preparation of skeletons. the priests were the only physicians, and so greatly did they abuse the office they assumed, that the evil at length became too intolerable to be borne. the church itself was obliged to prohibit the priesthood from interfering with the practice of medicine. all monks and canons who applied themselves to physic, were threatened with severe penalties, and all bishops, abbots, and priors who connived at their misconduct, were ordered to be suspended from their ecclesiastical functions. but it was not till three hundred years after this interdiction, that by a special bull which permitted physicians to marry, their complete separation from the clergy was effected. in the 14th century, mundinus, professor at bologna, astonished the world by the public dissection of two human bodies. in the 15th century, leonardo da vinci contributed essentially to the progress of the art, by the introduction of anatomical plates, which were admirably executed. in the 16th century, the emperor, charles the 5th, ordered a consultation to be held by the divines of salamanca, to determine whether it was lawful, in point of conscience, to dissect a dead body in order to learn its structure. in the 17th century, cortesius, professor of anatomy at bologna, and afterwards professor of medicine at messina, had long begun a treatise on practical anatomy, which he had an earnest desire to finish, but so great was the difficulty of prosecuting the study even in italy, that in 24 years he could only twice procure an opportunity of dissecting a human body, and even then with difficulty and in hurry; whereas, he had expected to have done so, he says, once every year, according to the custom of the famous academies of italy. in muscovy, until very lately, both anatomy and the use of skeletons were positively forbidden; the first as inhuman, and the latter as subservient to witchcraft. even the illustrious luther was so biassed by the prejudices of his age, that he ascribed the majority of the diseases to the arts of the devil, and found great fault with physicians when they attempted to account for them by natural causes. england acquired the bad fame of being the country of witches, and opposed almost insuperable obstacles to the cultivation of anatomy. even at present the prejudices of the people on this subject are violent and deeply rooted. the measure of that violence may be estimated by the degree of abhorrence with which they regard those persons who are employed to procure the subjects necessary for dissection. in this country, there is no other method of obtaining subjects but that of exhumation: aversion to this employment may be pardoned: dislike to the persons who engage in it is natural, but to regard them with detestation, to exult in their punishment, to determine for themselves its nature and measure, and to endeavor to assume the power of inflicting it with their own hands, is absurd. magistrates have too often fostered the prejudices of the people, and afforded them the means of executing their vengeance on the objects of their aversion. the press has uniformly allied itself with the ignorance and violence of the vulgar, and has done every thing in its power to inflame the passions, which it was its duty to endeavor to soothe. it is notorious that the winter before last there was scarcely a week in which the papers did not contain the most exaggerated and disgusting statements: the appetite which could be gratified with such representations, was sufficiently degraded: but still more base was the servility which could pander to it. half a century ago there was in scotland no difficulty in obtaining the subjects which were necessary to supply the schools of anatomy. the consequence was, that medicine and surgery assumed new life--started from the torpor in which they had been spell-bound--and made an immediate, and rapid, and brilliant progress. the new seminaries constantly sent into the world men of the most splendid abilities, at once demonstrating the excellence of the schools in which they were educated, and rendering them illustrious. pupils flocked to them from all quarters of the globe, and they essentially contributed to that advancement of science which the present age has witnessed. in the 19th century, the good people of scotland, that intelligent, that cool and calculating, that most reasonable and thinking people, have thought proper to return to the worst feeling and the worst conduct of the darkest periods of antiquity. there is at present no offence whatever, which seems to have such power to heat and exalt into a kind of torrent, the blood which usually flows so calmly and sluggishly in the veins of a scotchman. the people of 1823 (to compare great things with small) emulate the spirit of those of their forefathers who "_were out in the forty-five_;" the object, to be sure, is somewhat different, but it is amusing to see the intensity and seriousness of the excitement. about twelve months ago an honest farmer of the name of scott, who resides at linlithgow, apprehended a poor wight who was pursuing his vocation, we presume, in the churchyard of that place; and this service appeared so meritorious to the people in his neighborhood, that they absolutely presented him with a piece of plate. in the winter sessions of 1822-3, a body was discovered on its way to the lecture-room of an anatomist in glasgow, and in spite of the exertions of the police, aided by those of the military, this gentleman's premises and their contents, which were valuable, were entirely destroyed by the mob. for some time after this achievement, it was necessary to station a military guard at the houses of all the medical professors in that city. in the spring circuit of the justiciary court last year at stirling, while the judges were proceeding to the court, the procession was assaulted with missiles; several persons were injured, and it was necessary to call in the protection of a military force. the object of the mob was to inflict summary punishment on a man who was about to be tried for the exhumation of a body. we happen to know that the most disgraceful proceedings were some time ago instituted in that town against a young gentleman of respectable family and connections, who was in fact expatriated, and whose prospects in life were entirely changed, if not ruined, because he had too much honor to implicate his instructors in a transaction which would have put them to an inconvenience, and in which they had engaged from a desire faithfully to discharge their duty to their pupils. within the last five years three men were lodged in the county jail at haddington, charged with a trespass in the churchyard of that town. so enraged was the mob against them, that an attempt was made to force the jail in order to get at them. on their way to the court, the men were again attacked, forced from the carriage, and severely maimed. after examination they were admitted to bail; but, when set at liberty, they were assailed with more violence than ever, and were nearly killed. on the 29th of june, 1823, being sunday, a most extraordinary outrage was perpetrated in the streets of edinburgh. a coach containing an empty coffin and two men, was observed proceeding along the south bridge. the people suspecting that it was intended to convey a body taken from some churchyard, seized the coach. it was with difficulty that the police protected the men from the assaults of the populace: the coach they had no power to preserve. the horses were taken from it, and together with the coffin, after having been trundled a mile and a half through the streets of the city, it was deliberately projected over the steep side of the mound, and smashed into a thousand pieces. the people following it to the bottom, kindled a fire with its fragments, and surrounded it like the savages in robinson crusoe, till it was entirely consumed. in this case there was no foundation for their suspicions. the coffin was intended to have conveyed to his house in edinburgh the body of a physician who that morning had died in a cottage near the neighborhood. a similar assault was some time ago made on two american gentlemen, who went to visit the abbey of linlithgow after nightfall. the churchyards of the "gude scots" are now strictly guarded by men and dogs; watch-towers are erected within the grounds, and _mort-safes_, as they are called, that is to say, strong iron frames are deposited in the ground over the graves. these people sometimes declare that they will put an end to anatomy, and certainly they are succeeding in the accomplishment of this menace as rapidly as they can well desire. the average number of medical students in edinburgh is 700 each session. for several years past the difficulty of procuring subjects in that place has been so great, that out of all that number, not more than 150 or 200 have ever attempted to dissect; and even these have latterly been so opposed in their endeavours to prosecute their studies, that many of them have left the place in disgust. we have been informed by a friend, that he alone was personally acquainted with twenty individuals who retired from it at the beginning of last session, and who went to pursue their studies at dublin, and we know that vast numbers followed their example at the end of the winter course. the medical school at edinburgh, in fact, is now subsisting entirely on its past reputation; in the course of a few years it will be entirely at an end, unless the system be changed. let those who have the prosperity of the university at heart, and who have the power to protect it, consider this before it be too late: they may be assured it is no idle prediction; for we give them notice, that it is at this moment the universal opinion and the current language of every well-informed medical man in england. an excellent system of anatomical plates, which has been well received by the profession, has lately been published by mr. lizars, a lecturer on anatomy and physiology, in edinburgh. this gentleman states that he has been induced to undertake this work, in order to obviate the most fatal consequences to the public; as far, at least, as a reference to art, instead of nature, is capable of obviating those consequences. he affirms, that the difficulty of obtaining instruction from nature has risen to such a pitch, owing to the extraordinary severity exercised by the legal authorities of the kingdom against persons employed in procuring subjects for dissection, as to threaten the ultimate destruction of medical and anatomical science. in his preface to the second part of his work, he apologizes to his readers for dividing one portion of it from another, with which it ought to have been connected; but states that he has been compelled to do so from the prejudices of the place, which prevented him for upwards of five months, from procuring a subject from which he might make his drawings. "in place of living," he says, "in a civilized and enlightened period, we appear as if we had been thrown back some centuries into the dark ages of ignorance, bigotry and superstition. prejudices, worthy only of the multitude, have been conjured up and appealed to, in order to call forth popular indignation against those whose business it is to exhibit demonstratively the structure of the human body, and the functions of its different organs. the public journals, from a vicious propensity to pander to the vulgar appetite for excitement, have raked up and industriously circulated stories of exhumation of dead bodies, tending to exasperate and inflame the passions of the mob; and persons who, by their own showing, are friendly to the interests of science, have, in the excess of their zeal that bodies should remain undisturbed in their progress to decomposition, laboured to destroy in this country, that art, whose province it is to free living bodies from the consequences inseparable from accident and disease. and, which is worst of all, the prejudices of the multitude have been confirmed and rendered inveterate by the proceedings in our courts of justice, which have visited with the punishment due only to felons, the unhappy persons necessarily employed in the present state of the law, in procuring subjects for the dissecting-room." he then goes on to state, that until anatomy be publicly sanctioned in edinburgh, the school of medicine there can never flourish; that upon the present system, young men obtain a degree or a diploma after a year or two of grinding, that is, of learning by rote the answers to the questions which the examiners are in the habit of putting to the candidates; that ignorant of the very elements of their profession, numbers of persons thus educated annually, go to the east and west indies, and to the army and navy, where they have the charge of hundreds of their suffering fellow creatures, to whom they are in fact the instruments of cruelty and murder. in the preface to the 4th part, he adds, that when part ii. was published, in the early part of the session, he took occasion to express his sorrow for the degraded state of his profession, and the threatened ruin of the medical school of his native place, owing to the scarcity of subjects: that, for doing this, he has incurred considerable censure: that he regrets that he has yet found no reason to alter his opinion, for the winter session is now near its conclusion, and, he candidly declares, that such has been the scarcity of material, that _no teacher of anatomy or surgery has been able either to follow the regular plan of his course, or to do his duty to his pupils_; the consequence of which has been, that many of the students have left the school in disgust, and gone either to dublin or paris; while a still greater number, deprived of the means of dissecting, have contented themselves with lectures or theories, and with grinding; and entered on the practice of their profession ignorant of its fundamental principles. much of this opposition on the part of the people, arises from the present mode of procuring subjects. fortunately, there is in great britain no custom, no superstition, no law, and we may add, no prejudice, against anatomy itself. there is even a general conviction of its necessity; there may be a feeling that it is a repulsive employment, but it is commonly acknowledged that it must not be neglected. the opposition which is made, is made not against anatomy, but against the practice of exhumation: and this is a practice which ought to be opposed. it is in the highest degree revolting; it would be disgraceful to a horde of savages; every feeling of the human heart rises up against it: so long as no other means of procuring bodies for dissection are provided, it must be tolerated; but, in itself, it is alike odious to the ignorant and the enlightened, to the most uncultivated and the most refined. but the capital objection to this practice is, that it necessarily creates a crime, and educates a race of criminals.--exhumation is forbidden by the law. it is, indeed, prohibited by no statute, either in england or scotland: in both, it is an offence punishable at common law. there is a statute of james the first, which makes it felony to steal a dead body for the purpose of witchcraft; there is none against taking a body for the purpose of dissection. in the case of the king against lynn (1788), the court decided that the body being taken for the latter purpose, did not make it less an indictable offence; and that it is without doubt cognizable in a criminal court, because it is an act "highly indecent, at the bare idea of which nature revolts." it is punishable, therefore, by fine or imprisonment, or both: in scotland, it is also punishable by whipping, and even by transportation. we expected better things of america. we cannot express our astonishment and indignation, when we found that the state of new york has actually made it felony to remove a dead body from the place of sepulture for the purpose of dissection, without providing in any other mode for the schools of anatomy. this is worse than any thing that exists in any other part of the world. if these pages should meet the eye of any of our american brethren, we intreat them to read with attention, the facts which have been stated in the former part of this article, and to consider with seriousness the mischief they are doing. it will not be believed in england, that such scenes could have been witnessed in america, as were actually exhibited there scarcely a month ago. to satisfy our readers, however, that we do not misrepresent the state of things in that country, we transcribe the following accounts from _the new york evening post_, of _may 20th_. "at the late court of sessions, solomon parmeli was indicted for a misdemeanor, in entering potter's field, and removing the covers of two coffins deposited in a pit, and covered partly with earth. _the statute of this state making it a felony, to dig up or remove a dead human body with intent to dissect it_, did not embrace this case; because the prisoner had not dug up or removed the body. mr. schureman, the present keeper of potter's field, suspected that some person had entered it for the purpose of removing the dead; and, after sending for two watchmen, and calling his faithful dog, he went to ascertain the fact. on arriving at the grave, he found his suspicion confirmed; and requested the person concealed in the pit, to come out and show himself: no answer being given, mr. schureman sent his dog into the pit, and in the twinkling of an eye a tall stout fellow made his appearance, and took to his heels across the field. the night being dark, he might have effected his escape, had it not been for the sagacity and courage of the dog, who pursued him for some distance, but at last came up with him, seized and held him fast, until the arrival of mr. schureman and the watchmen, who secured him. the jury convicted the prisoner, and the court sentenced him to six months' imprisonment in the penitentiary. _the young gentlemen attending the medical school of this city, will take warning by this man's fate. they may rest assured, that the keeper of potter's field will do his duty, and public justice will be executed on any man, whatever may be his condition in life, who is found violating the law, and the decency of christian burial!_" the same paper gives the following account of a transaction, which took place at hartford, in connecticut, may 17. "yesterday morning, two ladies were taking a walk in the south burying ground, when they discovered a tape-string, and a piece of cloth, which upon examination was found to be the piece that was laced upon miss jane benton's face, who came to her death by drowning, and was buried a few days since. the ladies then went to the grave, and found that it had been disturbed--that she was taken out of her coffin, and a rope around her neck. the circumstance has produced great excitement in the public mind; and every one is on the alert to discover the perpetrators of this unfeeling, brutal act. _the citizens turned out in a body yesterday, and interred the corpse again!_" these scenes are highly disgraceful, and disgraceful to all, though not _alike_ to all parties. we do not blame the americans for abolishing the practice of exhumation; but we blame them for stopping there. we maintain, that it is both absurd and criminal, to make this practice felony, without providing in some other method for the cultivation of anatomy. in great britain, the law against the practice of exhumation is not allowed to slumber. there may be other cases which have not come to our knowledge; but we have ascertained that there have been 14 convictions for england alone, during the last year. the punishments inflicted have been imprisonment for various periods, with fines of different sums. the fines in general are heavy, considering the poverty of the offenders. several persons are, at this moment, suffering these penalties; among others, there is now in the gaol of st. alban's, a man who was sentenced for this offence to two years' imprisonment, and a fine of twenty pounds. the period of his confinement has expired some time; but he still remains in prison, on account of his inability to pay the fine.[1] since the passing of the new vagrant act, it has been the common practice to commit these offenders to hard labour for various periods. very lately, two men, convicted of this offence, were sent to the tread mill, in cold bath fields; one of whom died in one month after his commitment. it is an error to suppose that these punishments operate to prevent exhumation; their only effect is to raise the price of subjects: a little reflection will show that they can have no other operation. at present, exhumation is the only method by which subjects for dissection can be procured; but subjects for this purpose must be procured: and be the difficulties what they may, will be procured: diseases will occur, operations must be performed, medical men must be educated, anatomy must be studied, dissections must go on. unless some other means for affording a supply be adopted; whatever be the law or the popular feeling, neither magistrates, nor judges, nor juries, will, or can, put an entire stop to the practice. it is one, which, from the absolute necessity of the case, must be allowed. what is the consequence? so long as the practice of exhumation continues, a race of men must be trained up to violate the law. these men must go out in company for the purpose of nightly plunder, and plunder of the most odious kind, tending in a peculiar and most alarming measure to brutify the mind, and to eradicate every feeling and sentiment worthy of a man. this employment becomes a school in which men are trained for the commission of the most daring and inhuman crimes. its operation is similar, but much worse than the nightly banding to violate the game laws, because there is something in the violation of the grave, which tends still more to degrade the character and to harden the heart. this offence is connived at; nay, it is rewarded; these men are absolutely paid to violate the law; and paid by men of reputation and influence in society. the transition is but too easy to the commission of other offences in the hope of similar connivance, if not of similar reward. it is an odious thing that the teachers of anatomy should be brought into contact with such men: that they should be obliged to employ them, and that they should even be in their power; which they are to such a degree, that they are obliged to bear with the wantonness of their tyranny and insult. all the clamour against these men, all the punishment inflicted on them, only operate to raise the premium on the repetition of their offence. this premium the teachers of anatomy are obliged to pay, which these men perfectly understand, who do not at all dislike the opposition which is made to their vocation. it gives them no unreasonable pretext for exorbitancy in their demands. in general, they are men of infamous character; some of them are thieves, others are the companions and abettors of thieves. almost all of them are extremely destitute. when apprehended for the offence in question, the teachers of anatomy are obliged to pay the expenses of the trial, and to support their families while they are in prison: whence the idea of immunity is associated, in these men's minds, with the violation of the law, and when they do happen to incur its penalties, they practically find that they and their families are provided for, and this provision comes to them in the shape of a reward for the commission of their offence. the operation of such a system on the minds of the individuals themselves is exceedingly pernicious, and is not a little dangerous to the community. moreover, by the method of exhumation, the supply after all is scanty; it is never adequate to the wants of the schools; it is of necessity precarious, and it sometimes fails altogether for several months. but it is of the utmost importance that it should be abundant, regular, and cheap.--the number of young men who come annually to london for the purpose of studying medicine and surgery, may be about a thousand. their expenses are necessarily very considerable while in town; they have already paid a large sum for their apprenticeship in the country; the circumstances of country practitioners, in general, can but ill afford protracted expenses for their sons in london; few of them stay a month longer than the time prescribed by the college of surgeons. but the short period they spend in london, is the only time they have for acquiring the knowledge of their profession. if they mispend these precious hours, or if the means of employing them properly be denied them, they must necessarily remain ignorant for life. after they leave london they have no means of dissecting. we have seen that it is by dissecting alone, that they can make themselves acquainted even with the principles of their art; that without it they cannot so much as avail themselves of the opportunities of improvement, which experience itself may offer, nor, without the highest temerity, perform a single operation. we have seen that occasions suddenly occur, which require the prompt performance of important and difficult operations; we have seen that unless such operations are performed immediately, and with the utmost skill, life is inevitably lost. in many such cases, there is no time to send for other assistance. if a country practitioner (and most of these young men go to the country) be not himself capable of doing what is proper to be done, the death of the patient is certain. we put it to the reader to imagine what the feelings of an ingenuous young man must be, who is aware of what he ought to do, but who is conscious that his knowledge is not sufficient to authorise him to attempt to perform it, and who sees his patient die before him, when he knows that he might be saved, and that it would have been in his own power to save him, had he been properly educated. we put it to the reader to conceive what his own sensations would be, were an ignorant surgeon, with a rashness more fatal than the criminal modesty of the former, to undertake an important operation--suppose it were a tumor, which turned out to be an aneurism; suppose it were a hernia, in operating on which the epigastric artery were divided, or the intestine itself wounded: suppose it were his mother, his wife, his sister, his child, whom he thus saw perish before his eyes, what would the reader then think of the prejudice which withholds from the surgeon that information, without which the practice of his profession is murder? the study of anatomy is a severe and laborious study; the practice of dissection is on many accounts highly repulsive: it is even not without danger to life itself.[2] to men of clear understandings, to those especially of a philosophical turn of mind, the pursuit is its own reward; they are so fully satisfied, that the more it is cultivated the more satisfaction it will afford, that they need no stimulus to induce them to undergo the drudgery. but this is by no means the case with ordinary minds. the fatigue and disgust of the dissecting-room, are appalling to them, and they need the stimulus of necessity to urge them to the task. the court of examiners of the college of surgeons, requires from the candidates for surgical diplomas certificates that they have gone through at least two courses of dissections; the examiners at apothecaries'-hall do not require such certificates. the consequence is, that many young men content themselves with attending lectures, and with passing their examinations at apothecaries'-hall, and do not apply for a diploma at the college of surgeons. this single fact is sufficient to demonstrate to the public, that instead of throwing obstacles in the way of dissection, it is a duty which they owe to themselves to afford every possible facility to its practice, and to hold out to every member of the profession, the most powerful inducements to engage in it, by rewarding with confidence those who cultivate anatomy, by making excellence in anatomy indispensable to all offices in dispensaries and hospitals, and by thus rendering it impossible for any one who is ignorant of anatomy, to obtain rank in his profession. when a candidate presents himself for a diploma in denmark, in his first trial he is put into a room with a subject, a case of instruments, and a memorandum, and informed that he is to display the anatomy of the face and neck, or that of the upper extremity or that of the lower extremity: that by the anatomy is to be understood, the blood-vessels, nerves, and muscles; and that as soon as he has accomplished his task, the professors will attend his summons to judge of his attainments. these professors are the true examiners! we shall have entered into the discussion of this subject to little purpose, if we have not produced in the minds of our readers a deep conviction, that anatomy ought to form an essential part of medical education, that anatomy cannot be studied without the practice of dissection; that dissection cannot be practised without a supply of subjects, and that the manner in which that supply is obtained in england is detestable, and ought immediately to be changed. it might be changed easily. we agree with mr. mackenzie, that legislative interference is necessary; we are satisfied that nothing will be done in england without it. the plan which mr. mackenzie suggests is as follows: 1. that the clause of our criminal code, by which the dissection of the dead body is made part of the punishment for murder, be repealed. 2. that the exhumation of dead bodies be punishable as felony. 3. that no diploma in medicine or surgery, be granted by any faculty, college, or university, except to those persons who shall produce undoubted evidence of their having carefully dissected at least five human bodies. 4. that in each of the hospitals, infirmaries, work-houses, poor-houses, foundling-houses, houses of correction, and prisons of london, edinburgh, glasgow, and dublin, and if need be, of all other towns in great britain and ireland, an apartment be appointed for the reception of the bodies of all persons dying in the said hospitals, infirmaries, work houses, poor-houses, foundling-houses, houses of correction, and prisons, _unclaimed by immediate relatives, or whose relatives decline to defray the expenses of interment_. 5. that the bodies of all persons dying in these towns, and, if need be, in all other towns, and also in country parishes, _unclaimable by immediate relatives, or whose relatives decline to defray the expenses of interment_, shall be conveyed to a mort-house appointed in the said towns for their reception. 6. that no dead bodies shall be delivered from any hospital, infirmary, work house, poor-house, foundling-house, house of correction, prison, or mort-house for anatomical purposes, except upon the requisition of a member of the royal college of physicians or of surgeons, of london, edinburgh, or dublin, or of the faculty of physicians and surgeons of glasgow, and upon the payment of twenty shillings into the hands of the treasurer, of the hospital, infirmary, work-house, poor-house, foundling-house, house of correction, prison, or other officer appointed to receive the same. [this is too large a sum.] 7. that no dead body shall be conveyed from a hospital, infirmary, work-house, poor-house, foundling-house, house of correction, prison, or mort-house, to a school of anatomy, except in a covered bier, and between the hours of four and six in the morning. 8. that after the expiration of twenty-eight days, an officer appointed for this purpose, in each of the four towns above-mentioned, shall cause the remains of the dead to be placed in a coffin, removed from the school of anatomy, where the dead body has been examined, to the mort-house of the town and decently buried. 9. that the expenses attending the execution of these regulations, be defrayed out of fees paid by teachers and students of anatomy, on receiving dead bodies from the hospitals, infirmaries, work-houses, poor houses, foundling-houses, houses of correction, prisons, and mort-houses. to this plan there is but one objection, viz. that it is making the bodies of the poor public property. the answer is, that the limitation in the proposed law, which the objection does not notice, entirely removes the weight of that objection. though no maxim can be more indisputable than that those who are supported by the public die in its debt, and that their remains at least, might, without injustice, be converted to the public use, yet it is not proposed to dispose in this manner of the bodies of all the poor: but only of that portion of the poor who die unclaimed and without friends, and whose appropriation to this public service could, therefore, afford pain to no one. if any concession and co-operation on the part of the public, for this great public object is to be expected, and without concession and co-operation nothing can be done, it is not easy to conceive of any plan which requires less public concession or implies less violation of public feeling. in point of fact it would put no indignity, it would inflict no injury on the poor; it is the rejection of it that would really and practically be unjust and cruel. the question is, whether the surgeon shall be allowed to gain knowledge by operating on the bodies of the dead, or driven to obtain it by practising on the bodies of the living. if the dead bodies of the poor are not appropriated to this use, their living bodies will and must be. the rich will always have it in their power to select, for the performance of an operation, the surgeon who has already signalized himself by success: but that surgeon, if he have not obtained the dexterity which ensures success, by dissecting and operating on the dead, must have acquired it by making experiments on the living bodies of the poor. there is no other means by which he can possibly have gained the necessary information. every such surgeon who rises to eminence, must have risen to it through the suffering which he has inflicted, and the death which he has brought upon hundreds of the poor. the effect of the entire abolition of the practice of dissecting the dead, would be, to convert poor-houses and public hospitals into so many schools where the surgeon, by practising on the poor, would learn to operate on the rich with safety and dexterity. this would be the certain and inevitable result: and this, indeed, would be to treat them with real indignity, and horrible injustice; and proves, how possible it is to show an apparent consideration for the poor, and yet practically to treat them in the most injurious and cruel manner. nor would the proposed plan be the means of deterring this class of people from entering the hospitals. there is something reasonable in the apprehension on which this objection is founded: but the answer to it is complete, because it is an answer, derived from experience, to an objection, which is merely a deduction from what is probable. the plan has been acted on, and found to be unattended with this result: it was tried in edinburgh, and the hospital was as full as it is at present: it is universally acted on in france, and the hospitals are always crowded. the great advantages of the plan are, that it would accomplish the proposed object, easily and completely, whereas the plan in operation effects it imperfectly and with difficulty; and it would put an immediate and entire stop to all the evils of the present system. at once it would put an end to the needless education of daring and desperate violators of the law. it would tranquillize the public mind. their dead would rest undisturbed: the sepulchre would be sacred: and all the horrors which the imagination connects with its violation would cease for ever. we have stated, that the plan has been tried. experience has proved its efficacy. it was adopted with perfect success in edinburgh more than a century ago. in the council register for 1694, it is recorded that all unclaimed dead bodies in the charitable institutions or in the streets, were given for dissection to the college of surgeons, to one or two of its individual members, and to the professor of anatomy. this regulation, at that period, excited no opposition on the part of the people, but effectually answered the desired object. all the medical schools on the continent are supplied with subjects, by public authority, in a similar manner. we have obtained from a friend in paris, a gentleman who is at the head of the anatomical department in that city, the following account of the manner in which the schools of anatomy are supplied. it is stated; 1. that the faculty of medicine at paris is authorized to take from the civil hospitals, from the prisons, and from the depã´ts of mendicity, the bodies which are necessary for teaching anatomy. 2. that a gratuity of eight pence is given to the attendants in the hospitals for each body. 3. that upon the foundation by the national convention, of schools of health, the statutes of their foundation declare, that the subjects necessary for the schools of anatomy shall be taken from the hospitals, and that since this period, the council of hospitals and the prefect of police, have always permitted the practice. 4. that m. breschet, chief of the anatomical department of the faculty of paris, sends a carriage daily to the different hospitals, which brings back the necessary number of bodies: that this number has sometimes amounted to 2000 per annum for the faculty only, without reckoning those used in l'hã´pital de la pitiã©, but that since the general attention which has recently been bestowed upon pathologic anatomy, numbers of bodies are opened in the civil and military hospitals, and that the faculty seldom obtain more than 1000 or 1200. 5. that, besides the dissections by the faculty of medicine, and those pursued in l'hã´pital de la pitiã©, theatres of anatomy are opened in all the great hospitals, for the pupils of those establishments: that in these institutions anatomy is carefully taught, and that pupils have all the facilities for dissection that can be desired. 6. that the price of a body varies from four shillings to eight shillings and sixpence. 7. that after dissection, the bodies are wrapt in cloths, and carried to the neighbouring cemetery, where they are received for ten-pence. 8. that the practice of exhumation is abolished: that there are insurmountable obstacles to the return of that system, and that bodies are never taken from burial grounds, without an order for exhumation, which is given only when the tribunals require it for the purpose of medico-legal investigation. 9. that though the people have an aversion to the operations of dissection, yet they never make any opposition to them, provided respect be paid to the laws of decency and salubrity, on account of the deep conviction that prevails of their utility, 10. that the relatives of the deceased seldom or never oppose the opening of any body, if the physicians desire it. that all the medical students in france, with scarcely any exception, dissect, and that that physician or surgeon who is not acquainted with anatomy, is universally regarged as the most ignorant of men. it is time that the physicians and surgeons of england, should exert themselves to change a system which has so long retarded the progress of their science, and been productive of so much evil to the community. we are persuaded, that there is good sense enough, both in the people and in the legislature, to listen to their representations. we would advise them to avail themselves of the means they possess to communicate information to the people, and to make individual members of parliament acquainted with the subject. with this view we would recommend the whole body to act in concert, to appoint a committee for conducting the matter, and to petition parliament, as soon as they shall have made the nature of their claims, and the grounds on which they rest, more generally known. if they act in co-operation with each other, and pursue their object temperately, and steadily, we cannot but believe, that their efforts at no distant period, will be crowned with success. footnotes: [1] since the above was written, we have learned that this man has been recently liberated, and his fine remitted. [2] a winter never passes without proving fatal to several students who die from injuries received in dissection. this book is one of the pioneering works in laryngology. the original text is from the library of indiana university department of otolaryngology-head and neck surgery, bruce matt, md. it was scanned, converted to text, and proofed by alex tawadros. bronchoscopy and esophagoscopy a manual of peroral endoscopy and laryngeal surgery by chevalier jackson, m.d., f.a.c.s. professor of laryngology, jefferson medical college, philadelphia; professor of bronchoscopy and esophagoscopy, graduate school of medicine, university of pennsylvania; member of the american laryngological association; member of the laryngological, rhinological, and otological society; member of the american academy of ophthalmology and oto-laryngology; member of the american bronchoscopic society; member of the american philosophical society; etc., etc. with 114 illustrations and four color plates philadelphia and london w. b. saunders company 1922 copyrights 1922, by w. b. saunders company made in u.s.a. to my mother to whose interest in medical science the author owes his incentive, and to my father whose constant advice to "educate the eye and the fingers" spurred the author to continual effort, this book is affectionately dedicated. preface this book is based on an abstract of the author's larger work, peroral endoscopy and laryngeal surgery. the abstract was prepared under the author's direction by a reader, in order to get a reader's point of view on the presentation of the subject in the earlier book. with this abstract as a starting point, the author has endeavored, so far as lay within his limited abilities, to accomplish the difficult task of presenting by written word the various purely manual endoscopic procedures. the large number of corrections and revisions found necessary has confirmed the wisdom of the plan of getting the reader's point of view; and these revisions, together with numerous additions, have brought the treatment of the subject up to date so far as is possible within the limits of a working manual. acknowledgment is due the personnel of the w. b. saunders company for kindly help. chevalier jackson. october, 1922. ii contents page chapter i instrumentarium 17 chapter ii anatomy of larynx, trachea, bronchi and esophagus, endoscopically considered 52 chapter iii preparation of the patient for peroral endoscopy 63 chapter iv anesthesia for peroral endoscopy 65 chapter v bronchoscopic oxygen insufflation 71 chapter vi position of the patient for peroral endoscopy 73 chapter vii direct laryngoscopy 82 chapter viii direct laryngoscopy (continued) 91 chapter ix introduction of the bronchoscope 97 chapter x introduction of the esophagoscope 106 chapter xi acquiring skill 117 chapter xii foreign bodies in the air and food passages 126 chapter xiii foreign bodies in the larynx and tracheobronchial tree 149 chapter xiv removal of foreign bodies from the larynx 156 chapter xv mechanical problems of bronchoscopic foreign body extraction 158 chapter xvi foreign bodies in the bronchi for prolonged periods 177 chapter xvii unsuccessful bronchoscopy for foreign bodies 181 chapter xviii foreign bodies in the esophagus 183 chapter xix esophagoscopy for foreign body 187 chapter xx pleuroscopy 199 chapter xxi benign growths in the larynx 201 chapter xxii benign growths in the larynx (continued) 203 chapter xxiii benign growths primary in the tracheobronchial tree 207 chapter xxiv benign neoplasms of the esophagus 209 chapter xxv endoscopy in malignant disease of the larynx 210 chapter xxvi bronchoscopy in malignant growths of the trachea 214 chapter xxvii malignant disease of the esophagus 216 chapter xxviii direct laryngoscopy in diseases of the larynx 221 chapter xxix bronchoscopy in diseases of the trachea and bronchi 224 chapter xxx diseases of the esophagus 235 chapter xxxi diseases of the esophagus (continued) 245 chapter xxxii diseases of the esophagus (continued) 251 chapter xxxiii diseases of the esophagus (continued) 260 chapter xxxiv diseases of the esophagus (continued) 268 chapter xxxv gastroscopy 273 chapter xxxvi acute stenosis of the larynx 277 chapter xxxvii tracheotomy 279 chapter xxxviii chronic stenosis of the larynx and trachea 300 chapter xxxix decannulation after cure of laryngeal stenosis 309 bibliography 311 index 315 [17] chapter i--instrumentarium direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy are procedures in which the lower air and food passages are inspected and treated by the aid of electrically lighted tubes which serve as specula to manipulate obstructing tissues out of the way and to bring others into the line of direct vision. illumination is supplied by a small tungsten-filamented, electric, "cold" lamp situated at the distal extremity of the instrument in a special groove which protects it from any possible injury during the introduction of instruments through the tube. the bronchi and the esophagus will not allow dilatation beyond their normal caliber; therefore, it is necessary to have tubes of the sizes to fit these passages at various developmental ages. rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal. the armamentarium of the endoscopist must be complete, for it is rarely possible to substitute, or to improvise makeshifts, while the bronchoscope is in situ. furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them. _laryngoscopes_.--the regular type of laryngoscope shown in fig. i (a, b, c) is made in adult's, child's, and infant's sizes. the instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. the infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. for operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. with this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (fig. 1, d). the tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be passed through the adult glottis for work in the subglottic region. this instrument may also be used as an esophageal speculum and as a pleuroscope. a side-slide laryngoscope, used with or without the slide, is occasionally useful. _bronchoscopes_.--the regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. an auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. the accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (fig. 2, a, b, c, d). for certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful the drainage canal may be on top, or on the under surface next to the light-carrier canal. for ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (q.v.) which at the same time cleans the lamp. the drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome. as before mentioned, the lower air passages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the passages to be examined. four sizes are sufficient for any possible case, from a newborn infant to the largest adult. for infants under one year, the proper tube is the 4 mm. by 30 cm.; the child's size, 5 mm. by 30 cm., is used for children aged from one to five years. for children six years or over, the 7 mm. by 40 cm. bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. the adult bronchoscope measures 9 mm. by 40 cm. the author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35 cm., 8 mm. x 40 cm. _esophagoscopes_.-the esophagoscope, like the bronchoscope, is a hollow brass tube with beveled distal end containing a small electric light. it differs from the bronchoscope in that it has no perforations, and has a drainage canal on its upper surface, or next to the light-carrier canal which opens within the distal end of the tube. the exact size, position, and shape of the drainage outlets is important on bronchoscopes, and to an even greater degree on esophagoscopes. if the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube, the mucosa will be drawn into the outlet, not only obstructing it, but, most important, traumatizing the mucosa. if, for instance, the esophagoscope were to be pushed upon with a fold thus anchored in the distal end, the esophageal wall could easily be torn. to admit the largest sizes of esophagoscopic bougies (fig. 40), special esophagoscopes (fig. 5) are made with both light canal and drainage canal outside the lumen of the tube, leaving the full area of luminal cross-section unencroached upon. they can, of course, be used for all purposes, but the slightly greater circumference is at times a disadvantage. the esophageal and stomach secretions are much thinner than bronchial secretions, and, if free from food, are readily aspirated through a comparatively small canal. if the canal becomes obstructed during esophagoscopy, the positive pressure tube of the aspirator is used to blow out the obstruction. two sizes of esophagoscopes are all that are required--7 mm. x 45 cm. for children, and 10 mm. x 53 cm. for adults (fig. 3, a and b); but various other sizes and lengths are used by the author for special purposes.* large esophagoscopes cause dangerous dyspnea in children. if, it is desired to balloon the esophagus with air, the window plug shown in fig. 6, is inserted into the proximal end of the esophagoscope, and air insufflated by means of the hand aspirator or with a hand bulb. the window can be replaced by a rubber diaphragm with a perforation for forceps if desired. it will be noted that none of the endoscopic tubes are fitted with mandrins. they are to be introduced under the direct guidance of the eye only. mandrins are obtainable, but their use is objectionable for a number of reasons, chief of which is the danger of overriding a foreign body or a lesion, or of perforating a lesion, or even the normal esophageal wall. the slanted end on the esophagoscope obviates the necessity of a mandrin for introduction. the longer the slant, with consequent acuting of the angle, the more the introduction is facilitated; but too acute an angle increases the risk of perforating the esophageal wall, and necessitates the utmost caution. in some foreign-body cases an acute angle giving a long slant is useful, in others a short slant is better, and in a few cases the squarely cut-off distal end is best. to have all of these different slants on hand would require too many tubes. therefore the author has settled upon a moderate angle for the end of both esophagoscopes and bronchoscopes that is easy to insert, and serves all purposes in the version and other manipulations required by the various mechanical problems of foreign-body extraction. he has, however, retained all the experimental models, for occasional use in such cases as he falls heir to because of a problem of extraordinary difficulty. * a 9 mm. x 45 cm. esophagoscope will reach the stomach of almost all adults and is somewhat easier to introduce than the 10 mm. x 53 cm., which may be omitted from the set if economy must be practiced. [fig. i.--author's laryngoscopes. these are the standard sizes and fulfill all requirements. many other forms have been devised by the author, but have been omitted from the list as unnecessary. the infant diagnostic laryngoscope (c) is not for introducing bronchoscopes, and is not absolutely necessary, as the larynx of any infant can be inspected with the child's size laryngoscope (b). a adult's size; b, child's size; c, infant's diagnostic size; d, anterior commissure laryngoscope; e, with drainage canal; 17, intubating laryngoscope, large lumen. all the laryngoscopes are preferred without drainage canals.] [fig. 2.--the author's bronchoscopes of the sizes regularly used. various other lengths and diameters are on hand for occasional use for special purposes. with the exception of a 6 mm. x 35 cm. size for older children, these special bronchoscopes are very rarely used and none of them can be regarded as necessary. for special purposes, however, special shapes of tube-mouth are useful, as, for instance, the oval end to facilitate the getting of both points of a staple into the tube-mouth the illustrated instruments are as follows: a, infant's size, 4 mm. x 30 cm.; b, child's size, 5 mm. x 30 cm.; c, adolescent's size, 7 mm. x 40 cm.; d, adult's size, 9 mm. x 40 cm.; e, aspirating bronchoscope made in all the foregoing sizes, and in a special size, 5 mm. x 45 cm.] [fig. 3.--the author's esophagoscopes of the sizes he has standardized for all ordinary requirements. he uses various other lengths and sizes for special purposes, but none of them are really necessary. a gastroscope, 10 mm. x 70 cm., is useful for adults, especially in cases of gastroptosis. drainage canals are placed at the top or at the side of the tube, next to the light-carrier canal. a, adult's size, 10 mm. x 53 cm.; b, child's size, 7 mm. x 45 cm.; c and d, full lumen, with both light canal and drainage canal outside the wall of the tube, to be used for passing very large bougies. this instrument is made in adult, child, and adolescent (8 mm. by 45 cm.) sizes. gastroscopes and esophagoscopes of the sizes given above (a) and (b), can be used also as gastroscopes. a small form of c, 5 mm. x 30 cm. is used in infants, and also as a retrograde esophagoscope in patients of any age. e, window plug for ballooning gastroscope, f.] [fig. 4.--author's short esophagoscopes and esophageal specula a, esophageal speculum and hypopharyngoscope, adult's size; b, esophageal speculum and hypopharyngoscope, child's size; c, heavy handled short esophagoscope; d, heavy handled short esophagoscope with drainage.] [fig. 5.--cross section of full-lumen esophagoscope for the use of largest bourgies. the canals for the light carrier and for drainage are so constructed that they do not encroach upon the lumen of the tube.] [25] the special sized esophagoscopes most often useful are the 8 mm. x 30 cm., the 8 mm. x 45 cm., and the 5 mm. x 45 cm. these are made with the drainage canal in various positions. for operations on the upper end of the esophagus, and particularly for foreign body work, the esophageal speculum shown at a and b, in fig. 4, is of the greatest service. with it, the anterior wall of the post-cricoidal pharynx is lifted forward, and the upper esophageal orifice exposed. it can then be inserted deeper, and the upper third of the esophagus can be explored. two sizes are made, the adult's and the child's size. these instruments serve, very efficiently as pleuroscopes. they are made with and without drainage canals, the latter being the more useful form. [fig. 6.--window-plug with glass cap interchangeable with a cap having a rubber diaphragm with a perforation so that forceps may be used without allowing air to escape. valves on the canals (e, f, fig. 3) are preferable.] _gastroscopes_.--the gastroscope is of the same construction as the esophagoscope, with the exception that it is made longer, in order to reach all parts of the stomach. in ordinary cases, the regular esophagoscopes for adults and children respectively will afford a good view of the stomach, but there are cases which require longer tubes, and for these a gastroscope 10 mm. x 70 cm. is made, and also one 10 mm. x 80 cm., though the latter has never been needed but once. [26] _pleuroscopes_.--as mentioned above the anterior commissure laryngoscope and the esophageal specula make very efficient pleuroscopes; but three different forms of pleuroscopes have been devised by the author for pleuroscopy. the retrograde esophagoscope serves very well for work through small fistulae. _measuring rule_ (fig. 7).--it is customary to locate esophageal lesions by denoting their distance from the incisor teeth. this is readily done by measuring the distance from the proximal end of the esophagoscope to the upper incisor teeth, or in their absence, to the upper alveolar process, and subtracting this measurement from the known length of the tube. thus, if an esophagoscope 45 cm. long be introduced and we find that the distance from the incisor teeth to the ocular end of the esophagoscope as measured by the rule is 20 cm., we subtract this 20 cm. from the total length of the esophagoscope (45 cm.) and then know that the distal end of the tube is 25 cm. from the incisor teeth. graduation marks on the tube have been used, but are objectionable. [fig. 7.--measuring rule for gauging in centimeters the depth of any location by subtraction of the length of the uninserted portion of the esophagoscope or bronchoscope. this is preferable to graduations marked on the tubes, though the tubes can be marked with a scale if desired.] _batteries_.--the simplest, best, and safest source of current is a double dry battery arranged in three groups of two cells each, connected in series (fig. 8). each set should have two binding posts and a rheostat. the binding posts should have double holes for two additional cords, to be kept in reserve for use in case a cord becomes defective.* the commercial current reduced through a rheostat should never be used, because there is always the possibility of "grounding" the circuit through the patient; a highly dangerous accident when we consider that the tube makes a long moist contact in tissues close to the course of both the vagi and the heart. the endoscopist should never depend upon a pocket battery as a source of illumination, for it is almost certain to fail during the endoscopy. the wires connecting the battery and endoscopic instrument are covered with rubber, so that they may be cleansed and superficially sterilized with alcohol. they may be totally immersed in alcohol for any length of time without injury. * when this is done care is necessary to avoid attempting to use simultaneously the two cords from one pair of posts. [fig 8.--the author's endoscopic battery, heavily built for reliability. it contains 6 dry cells, series-connected in 3 groups of 2 cells each. each group has its own rheostat and pair of binding posts.] _aspirating tubes_.--independent aspirating tubes involve delay in their use as compared to aspirating canals in the wall of the endoscopic tube; but there are special cases in which an independent tube is invaluable. three forms are used by the author. the "velvet eye" cannot traumatize the mucosa (fig. 9). to hold a foreign body by suction, a squarely cut off end is necessary. for use through the tracheotomic wound without a bronchoscope a malleable tube (fig. 10) is better. [fig. 9.--the author's protected-aperture endoscopic aspirating tube for aspiration of pharyngeal secretions during direct laryngoscopy and endotracheobronchial secretions at bronchoscopy, also for draining retropharyngeal abscesses. the laryngoscopes are obtainable with drainage canals, but for most purposes the independent aspirating tube shown above is more satisfactory. the tubes are made in 20 30, 40, and 60 cm. lengths. an aperture on both sides prevents drawing in the mucosa. it can be used for insufflation of ether if desired. an aspirating tube of the same design, but having a squarely cut off end, is sometimes useful for removing secretions lying close to a foreign body; for removing papillomata; and even for withdrawing foreign bodies of a soft surface consistency. it is not often that the foreign bodies can be thus withdrawn through the glottis, but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps spaces will permit application of forceps. such aspirating tubes, however, are not so safe to use as the protected, double aperture tubes.] [fig. 10.--the author's malleable tracheotomic aspirating tube for removal of secretions, exudates, crusts, etc., from the tracheobronchial tree through the tracheotomic wound without a bronchoscope. the tube is made of copper so that it can be bent to any curve, and the copper wire stylet prevents kinking. the stylet is removed before using the tube for aspiration.] [28] _aspirators_.--the various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage canals. they, however, have the disadvantages of not being easily transported, and of occasionally being out of order. the hand aspirator shown in fig. 11 is, therefore, a necessary part of the instrumental equipment. it never fails to work, is portable, and affords both positive and negative pressures. the positive pressure is sometimes useful in clearing the drainage canal of any particles of food, tissue, clots, or secretion which may obstruct it; and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used. the mechanical aspirator (fig. 12) is highly efficient and is the one used in the bronchoscopic clinic. the positive pressure will quickly clear obstructed drainage canals, and may be used while the esophagoscope is in situ, by simply detaching the minus pressure tube and attaching the plus pressure. in the lungs, however, high plus pressures are so dangerous that the pressure valve must be lowered. [fig. 11--portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage canal. this aspirator has the advantage of great power with portability. where portability is not required the electrically operated aspirator is better.] [fig. 12.--robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author. the positive pressure is used for clearing obstructed drainage canals and tubes.] [fig. 13.--apparatus for insufflation of ether or chloroform during bronchoscopy, for those who may desire to use general anesthesia. the mechanical methods of intratracheal insufflation anesthesia subsequently developed by meltzer and auer, elsberg, geo. p. muller and others have rightly superseded this apparatus for all general surgical purposes.] _sponge-pumping_.--while the usually thin, watery esophageal and gastric secretions, if free from food, are readily aspirated through a drainage canal, the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty. further-more, bronchial secretions as a rule are not collected in pools, but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough. the aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is unobjectionable. in most cases, however, the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier (fig. 14), so that the sponge extends beyond the distal end of the bronchoscope, causing cough. then withdrawal of the sponge carrier will remove all of the secretion in the tube just as the plunger in a pump will lift all of the water above it. by this maneuver the walls of the bronchus are wiped free from secretions, and the lamp itself is cleansed. [fig. 14.--sponge carrier with long collar for carrying the small sponges shown in fig. 15. the collar screws down as in the coolidge cotton carrier. about a dozen of these are needed and they should all be small enough to go through the 4 mm. (diameter) bronchoscope and long enough to reach through the 53 cm. (length) esophagoscope, so that one set will do for all tubes. the schema shows method of sponging. the carrier c, armed with the sponge, s, when rotated as shown by the dart, d, wipes the field, p, at the same time wiping the lamp, l. the lamp does not need ever to be withdrawn for cleaning during bronchoscopy. it is protected in a recess so that it does not catch in the sponges.] [fig 15.--exact size to which the bandage-gauze is cut to make endoscopic sponges. each rectangle is the size for the tubal diameter given. the dimensions of the respective rectangles are not given because it is easier for the nurse or any one to cut a cardboard pattern of each size directly from this drawing. the gauze rectangles are folded up endwise as shown at a, then once in the middle as at b, then strung one dozen on a safety pin. in america gauze bandages run about 16 threads to the centimeter. different material might require a slightly different size and the pattern could be made to suit.] [32] the gauze sponges are made by the instrument nurse as directed in fig. 15, and are strung on safety pins, wrapped in paper, the size indicated by a figure on the wrapper, and then sterilized in an autoclave. the sterile packages are opened only as needed. these "bronchoscopic sponges" are also made by johnston and johnston, of new brunswick, n. j. and are sold in the shops. _mouth-gag_.--wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone. the mouth should be gently opened and a bite block (fig. 16) inserted between the teeth on the left side of the patient's mouth, to prevent closing of the jaws on the delicate bronchoscope or esophagoscope. [fig. 16.--bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube. this is the mckee-mccready modification of the boyce thimble with the omission of the etherizing tube, which is no longer needed. the block has been improved by dr. w. f. moore of the bronchoscopic clinic.] _forceps_.--delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality; therefore, heavily built and spring-opposed forceps are dangerous as well as useless. for foreign-body work in the larynx, and for the removal of benign laryngeal growths, the alligator forceps with roughened jaws shown in fig. 17 serve every purpose. [fig. 17.--laryngeal grasping forceps designed by mosher. for my own use i have taken off the ratchet-locking device for all general work, to be reapplied on the rare occasions when it is required.] _bronchoscopic and esophagoscopic grasping forceps_ are of the tubular type, that is, a stylet carrying the jaws works in a slender tube so that traction on the stylet draws the v of the open jaws into the lumen of the tube, thus causing the blades to approximate. they are very delicate and light, yet have great grasping power and will sustain any degree of traction that it is safe to exert. they permit of the delicacy of touch of a violin bow. the two types of jaws most frequently used, are those with the forward-grasping blades shown in fig. 18, and those having side-grasping blades shown in fig. 19. the side-curved forceps are perhaps the most generally useful of all the endoscopic forceps; the side projection of the jaws makes them readily visible during their closure on an object; their broader grasp is also an advantage., the projection of the blades in the side-curved grasping forceps should always be directed toward the left. if it is desired that they open in another direction this should be accomplished by turning the handle and not by adjusting the blade itself. if this rule be followed it will always be possible to tell by the position of the handle exactly where the blades are situated; whereas, if the jaws themselves are turned, confusion is sure to result. the forward-grasping forceps are always so adjusted that the jaws open in an up-and-down direction. on rare occasions it may be deemed desirable to turn the stylet of either forceps in some other direction relative to the handle. [fig. 18.--the author's forward grasping tube forceps. the handle mechanism is so simple and delicate that the most exquisite delicacy of touch is possible. two locknuts and a thumbscrew take up all lost motion yet afford perfect adjustability and easy separation for cleansing. at a is shown a small clip for keeping the jaws together to prevent injurious bending in the sterilizer, or carrying case. at the left is shown a handle-clamp for locking the forceps on a foreign body in the solution of certain rarely encountered mechanical problems. the jaws are serrated and cupped.] [fig. 19.--jaws of the author's side-curved endoscopic forceps. these work as shown in the preceding illustration, each forceps having its own handle and tube. originally the end of the cannula and stylet were squared to prevent rotation of the jaws in the cannula. this was found to be unnecessary with properly shaped jaws, which wedge tightly.] _rotation forceps_.--it is sometimes desired to make traction on an irregularly shaped foreign body, and yet to allow the object to turn into the line of least resistance while traction is being made. this can be accomplished by the use of the rotation forceps (fig. 20), which have for blades two pointed hooks that meet at their points and do not overlap. rotation forceps made on the model of the laryngeal grasping forceps, but having opposing points at the end of the blades, are sometimes very useful for the removal of irregular foreign bodies in the larynx, or when used through the esophageal speculum they are of great service in the extraction of such objects as bones, pin-buttons, and tooth-plates, from the upper esophagus. these forceps are termed laryngeal rotation forceps (fig. 31). all the various forms of forceps are made in a very delicate size often called the "mosquito" or "extra light" forceps, 40 cm. in length, for use in the 4 mm. and the 5 mm. bronchoscopes. for the 5 mm. bronchoscopes heavier forceps of the 40 cm. length are made. for the larger tubes the forceps are made in 45 cm., 50 cm., and 60 cm. lengths. a square-cannula forceps to prevent turning of the jaws was at one time used by the author but it has since been found that round cannula pattern serves all purposes. [fig. 20.--the author's rotation forceps. useful to allow turning of an irregular foreign body to a safer relation for withdrawal and for the esophagoscopic removal of safety pins by the method of pushing them into the stomach, turning and withdrawal, spring up.] _upper-lobe-bronchus forceps_.--foreign bodies rarely lodge in an upper-lobe bronchus, yet with such a problem it is necessary to have forceps that will reach around a corner. the upper-lobe-bronchus forceps shown in fig. 27 have curved jaws so made as to straighten out while passing through the bronchoscope and to spring back into their original shape on up from the lower jaw emerging from the distal end of the bronchoscopic tube, the radius of curvature being regulated by the extent of emergence permitted. they are made in extra-light pattern, 40 cm. long, and the regular model 45 cm. long. the full-curved model, giving 180 degrees and reaching up into the ascending branches, is made in both light and heavy patterns. forceps with less curve, and without the spiral, are used when it is desired to reach only a short distance "around the corner" anywhere in the bronchi. these are also useful, as suggested by willis f. manges, in dealing with safety pins in the esophagus or tracheobronchial tree. [fig. 21.--tucker jaws for the author's forceps. the tiny lip projecting down from the upper, and up from the lower jaw prevents sidewise escape of the shaft of a pin, tack, nail or needle. the shaft is automatically thrown parallel to the bronchoscopic axis. drawing about four times actual size.] [36] _tucker forceps_--gabriel tucker modified the regular side-curved forceps by adding a lip (fig. 21) to the left hand side of both upper and lower jaws. this prevents the shaft of a tack, nail, or pin, from springing out of the grasp of the jaws, and is so efficient that it has brought certainty of grasp never before obtainable. with it the solution of the safety-pin problem devised by the author many years ago has a facility and certainty of execution that makes it the method of choice in safety-pin extraction. [fig. 22.--the author's down-jaw esophageal forceps. the dropping jaw is useful for reaching backward below the cricopharyngeal fold when using the esophageal speculum in the removal of foreign bodies. posterior forceps-spaces are often scanty in cases of foreign bodies lodged just below the cricopharyngeus.] [fig. 23.--expansile forceps for the endoscopic removal of hollow foreign bodies such as intubation tubes, tracheal cannulae, caps, and cartridge shells.] _screw forceps_.--for the secure grasp of screws the jaws devised by dr. tucker for tacks and pins are excellent (fig. 21). _expanding forceps_.--hollow objects may require expanding forceps as shown in fig. 23. in using them it is necessary to be certain that the jaws are inside the hollow body before expanding them and making traction. otherwise severe, even fatal, trauma may be inflicted. [fig. 24.--the author's fenestrated peanut forceps. the delicate construction with long, springy and fenestrated jaws give in gentle hands a maximum security with a minimum of crushing tendency.] [fig. 25--the author's bronchial dilators, useful for dilating strictures above foreign bodies. the smaller size, shown at the right is also useful as an expanding forceps for removing intubation tubes, and other hollow objects. the larger size will go over the shaft of a tack.] [fig. 26.--the author's self-expanding bronchial dilator. the extent of expansion can be limited by the sense of touch or by an adjustable checking mechanism on the handle. the author frequently used smooth forceps for this purpose, and found them so efficient that this dilator was devised. the edges of forceps jaws are likely to scratch the epithelium. occasionally the instrument is useful in the esophagus; but it is not very safe, unless used with the utmost caution.] _tissue forceps_.--with the forceps illustrated in fig. 28 specimens of tissue may be removed for biopsy from the lower air and food passages with ease and certainty. they have a cross in the outer blade which holds the specimen removed. the action is very delicate, there being no springs, and the sense of touch imparted is often of great aid in the diagnosis. [fig. 27.--the author's upper-lobe bronchus forceps. at a is shown the full-curved form, for reaching into the ascending branches of the upper-lobe bronchus a number of different forms of jaws are made in this kind of forceps. only 2 are shown.] [fig 28--the author's endoscopic tissue forceps. the laryngeal length is 30 cm. for esophageal use they are made 50 and 60 cm. long. these are the best forceps for cutting out small specimens of tissue for biopsy.] the large basket punch forceps shown in fig. 33 are useful in removing larger growths or specimens of tissue from the pharynx or larynx. a portion or the whole of the epiglottis may be easily and quickly removed with these forceps, the laryngoscope introduced along the dorsum of the tongue into the glossoepiglottic recess, bringing the whole epiglottis into view. the forceps may be introduced through the laryngoscope or alongside the tube. in the latter method a greater lateral action of the forceps is obtainable, the tube being used for vision only. these forceps are 30 cm. long and are made in two sizes; one with the punch of the largest size that can be passed through the adult laryngoscope, and a smaller one for use through the anterior-commissure laryngoscope and the child's size laryngoscope. [fig. 29.--the author's papilloma forceps. the broad blunt nose will scalp off the growths without any injury to the normal basal tissues. voice-destroying and stenosing trauma are thus easily avoided.] [fig. 30.--the author's short mechanical spoon (30 cm. long).] _papilloma forceps_.--papillomata do not infiltrate; but superficial repullulations in many cases require repeated removals. if the basal tissues are traumatized, an impaired or ruined voice will result. the author designed these forceps (fig. 29) to scalp off the growths without injury to the normal tissues. [fig. 31.--the author's laryngeal rotation forceps.] [fig. 32.--enlarged view of the jaws of the author's vocal-nodule forceps. larger cups are made for other purposes but these tiny cups permit of that extreme delicacy required in the excision of the nodules from the vocal cords of singers and other voice users.] [fig 33.-extra large laryngeal tissue forceps. 30 cm. long, for removing entire growths or large specimens of tissue. a smaller size is made.] _bronchial dilators_.--it is not uncommon to find a stricture of the bronchus superjacent to a foreign body that has been in situ for a period of months. in order to remove the foreign body, this stricture must be dilated, and for this the bronchial dilator shown in fig. 25 was devised. the channel in each blade allows the closed dilator to be pushed down over the presenting point of such bodies as tacks, after which the blades are opened and the stricture stretched. a small and a large size are made. for enlarging the bronchial narrowing associated with pulmonary abscess and sometimes found above a bronchiectatic or foreign body cavity, the expanding dilator shown in fig. 26 is perhaps less apt to cause injury than ordinary forceps used in the same way. the stretching is here produced by the spring of the blades of the forceps and not by manual force. the closed blades are to be inserted through the strictured area, opened, and then slowly withdrawn. for cicatricial stenoses of the trachea the metallic bougies, fig. 40, are useful. for the larynx, those shown in fig. 41 are needed. [fig. 34.--a, mosher's laryngeal curette; b, author's flat blade cautery electrode; c, pointed cautery electrode; d, laryngeal knife. the electrodes are insulated with hard-rubber vulcanized onto the conducting wires.] [fig. 35.--retrograde esophageal bougies in graduated sizes devised by dr. gabriel tucker and the author for dilatation of cicatricial esophageal stenosis. they are drawn upward by an endless swallowed string, and are therefore only to be used in gastrostomized cases.] [fig. 36.--author's bronchoscopic and esophagoscopic mechanical spoon, made in 40, 50 and 60 cm. lengths.] [fig. 37.--schema illustrating the author's method of endoscopic closure of open safety pins lodged point upward the closer is passed down under ocular control until the ring, r, is below the pin. the ring is then erected to the position shown dotted at m, by moving the handle, h, downward to l and locking it there with the latch, z. the fork, a, is then inserted and, engaging the pin at the spring loop, k, the pin is pushed into the ring, thus closing the pin. slight rotation of the pin with the forceps may be necessary to get the point into the keeper. the upper instrument is sometimes useful as a mechanical spoon for removing large, smooth foreign bodies from the esophagus.] _esophageal dilators_.--the dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods. blind esophageal bouginage is highly dangerous, for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate the wall rather than find the small opening. often there is present a pouching of the esophagus above a stricture, in which the bougie may lodge and perforate. bougies should be introduced under visual guidance through the esophagoscope, which is so placed that the lumen of the stricture is in the center of the endoscopic field. the author's endoscopic bougies (fig. 40) are made with a flexible silk-woven tip securely fastened to a steel shaft. this shaft lends rigidity to the instrument sufficient to permit its accurate placement, and its small size permits the eye to keep the silk-woven tip in view. these endoscopic bougies are made in sizes from 8 to 40, french scale. the larger sizes are used especially for the dilatation of laryngeal and tracheal stenoses. for the latter work it is essential that the bougies be inspected carefully before they are used, for should a defective tip come off while in the lower air passages a difficult foreign body problem would be created. soft-rubber retrograde dilators to be drawn upward from the stomach by a swallowed string are useful in gastrostomized cases (fig. 35). [fig 38.--half curved hook, 45 cm. and 60 cm. full curved patterns are made but caution is necessary to avoid them becoming anchored in the bronchi. spiral forms avoid this. the author makes for himself steel probe-pointed rods out of which he bends hooks of any desired shape. the rod is held in a pin-vise to facilitate bending of the point, after heating in an alcohol or bunsen flame.] _hooks_.--no hook greater than a right angle should be used through endoscopic tubes; for should it become caught in some of the smaller bronchi its extraction might result in serious trauma. the half curved hook shown in fig. 38 is the safest type; better still, a spiral twist to the hook will add to its uses, and by reversing the turning motion it may be "unscrewed" out if it becomes caught. hooks may easily be made from rods of malleable steel by heating the end in a spirit lamp and shaping the curve as desired by means of a pin-vise and pliers. about 2 cm. of the proximal end of the rod should be bent in exactly the opposite direction from that of the hook so as to form a handle which will tell the position of the hook by touch as well as by sight. coil-spring hooks for the upper-lobe-bronchus (fig. 39) will reach around the corner into the ascending bronchus of the upper-lobe-bronchus, but the utmost skill and care are required to make their use justifiable. [fig. 39.--author's coil-spring hook for the upper-lobe, bronchus] _safety-pin closer_.--there are a number of methods for the endoscopic removal of open safety-pins when the point is up, one of which is by closing the pin with the instrument shown in fig. 37 in the following manner. the oval ring is passed through the endoscope until it is beyond the spring of the safety-pin, the ring is then turned upward by depressing the handle, and by the aid of the prong the pin is pushed into the ring, which action approximates the point of the pin and the keeper and closes the pin. removal is then less difficult and without danger. this instrument may also be used as a mechanical spoon, in which case it may be passed to the side of a difficultly grasped foreign body, such as a pebble, the ring elevated and the object withdrawn. elsewhere will be found a description of the various safety-pin closers devised by various endoscopists. the author has used arrowsmith's closer with much satisfaction. _mechanical spoon_.--when soft, friable substances, such as a bolus of meat, become impacted in the upper esophagus, the short mechanical spoon (fig. 30) used through the esophageal speculum is of great aid in their removal. the blade in this instrument, as the name suggests, is a spoon and is not fenestrated as is the safety-pin closer, which if used for friable substances would allow them to slip through the fenestration. a longer form for use through bronchoscopes and esophagoscopes is shown in fig. 36. a laryngeal curette, cautery electrodes, cautery handle, and laryngeal knife are illustrated in fig. 34. the cautery is to be used with a transformer, or a storage battery. _spectacles_.--if the operator has no refractive error he will need two pairs of plane protective spectacles with very large "eyes." if ametropic, corrective lenses are necessary, and duplicate spectacles must be in charge of a nurse. for presbyopia two pairs of spectacles for 40 cm. distance and 65 cm. distance must be at hand. hook temple frames should be used so that they can be easily changed and adjusted by the nurse when the lenses become spattered. the spectacle nurse has ready at all times the extra spectacles, cleaned and warmed in a pan of heated water so that they will not be fogged by the patient's breath, and she changes them without delay as often as they become soiled. the operator should work with both eyes open and with his right eye at the tube mouth. the operating room should be somewhat darkened so as to facilitate the ignoring of the image in the left eye; any lighting should be at the operator's back, and should be insufficient to cause reflections from the inner surface of his glasses. [fig. 40.--the author's endoscopic bougies. the end consists of a flexible silk woven tip attached securely to a steel shank. sizes 8 to 30 french catheter scale. a metallic form of this bougie is useful in the trachea; but is not so safe for esophageal use.] [fig. 41.--the author's laryngeal bougie for the dilatation of cicatricial laryngeal stenosis. made in 10 sizes. the shaded triangle shows the cross-section at the widest part.] [fig. 42.--the author's bronchoscopic and esophagoscopic table.] [46] _endoscopic table_.--any operating table may be used, but the work is facilitated if a special table can be had which allows the placing of the patient in all required positions. the table illustrated in fig. 42 is so arranged that when the false top is drawn forward on the railroad, the head piece drops and the patient is placed in the correct (boyce) position for esophagoscopy or bronchoscopy, i.e., with the head and shoulders extending over the end of the table. by means of the wheel the plane of the table may be altered to any desired angle of inclination or height of head. _operating room_.--all endoscopic procedures should be performed in a somewhat darkened operating room where all the desired materials are at hand. an endoscopic team consists of three persons: the operator, the assistant who holds the head, and the instrument assistant. another person is required to hold the patient's arms and still another for the changing of the operator's glasses when they become spattered. the endoscopic team of three maintain surgical asepsis in the matter of hands and gowns, etc. the battery, on a small table of its own, is placed at the left hand of the operator. beyond it is the table for the mechanical aspirator, if one is used. all extra instruments are placed on a sterile table, within reach, but not in the way, while those instruments for use in the particular operation are placed on a small instrument table back of the endoscopist. only those instruments likely to be wanted should be placed on the working table, so that there shall be no confusion in their selection by the instrument nurse when called for. each moment of time should be utilized when the endoscopic procedure has been started, no time should be lost in the hunting or separating of instruments. to have the respective tables always in the same position relative to the operator prevents confusion and avoids delay. [fig 43.--the author's retrograde esophagoscope.] _oxygen tank and tracheotomy instruments_.--respiratory arrest may occur from shifting of a foreign body, pressure of the esophagoscope, tumor, or diverticulum full of food. rare as these contingencies are, it is essential that means for resuscitation be at hand. no endoscopic procedure should be undertaken without a set of tracheotomy instruments on the sterile table within instant reach. in respiratory arrest from the above mentioned causes, respiratory efforts are not apt to return unless oxygen and amyl nitrite are blown into the trachea either through a tracheotomy opening or better still by means of a bronchoscope introduced through the larynx. the limpness of the patient renders bronchoscopy so easy that the well-drilled bronchoscopist should have no difficulty in inserting a bronchoscope in 10 or 15 seconds, if proper preparedness has been observed. it is perhaps relatively rarely that such accidents occur, yet if preparations are made for such a contingency, a life may be saved which would otherwise be inevitably lost. the oxygen tank covered with a sterile muslin cover should stand to the left of the operating table. _asepsis_.--strict aseptic technic must be observed in all endoscopic procedures. the operator, first assistant, and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation. the operator and first assistant should wear masks and sterile gloves. the patient is instructed to cleanse the mouth thoroughly with the tooth brush and a 20 per cent alcohol mouth wash. any dental defects should, if time permit, as in a course of repeated treatments, be remedied by the dental surgeon. when placed on the table with neck bare and the shoulders unhampered by clothing, the patient is covered with a sterile sheet and the head is enfolded in a sterile towel. the face is wiped with 70 per cent alcohol. it is to be remembered that while the patient is relatively immune to the bacteria he himself harbors, the implantation of different strains of perhaps the same type of organisms may prove virulent to him. furthermore the transference of lues, tuberculosis, diphtheria, pneumonia, erysipelas and other infective diseases would be inevitable if sterile precautions were not taken. all of the tubes and forceps are sterilized by boiling. the light-carriers and lamps may be sterilized by immersion in 95 per cent alcohol or by prolonged exposure to formaldehyde gas. continuous sterilization by keeping them put away in a metal box with formalin pastilles or other source of formaldehyde gas is an ideal method. knives and scissors are immersed in 95 per cent alcohol, and the rubber covered conducting cords are wiped with the same solution. _list of instruments_.--the following list has been compiled as a convenient basis for equipment, to which such special instruments as may be needed for special cases can be added from time to time. the instruments listed are of the author's design. 1 adult's laryngoscope. 1 child's laryngoscope. 1 infant's diagnostic laryngoscope. 1 anterior commissure laryngoscope. 1 bronchoscope, 4 mm. x 30 cm. 1 bronchoscope, 5 mm. x 30 cm. 1 bronchoscope, 7 mm. x 40 cm. 1 bronchoscope, 9 mm. x 40 cm. 1 esophagoscope, 7 mm. x 45 cm. 1 esophagoscope, 10 mm. x 53 cm. 1 esophagoscope, full lumen, 7 mm. x 45 cm. 1 esophagoscope, full lumen, 9 mm. x 45 cm. 1 esophageal speculum, adult. 1 esophageal speculum, child. 1 forward-grasping forceps, delicate, 40 cm. 1 forward-grasping forceps, regular, 50 cm. 1 forward-grasping forceps, regular, 60 cm. 1 side-grasping forceps, delicate, 40 cm. 1 side-grasping forceps, regular, 50 cm. 1 side-grasping forceps, regular, 60 cm. 1 rotation forceps, delicate, 40 cm. 1 rotation forceps, regular, 50 cm. 1 rotation forceps, regular, 60 cm. 1 laryngeal alligator forceps. 1 laryngeal papilloma forceps. 10 esophageal bougies, nos. 8 to 17 french (larger sizes to no. 36 may be added). 1 special measuring rule. 6 light sponge carriers. 1 aspirator with double tube for minus and plus pressure. 2 endoscopic aspirating tubes 30 and 50 cm. 1 half curved hook, 60 cm. 1 triple circuit bronchoscopy battery. 6 rubber covered conducting cords for battery. 1 box bronchoscopic sponges, size 4. 1 box bronchoscopic sponges, size 5. 1 box bronchoscopic sponges, size 7. 1 box bronchoscopic sponges, size 10. 1 bite block, 1 adult. 1 bite block, child. 2 dozen extra lamps for lighted instruments. 1 extra light carrier for each instrument.* 4 yards of pipe-cleaning, worsted-covered wire. [* messrs. george p. pilling and sons who are now making these instruments supply an extra light carrier and 2 extra lamps with each instrument.] _care of instruments_.--the endoscopist must either personally care for his instruments, or have an instrument nurse in his own employ, for if they are intrusted to the general operating room routine he will find that small parts will be lost; blades of forceps bent, broken, or rusted; tubes dinged; drainage canals choked with blood or secretions which have been coagulated by boiling, and electric attachments rendered unstable or unservicable, by boiling, etc. the tubes should be cleansed by forcing cold water through the drainage canals with the aspirating syringe, then dried by forcing pipe-cleaning worsted-covered wire through the light and drainage canals. gauze on a sponge carrier is used to clean the main canal. forceps stylets should be removed from their cannulae, and the cannulae cleansed with cold water, then dried and oiled with the pipe-cleaning material. the stylet should have any rough places smoothed with fine emery cloth and its blades carefully inspected; the parts are then oiled and reassembled. nickle plating on the tubes is apt to peel and these scales have sharp, cutting edges which may injure the mucosa. all tubes, therefore, should be unplated. rough places on the tubes should be smoothed with the finest emery cloth, or, better, on a buffing wheel. the dry cells in the battery should be renewed about every 4 months whether used or not. lamps, light carriers, and cords, after cleansing, are wiped with 95 per cent alcohol, and the light-carriers with the lamps in place are kept in a continuous sterilization box containing formaldehyde pastilles. it is of the utmost importance that instruments be always put away in perfect order. not only are cleaning and oiling imperative, but any needed repairs should be attended to at once. otherwise it will be inevitable that when gotten out in an emergency they will fail. in general surgery, a spoon will serve for a retractor and good work can be done with makeshifts; but in endoscopy, especially in the small, delicate, natural passages of children, the handicap of a defective or insufficient armamentarium may make all the difference between a success and a fatal failure. a bronchoscopic clinic should at all times be in the same state of preparedness for emergency as is everywhere required of a fire-engine house. [plate i--a working set of the author's endoscopic tubes for laryngoscopy, bronchoscopy, esophagoscopy, and gastroscopy: a, adult's laryngoscope; b, child's laryngoscope; c, anterior commissure laryngoscope; d, esophageal speculum, child's size; e, esophageal speculum, adult's size; f, bronchoscope, infant's size, 4 mm. x 30 cm.; g, bronchoscope, child's size, 5 mm. x 30 cm.; h, aspirating bronchoscope for adults, 7 mm. x 40 cm.; i, bronchoscope, adolescent's size, 7 mm. x 40 cm., used also for the deeper bronchi of adults; j, bronchoscope, adult size, g mm. x 40 cm.; k, child's size esophagoscope, 7 mm. x 45 cm.; l, adult's size esophagoscope, full lumen construction, 9 mm. x 45 cm.; m, adult's size gastroscope. c, i, and e are also hypopharyngoscopes. c is an excellent esophageal speculum for children, and a longer model is made for adults. if the utmost economy must be practised d, e, and m may be omitted. the balance of the instruments are indispensable if adults and children are to be dealt with. the instruments are made by charles j. pilling & sons, philadelphia.] [52] chapter ii--anatomy of larynx, trachea, bronchi and esophagus, endoscopically considered the _larynx_ is a cartilaginous box, triangular in cross-section, with the apex of the triangle directed anteriorly. it is readily felt in the neck and is a landmark for the operation of tracheotomy. we are concerned endoscopically with four of its cartilaginous structures: the epiglottis, the two arytenoid cartilages, and the cricoid cartilage. the _epiglottis_, the first landmark in direct laryngoscopy, is a leaf-like projection springing from the anterointernal surface of the larynx and having for its function the directing of the bolus of food into the pyriform sinuses. it does not close the larynx in the trap-door manner formerly taught; a fact easily demonstrated by the simple insertion of the direct laryngoscope and further demonstrated by the absence of dysphagia when the epiglottis is surgically removed, or is destroyed by ulceration. closure of the larynx is accomplished by the approximation of the ventricular bands, arytenoids and aryepiglottic folds, the latter having a sphincter-like action, and by the raising and tilting of the larynx. the _arytenoids_ form the upper posterior boundary of the larynx and our particular interest in them is directed toward their motility, for the rotation of the arytenoids at the cricoarytenoid articulations determines the movements of the cords and the production of voice. approximation of the arytenoids is a part of the mechanism of closure of the larynx. the _cricoid cartilage_ was regarded by esophagoscopists as the chief obstruction encountered on the introduction of the esophagoscope. as shown by the author, it is the cricopharyngeal fold, and the inconceivably powerful pull of the cricopharyngeal muscle on the cricoid cartilage, that causes the difficulty. the cricoid is pulled so powerfully back against the cervical spine, that it is hard to believe that this muscles is inserted into the median raphe and not into the spine itself (fig. 68). the _ventricular bands_ or false vocal cords vicariously phonate in the absence of the true cords, and assist in the protective function of the larynx. they form the floor of the _ventricles_ of the larynx, which are recesses on either side, between the false and true cords, and contain numerous mucous glands the secretion from which lubricates the cords. the ventricles are not visible by mirror laryngoscopy, but are readily exposed in their depths by lifting the respective ventricular bands with the tip of the laryngoscope. the _vocal cords_, which appear white, flat, and ribbon-like in the mirror, when viewed directly assume a reddish color, and reveal their true shelf-like formation. in the subglottic area the tissues are vascular, and, in children especially, they are prone to swell when traumatized, a fact which should be always in mind to emphasize the importance of gentleness in bronchoscopy, and furthermore, the necessity of avoiding this region in tracheotomy because of the danger of producing chronic laryngeal stenosis by the reaction of these tissues to the presence of the tracheotomic cannula. the _trachea_ just below its entrance into the thorax deviates slightly to the right, to allow room for the aorta. at the level of the second costal cartilage, the third in children, it bifurcates into the right and left main bronchi. posteriorly the bifurcation corresponds to about the fourth or fifth thoracic vertebra, the trachea being elastic, and displaced by various movements. the endoscopic appearance of the trachea is that of a tube flattened on its posterior wall. in two locations it normally often assumes a more or less oval outline; in the cervical region, due to pressure of the thyroid gland; and in the intrathoracic portion just above the bifurcation where it is crossed by the aorta. this latter flattening is rhythmically increased with each pulsation. under pathological conditions, the tracheal outline may be variously altered, even to obliteration of the lumen. the mucosa of the trachea and bronchi is moist and glistening, whitish in circular ridges corresponding to the cartilaginous rings, and reddish in the intervening grooves. the right bronchus is shorter, wider, and more nearly vertical than its fellow of the opposite side, and is practically the continuation of the trachea, while the left bronchus might be considered as a branch. the deviation of the right main bronchus is about 25 degrees, and its length unbranched in the adult is about 2.5 cm. the deviation of the left main bronchus is about 75 degrees and its adult length is about 5 cm. the right bronchus considered as a stem, may be said to give off three branches, the epiarterial, upperor superior-lobe bronchus; the middle-lobe bronchus; and the continuation downward, called the loweror inferior-lobe bronchus, which gives off dorsal, ventral and lateral branches. the left main bronchus gives off first the upper-or superior-lobe bronchus, the continuation being the lower-or inferior-lobe bronchus, consisting of a stem with dorsal, ventral and lateral branches. [fig. 44.--tracheo-bronchial tree. lm, left main bronchus; sl, superior lobe bronchus; ml, middle lobe bronchus; il, inferior lobe bronchus.] the septum between the right and left main bronchi, termed the carina, is situated to the left of the midtracheal line. it is recognized endoscopically as a short, shining ridge running sagitally, or, as the patient lies in the recumbent position, we speak of it as being vertical. on either side are seen the openings of the right and left main bronchi. in fig. 44, it will be seen that the lower border of the carina is on a level with the upper portion of the orifice of the right superior-lobe bronchus; with the carina as a landmark and by displacing with the bronchoscope the lateral wall of the right main bronchus, a second, smaller, vertical spur appears, and a view of the orifice of the right upper-lobe bronchus is obtained, though a lumen image cannot be presented. on passing down the right stem bronchus (patient recumbent) a horizontal partition or spur is found with the lumen of the middle-lobe bronchus extending toward the ventral surface of the body. all below this opening of the right middle-lobe bronchus constitutes the lower-lobe bronchus and its branches. [fig. 45.--bronchoscopic views. s; superior lobe bronchus; sl, superior lobe bronchus; i, inferior lobe bronchus; m, middle lobe bronchus.] [56] coming back to the carina and passing down the left bronchus, the relatively great distance from the carina to the upper-lobe bronchus is noted. the spur dividing the orifices of the left upperand lower-lobe bronchi is oblique in direction, and it is possible to see more of the lumen of the left upper-lobe bronchus than of its homologue on the right. below this are seen the lower-lobe bronchus and its divisions (fig. 45). _dimensions of the trachea and bronchi_.--it will be noted that the bronchi divide monopodially, not dichotomously. while the lumina of the individual bronchi diminish as the bronchi divide, the sum of the areas shows a progressive increase in total tubular area of cross-section. thus, the sum of the areas of cross-section of the two main bronchi, right and left, is greater than the area of cross section of the trachea. this follows the well known dynamic law. the relative increase in surface as the tubes branch and diminish in size increases the friction of the passing air, so that an actual increase in area of cross section is necessary, to avoid increasing resistance to the passage of air. the cadaveric dimensions of the tracheobronchial tree may be epitomized approximately as follows: adult male female child infant diameter trachea, 14 x 20 12 x 16 8 x 10 6 x 7 length trachea, cm. 12.0 10.0 6.0 4.0 length right bronchus 2.5 2.5 2.0 1.5 length left bronchus 5.0 5.0 3.0 2.5 length upper teeth to trachea 15.0 23.0 10.0 9.0 length total to secondary bronchus 32.0 28.0 19.0 15.0 in considering the foregoing table it is to be remembered that in life muscle tonus varies the lumen and on the whole renders it smaller. in the selection of tubes it must be remembered that the full diameter of the trachea is not available on account of the glottic aperture which in the adult is a triangle measuring approximately 12 x 22 x 22 mm. and permitting the passage of a tube not over 10 mm. in diameter without risk of injury. furthermore a tube which filled the trachea would be too large to enter either main bronchus. the normal movements of the trachea and bronchi are respiratory, pulsatory, bechic, and deglutitory. the two former are rhythmic while the two latter are intermittently noted during bronchoscopy. it is readily observed that the bronchi elongate and expand during inspiration while during expiration they shorten and contract. the bronchoscopist must learn to work in spite of the fact that the bronchi dilate, contract, elongate, shorten, kink, and are dinged and pushed this way and that. it is this resiliency and movability that make bronchoscopy possible. the inspiratory enlargement of lumen opens up the forceps spaces, and the facile bronchoscopist avails himself of the opportunity to seize the foreign body. the esophagus a few of the anatomical details must be kept especially in mind when it is desired to introduce straight and rigid instruments down the lumen of the gullet. first and most important is the fact that the esophageal walls are exceedingly thin and delicate and require the most careful manipulation. because of this delicacy of the walls and because the esophagus, being a constant passageway for bacteria from the mouth to the stomach, is never sterile, surgical procedures are associated with infective risks. for some other and not fully understood reason, the esophagus is, surgically speaking, one of the most intolerant of all human viscera. the anterior wall of the esophagus is in a part of its course, in close relation to the posterior wall of the trachea, and this portion is called the party wall. it is this party wall that contains the lymph drainage system of the posterior portion of the larynx, and it is largely by this route that posteriorly located malignant laryngeal neoplasms early metastasize to the mediastinum. [58] [fig 46.--esophagoscopic and gastroscopic chart birth 1 yr. 3 yrs. 6 yrs. 10 yrs. 14 yrs.adults 23 27 30 33 36 43 53 cm. greater curvature 18 20 22 25 27 34 40 cm. cardia 19 21 23 24 25 31 36 cm. hiatus 13 15 16 18 20 24 27 cm. left bronchus 12 14 15 16 17 21 23 cm. aorta 7 9 10 11 12 14 16 cm. cricopharyingeus 0 0 0 0 0 0 0 cm. incisors fig. 46.--the author's esophagoscopic chart of approximate distances of the esophageal narrowings from the upper incisor teeth, arranged for convenient reference during esophagoscopy in the dorsally recumbent patient.] the lengths of the esophagus at different ages are shown diagrammatically in fig. 46. the diameter of the esophageal lumen varies greatly with the elasticity of the esophageal walls; its diameter at the four points of anatomical constriction is shown in the following table: constriction diameter vertebra cricopharyngeal transverse 23 mm. (1 in.) sixth cervical antero-posterior 17 mm. (3/4 in.) aortic transverse 24 mm. (1 in.) fourth thoracic antero-posterior 19 mm. (3/4 in.) left-bronchial transverse 23 mm. (1 in.) fifth thoracic antero-posterior 17 mm. (3/4 in.) diaphragmatic transverse 23 mm. (1 in+) tenth thoracic antero-posterior 23 mm. (in.--) for practical endoscopic purposes it is only necessary to remember that in a normal esophagus, straight and rigid tubes of 7 mm. diameter should pass freely in infants, and in adults, tubes of 10 mm. the 4 demonstrable constrictions from above downward are at 1. the crico-pharyngeal fold. 2. the crossing of the aorta. 3. the crossing of the left bronchus. 4. the hiatus esophageus. there is a definite fifth narrowing of the esophageal lumen not easily demonstrated esophagoscopically and not seen during dissection, but readily shown functionally by the fact that almost all foreign bodies lodge at this point. this narrowing occurs at the superior aperture of the thorax and is probably produced by the crowding of the numerous organs which enter or leave the thorax through this orifice. _the crico-pharyngeal constriction_, as already mentioned, is produced by the tonic contraction of a specialized band of the orbicular fibers of the lowermost portion of the inferior pharyngeal constrictor muscle, called the cricopharyngeal muscle. as shown by the author it is this muscle and not the cricoid cartilage alone that causes the difficulty in the insertion of an esophagoscope. this muscle is attached laterally to the edges of the signet of the cricoid which it pulls with an incomprehensible power against the posterior wall of the hypopharynx, thus closing the mouth of the esophagus. its other attachment is in the median posterior raphe. between these circular fibers (the cricopharyngeal muscle) and the oblique fibers of the inferior constrictor muscle there is a weakly supported point through which the esophageal wall may herniate to form the so-called pulsion diverticulum. it is at this weak point that fatal esophagoscopic perforation by inexperienced operators is most likely to occur. _the aortic narrowing_ of the esophagus may not be noticed at all if the patient is placed in the proper sequential "high-low" position. it is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt. the bronchial narrowing of the esophagus is due to backward displacement caused by the passage of the left bronchus over the anterior wall of the esophagus at about 27 cm. from the upper teeth in the adult. the ridge is quite prominent in some patients, especially those with dilatation from stenoses lower down. the hiatal narrowing is both anatomic and spasmodic. the peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion. there are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus, which contribute to tonic closure in the same way that a pinch-cock closes a rubber tube. the author has called the hiatal closure the "diaphragmatic pinchcock." _direction of the esophagus_.--the esophagus enters the chest in a decidedly backward as well as downward direction, parallel to that of the trachea, following the curves of the cervical and upper dorsal spine. below the left bronchus the esophagus turns forward, passing through the hiatus in the diaphragm anterior to and to the left of the aorta. the lower third of the esophagus in addition to its anterior curvature turns strongly to the left, so that an esophagoscope inserted from the right angle of the mouth, when introduced into the stomach, points in the direction of the anterior superior spine of the left ileum. it is necessary to keep this general course constantly in mind in all cases of esophagoscopy, but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level. in such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation. the extrinsic or transmitted movements of the esophagus are respiratory and pulsatory, and to a slight extent, bechic. the respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration, due to the negative intrathoracic pressure. the normal pulsatory movements are due to the pulsatile pressure of the aorta, found at the 4th thoracic vertebra (24 cm. from the upper teeth in the adult), and of the heart itself, most markedly felt at the level of the 7th and 8th thoracic vertebrae (about 30 cm. from the upper teeth in adults). as the distances of all the narrowings vary with age, it is useful to frame and hang up for reference a copy of the chart (fig. 46). the intrinsic movements of the esophagus are involuntary muscular contractions, as in deglutition and regurgitation; spasmodic, the latter usually having some pathologic cause; and tonic, as the normal hiatal closure, in the author's opinion may be considered. swallowing may be involuntary or voluntary. the constrictors are anatomically not considered part of esophagus proper. when the constrictors voluntarily deliver the bolus past the cricopharyngeal fold, the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward. there is no sphincter at the cardiac end of the esophagus. the site of spasmodic stenosis in the lower third, the so-called cardiospasm, was first demonstrated by the author to be located at the hiatus esophageus and the spasmodic contractions are of the specialized muscle fibers there encircling the esophagus, and might be termed "phrenospasm," or "hiatal esophagismus." regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure (called by the author the "diaphragmatic pinchcock") plus the kinking of the abdominal esophagus. in the author's opinion there is no spasm in the disease called "cardiospasm." it is simply the failure of the diaphragmatic pinchcock to open normally in the deglutitory cycle. a better name is functional hiatal stenosis. at retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist. the top of the stomach seems to be closed by the diaphragmatic pinchcock in the same way that the top of a bag is closed by a puckering string. [63] chapter iii--preparation of the patient for peroral endoscopy the suggestions of the author in the earlier volumes in regard to preparation of the patient, as for any operation, by a bath, laxative, etc., and especially by special cleansing of the mouth with 25 per cent alcohol, have received general endorsement. care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it. artificial dentures should be removed. even if no anesthetic is to be used, the patient should be fasted for five hours if possible, even for direct laryngoscopy in order to forestall vomiting. except in emergency cases every patient should be gone over by an internist for organic disease in any form. if an endolaryngeal operation is needed by a nephritic, preparatory treatment may prevent laryngeal edema or other complications. hemophilia should be thought of. it is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow, or the lodgment of a bolus of meat or other foreign body. if aneurysm is present and esophagoscopy is necessary, as it always is in foreign body cases, "to be fore-warned is to be forearmed." pulmonary tuberculosis is often unsuspected in very young children. there is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food; or the food maybe regurgitated and aspirated into the larynx and trachea. therefore, in all esophageal cases the esophagus should be emptied by regurgitation induced by titillating the fauces with the finger after swallowing a tumblerful of water, pressure on the neck, etc. aspiration will succeed in some cases. in others it is absolutely necessary to remove food with the esophagoscope. if the aspirating tube becomes clogged by solid food, the method of swab aspiration mentioned under bronchoscopy will succeed. of course there is usually no cough to aid, but the involuntary abdominal and thoracic compression helps. should a patient arrive in a serious state of water-hunger, as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis, and if necessary the endoscopy, except in dyspneic cases, must be delayed until the danger of water-starvation is past. as pointed out by ellen j. patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child. every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. this becomes doubly necessary in cases that are to be anesthetized. [65] chapter iv--anesthesia for peroral endoscopy a dyspneic patient should never be given a general anesthetic. cocaine should not be used on children under ten years of age because of its extreme toxicity. to these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added--total abolition of the cough-reflex should be for short periods only. general anesthesia is never used in the bronchoscopic clinic for endoscopic procedures. the choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. in other words, the operator must decide what is best for his particular patient under the conditions then existing. _children_ in the bronchoscopic clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of prof. hare, been preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a child of six years) or a full physiologic dose of sodium bromide. the apprehension is thus somewhat allayed and the excessive cough-reflex quieted. the morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the analgesic effects. dosage is more dependent on temperament than on age or body weight. atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. true, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be. in cases of large quantities of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. no food or water is allowed for 5 hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. if the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work. with _adults_ no anesthesia, general or local, is given for esophagoscopy. for laryngeal operation and bronchoscopy the following technic is used: one hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded with atropin sulphate (gr. 1/150). care must be taken that the injection be not given into a vein. on the operating table the epiglottis and pharynx are painted with 10 per cent solution of cocain. two applications are usually sufficient completely to anesthetize the exterior and interior of the larynx by blocking of the superior laryngeal nerve without any endolaryngeal applications. the laryngoscope is now introduced and if found necessary a 20 per cent cocain solution is applied to the interior of the larynx and subglottic region, by means of gauze swabs fastened to the sponge carriers. here also two applications are quite sufficient to produce complete anesthesia in the larynx. if bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina, thus anesthetizing the tracheal mucosa. if further anesthetization of the bronchial mucosa is required, cocain may be applied in the same manner through the bronchoscope. in all these local applications prolonged contact of the swab is much more efficient than simply painting the surface. [67] in cases in which cocain is deemed contraindicated morphin alone is used. if given in sufficient dosage cocain can be altogether dispensed with in any case. it is perhaps _safer for the beginner_ in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia, provided the patient is not dyspneic to begin with, or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal "party wall." as proficiency develops, however, he will find anesthesia unnecessary. local anesthesia is needless for esophagoscopy, and if used at all should be limited to the laryngopharynx and never applied to the esophagus, for the esophagus is without sensation, as anyone may observe in drinking hot liquids. _direct laryngoscopy in children_ requires neither local nor general anesthesia, either for diagnosis or for removal of foreign bodies or growths from the larynx. general anesthesia is contraindicated because of the dyspnea apt to be present, and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level. the latter accident is also prone to follow attempts to cocainize the larynx. _technic for general anesthesia_.--for esophagoscopy and gastroscopy, if general anesthesia is desired, ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced. endo-tracheal administration of ether is, however, far safer than peroral administration, for it overcomes the danger of respiratory arrest from pressure of the esophagoscope, foreign body, or both, on the trachea. chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center. for bronchoscopy, ether or chloroform may be started in the usual way and continued by insufflating through the branch tube of the bronchoscope by means of the apparatus shown in fig. 13. in case of paralysis of the larynx, even if only monolateral, a general anesthetic if needed should be given by intratracheal insufflation. if the apparatus for this is not available the patient should be tracheotomized. hence, every adult patient should be examined with a throat mirror before general anesthesia for any purpose, and the necessity becomes doubly imperative before goiter operations. a number of fatalities have occurred from neglect of this precaution. _anesthetizing a tracheotomized patient_ is free from danger so long as the cannula is kept free from secretion. ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner. if the laryngeal stenosis is not complete, ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube. _endo-tracheal anesthesia_ is by far the safest way for the administration of ether for any purpose. by means of the silk-woven catheter introduced into the trachea, ether-laden air from an insufflation apparatus is piped down to the lungs continuously, and the strong return-flow prevents blood and secretions from entering the lower air-passages. the catheter should be of a size, relative to that of the glottic chink, to permit a free return-flow. a number 24 french is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx. because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations. operations on the nose, accessory sinuses and the pharynx, apt to be attended by considerable bleeding, are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia. it is the safest anesthesia for goiter operations. endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery, for by proper regulation of the pressure under which the ether ladened air is delivered, a lung may be held in any desired degree of expansion when the pleural cavity is opened. it is indicated in operations of the head, neck, or thorax, in which there is danger of respiratory arrest by centric inhibition or peripheral pressure; in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions; and in operations where it is desired to keep the anesthetist away from the operating field. various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management. we are concerned here mainly with the technic of the insertion of the intratracheal tube. the larynx should be examined with the mirror, preferably before the day of operation, for evidence of disease, and incidentally to determine the size of the catheter to be introduced, though the latter can be determined after the larynx is laryngoscopically exposed. the following list of rules for the introduction of the catheter will be of service (see fig. 59). rules for insertion of the catheter for insufflation anesthesia 1. the patient should be fully under the anesthetic by the open method so as to get full relaxation of the muscles of the neck. 2. the patient's head must be in full extension with the vertex firmly pushed down toward the feet of the patient, so as to throw the neck upward and bring the occiput down as close as possible beneath the cervical vertebrae. 3. no gag should be used, because the patient should be sufficiently anesthetized not to need a gag, and because wide gagging defeats the exposure of the larynx by jamming down the mandible. 4. the epiglottis must be identified before it is passed. 5. the speculum must pass sufficiently far below the tip of the epiglottis so that the latter will not slip. 6. too deep insertion must be avoided, as in this case the speculum goes posterior to the cricoid, and the cricoid is lifted, exposing the mouth of the esophagus, which is bewildering until sufficient education of the eye enables the operator to recognize the landmarks. 7. the patient's head is lifted off the table by the spatular tip of the laryngoscope. actual lifting of the head will not be necessary if the patient is fully relaxed; but the idea of lifting conveys the proper conception of laryngeal exposure (fig. 55). [71] chapter v--bronchoscopic oxygen insufflation bronchoscopic oxygen insufflation is a life-saving measure equalled by no other method known to the science of medicine, in all cases of asphyxia, or apnea, present or impending. its especial sphere of usefulness is in severe cases of electric shock, hanging, smoke asphyxia, strangulation, suffocation, thoracic or abdominal pressure, apnea, acute traumatic pneumothorax, respiratory arrest from absence of sufficient oxygen, or apnea from the presence of quantities of irrespirable or irritant gases. combined with bronchoscopic aspiration of secretions it is the best method of treatment for poisoning by chlorine gas, asphyxiating, and other war gases. bronchoscopic oxygen insufflation should be taught to every interne in every hospital. the emergency or accident ward of every hospital should have the necessary equipment and an interne familiar with its use. the method is simple, once the knack is acquired. the patient being limp and recumbent on a table, the larynx is exposed with the laryngoscope, and the bronchoscope is inserted as hereinafter described. the oxygen is turned on at the tank and the flow regulated before the rubber tube from the wash-bottle of tank is attached to the side-outlet of the bronchoscope. it is necessary to be certain that the flow is gentle, so that, with a free return flow the introduced pressure does not exceed the capillary pressure; otherwise the blood will be forced out of the capillaries and the ischemia of the lungs will be fatal. another danger is that overdistension causes inhibition of inspiration resulting in apnea continuing as long as the distension is maintained, if not longer. the return flow from the bronchoscope should be interrupted for 2 or 3 seconds several times a minute to inflate the lungs, but the flow must not be occluded longer than 3 seconds, because the intrapulmonary pressure would rise. a pearl of amyl nitrite may be broken in the wash bottle. slow rhythmic artificial respiratory movements are a useful adjunct, and unless the operator is very skillful in gauging the alternate pressures and releases with the thumb according to the oxygen pressure, it is vitally necessary to fill and deflate the lungs rhythmically by one of the well known methods of artificial respiration. anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds, and it is especially easy in cases of respiratory arrest, because of the limp condition of the patient. the foregoing applies to cases in which a pulmotor would be used, such as apnea from electric shocks, etc. for obstructive dyspnea and asphyxia, tracheotomy is the procedure of choice, and the skillful tracheotomist would be justified in preferring tracheotomy for the other class of cases, insufflating the oxygen and amyl nitrite through the tracheotomic wound. the pulmotor and similar mechanisms are, perhaps, the best things the use of which can be taught to laymen; but as compared to bronchoscopic oxygen insufflation they are woefully inefficient, because the intraoral pressure forces the tongue back over the laryngeal orifice, obstructing the airway in this "death zone." by the introduction of the bronchoscope this death zone is entirely eliminated, and a free airway established for piping the oxygen directly into the lungs. [73] chapter vi--position of the patient for peroral endoscopy it is the author's invariable practice to place the patient in the dorsally recumbent position. the sitting position is less favorable. while lying on a well-padded, flat table the patient is readily controlled, the head is freely movable, secretions can be easily removed, the view obtained by the endoscopist is truly direct (without reversal of sides), and, most important, the employment of one position only favors smoother and more efficient team work, and a better endoscopic technic. _general principles of position_.--as will be seen in fig. 47 the trachea and esophagus are not horizontal in the thorax, but their long axes follow the curves of the cervical and dorsal spine. therefore, if we are to bring the buccal cavity and pharynx in a straight line with the trachea and esophagus it will be found necessary to elevate the whole head above the plane of the table, and at the same time make extension at the occipito-atloid joint. by this maneuver the cervical spine is brought in line with the upper portion of the dorsal spine as shown in fig. 55. it was formerly taught, and often in spite of my better knowledge i am still unconsciously prone to allow the head and cervical spine to assume a lower position than the plane of the table, the so-called rose position. with the head so placed, it is impossible to enter the lower air or food passages with a rigid tube, as will be shown by a study of the radiograph shown in fig. 49. extension of the head on the occipito-atloid joint is for the purpose of freeing the tube from the teeth, and the amount required will vary with the degree to which the mouth can be opened. whether the head be extended, flexed, or kept mid-way, the fundamental principle in the introduction of all endoscopic tubes is the anterior placing of the cervical spine and the high elevation of the head. the esophagus, just behind the heart, turns ventrally and to the left. in order to pass a rigid tube through this ventral curve the dorsal spine is now extended by lowering the head and shoulders below the plane of the table. this will be further explained in the chapter on esophagoscopy. in all of these procedures, the nose of the patient should be directed toward the zenith, and the assistant should _prevent rotation of the head_ as well as _prevent lowering of the head_. the patient should be urged as follows: "don't hold yourself so rigid." "let your head and neck go loose." "let your head rest in my hand." "don't try to hold it." "let me hold it." "relax." "don't raise your chest." [fig. 47.--schematic illustration of normal position of the intra-thoracic trachea and esophagus and also of the entire trachea when the patient is in the correct position for peroral bronchoscopy. when the head is thrown backward (as in the rose position) the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated. the anterior deviation of the lower third of the esophagus shows the anatomical basis for the "high low" position for esophagoscopy] [fig. 48.--correct position of the cervical spine for esophagoscopy and bronchoscopy. (_illustration reproduced from author's article jour. am. med. assoc., sept. 25, 1909_)] [fig. 49.--curved position of the cervical spine, with anterior convexity, in the rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. the devious course of the pharynx, larynx and trachea are plainly visible. the extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint. this is the usual and very faulty conception of the extended position. (_illustration reproduced from author's article, jour. am. med. assoc., sept. 25, 1909._)] [76] for _direct laryngoscopy_ the patient's head is raised above the plane of the table by the first assistant, who stands to the right of the patient, holding the bite block on his right thumb inserted in the left corner of the patient's mouth, while his extended right hand lies along the left side of the patient's cheek and head, and prevents rotation. his left hand, placed under the patient's occiput, elevates the head and maintains the desired degree of extension at the occipito-atloid joint (fig. 50). [fig 50.--direct laryngoscopy, recumbent patient. the second assistant is sitting holding the head in the boyce position, his left forearm on his left thigh his left foot on a stool whose top is 65 cm. lower than the table-top. his left hand is on the patient's sterile-covered scalp, the thumb on the forehead, the fingers under the occiput, making forced extension. the right forearm passes under the neck of the patient, so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth. the fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope. this is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist.] _position for bronchoscopy and esophagoscopy_.--the dorsally recumbent patient is so placed that the head and shoulders extend beyond the table, the edge of which supports the thorax at about the level of the scapulae. during introduction, the head must be maintained in the same relative position to the table as that described for direct laryngoscopy, that is, elevated and extended. the first assistant, in this case, sits on a stool to the right of the patient's head, his left foot resting on a box about 14 inches in height, the left knee supporting the assistant's left hand, which being placed under the occiput of the patient maintains elevation and extension. the right arm of the assistant passes under the neck of the patient, the bite block being carried on the middle finger of the right hand and inserted into the left side of the patient's mouth. the right hand also prevents rotation of the head (fig. 51). as the bronchoscope or esophagoscope is further inserted, the head must be placed so that the tube corresponds to the axis of the lumen of the passage to be examined. if the left bronchus is being explored, the head must be brought strongly to the right. if the right middle lobe bronchus is being searched, the head would require some left lateral deflection and a considerable degree of lowering, for this bronchus, as before mentioned, extends anteriorly. during esophagoscopy when the level of the heart is reached, the head and upper thorax must be strongly depressed below the plane of the table in order to follow the axis of the lumen of the ventrally turning esophagus; at the same time the head must be brought somewhat to the right, since the esophagus in this region deviates strongly to the left. [fig. 51.--position of patient and assistant for introduction of the bronchoscope and esophagoscope. the middle of the scapulae rest on the edge of the table; the head and shoulders, free to move, are supported by the assistant, whose right arm passes under the neck; the right middle finger inserts the bite block into the left side of the mouth. the left hand, resting on the left knee maintains the desired degree of elevation, extension and lateral deflection required by the operator. the patient's vertex should be 10 cm. higher than the level of the top of the table. this is the boyce position, which has never been improved upon for bronchoscopy and esophagoscopy.] [fig. 52.--schema of position for endoscopy. a. normal recumbency on the table with pillow supporting the head. the larynx can be directly examined in this position, but a better position is obtainable. b. head is raised to proper position with head flexed. muscles of front of neck are relaxed and exposure of larynx thus rendered easier; but, for most endoscopic work, a certain amount of extension is desired. the elevation is the important thing. c. the neck being maintained in position b, the desired amount of extension of the head is obtained by a movement limited to the occipito-atloid articulation by the assistant's hand placed as shown by the dart (b). d. faulty position. unless prevented, almost all patients will heave up the chest and arch the lumbar spine so as to defeat the object and to render endoscopy difficult by bringing the chest up to the high-held head, thus assuming the same relation of the head to the chest as exists in the rose position (a faulty one for endoscopy) as will be understood by assuming that the dotted line, e, represents the table. if the pelvis be not held down to the table the patient may even assume the opisthotonous position by supporting his weight on his heels on the table and his head on the assistant's hand.] in obtaining the position of high head with occipito-atloid extension, the easiest and most certain method, as pointed out to me by my assistant, gabriel tucker, is first to raise the head, strongly flexed, as shown in fig. 52; then while maintaining it there, make the occipito-atloid extension. this has proven better than to elevate and extend in a combined simultaneous movement. if the patient would relax to limpness exposure of the larynx would be easily obtained, simply by lifting the head with the lip of the laryngoscope passed below the tip of the epiglottis (as in fig. 55) and no holding of the head would be necessary. but only rarely is a patient found who can do this. this degree of relaxation is of course, present in profound general ether anesthesia, which is not to be thought of for direct laryngoscopy, except when it is used for the purpose of insertion of intratracheal insufflation anesthetic tubes. for this, of course, the patient is already to be deeply anesthetized. the muscular tension exerted by some patients in assuming and holding a faulty position is almost as much of a hindrance to peroral endoscopy as is the position itself. the tendency of the patient to heave up his chest and assume a false position simulating the opisthotonous position (fig. 52) must be overcome by persuasion. this position has all the disadvantages of the rose position for endoscopy. [fig. 53.--the author's position for the removal of foreign bodies from the larynx or from any of the upper air or food passages. if dislodged, the intruder will not be aided by gravity to reach a deeper lodgement.] the one exception to these general positions is found in procedures for the removal of foreign bodies from the larynx. in such cases, while the same relative position of the head to the plane of the table is maintained, the whole table top is so inclined as to elevate the feet and lower the head, known as jackson's position. this semi-inversion of the patient allows the foreign body to drop into the pharynx if it should be dislodged, or slip from the forceps (fig. 53). [82] chapter vii--direct laryngoscopy _importance of mirror examination of the larynx_.--the presence of the direct laryngoscope incites spasmodic laryngeal reflexes, and the traction exerted somewhat distorts the tissues, so that accurate observations of variations in laryngeal mobility are difficult to obtain. the function of the laryngeal muscles and structures, therefore, can best be studied with the laryngeal mirror, except in infants and small children who will not tolerate the procedure of indirect laryngoscopy. a true idea of the depth of the larynx is not obtained with the mirror, and a view of the ventricles is rarely had. with the introduction of the direct laryngoscope it is found that the larynx is funnel shaped, and that the adult cords are situated about 3 cm. below the aryepiglottic folds; the cords also assume their true shelf-like character and take on a pinkish or yellowish tinge, rather than the pearly white seen in the mirror. they are not to any extent differentiated by color from the neighboring structures. their recognition depends almost wholly on form, position and movement. accurate observation is stimulated in all pathologic cases by making colored crayon sketches, however crude, of the mirror image of the larynx. the location of a growth may be thus graphically recorded, so that at the time of operation a glance will serve to refresh the memory as to its site. it is to be constantly kept in mind, however, that in the mirror image the sides are reversed because of the facing positions of the examiner and patient. direct laryngoscopy is the only method by which the larynx of children can be seen. the procedure need require less than a minute of time, and an accurate diagnosis of the condition present, whether papilloma, foreign body, diphtheria, paralysis, etc., may be thus obtained. the posterior pharyngeal wall should be examined in all dyspneic children for the possible existence of retropharyngeal abscess. [plate ii--direct and indirect laryngeal views from author's oil-color drawings from life: 1, epiglottis of child as seen by direct laryngoscopy in the recumbent position. 2, normal larynx spasmodically closed, as is usual on first exposure without anesthesia. 3, same on inspiration. 4, supraglottic papillomata as seen on direct laryngoscopy in a child of two years. 5, cyst of the larynx in a child of four years, seen on direct laryngoscopy without anesthesia. 6, indirect view of larynx eight weeks after thyrotomy for cancer of the right cord in a man of fifty years. 7, same after two years. an adventitious band indistinguishable from the original one has replaced the lost cord. 8, condition of the larynx three years after hemilaryngectomy for epithelioma in a patient fifty-one years of age. thyrotomy revealed such extensive involvement, with an open ulceration which had reached the perichondrium, that the entire left wing of the thyroid cartilage was removed with the left arytenoid. a sufficiently wide removal was accomplished without removing any part of the esophageal wall below the level of the crico-arytenoid joint. there is no attempt on the part of nature to form an adventitious cord on the left side. the normal arytenoid drew the normal cord over, approximately to the edge of the cicatricial tissue of the operated side. the voice, at first a very hoarse whisper, eventually was fairly loud, though slightly husky and inflexible. 9, the pharynx seen one year after laryngectomy for endothelioma in a man aged sixty-eight years. the purple papilla; anteriorly are at the base of the tongue, and from this the mucosa slopes downward and backward smoothly into the esophagus. there are some slight folds toward the left and some of these are quite cicatricial. the epiglottis was removed at operation. the trachea was sutured to the skin and did not communicate with the pharynx. (direct view.)] _contraindications to direct laryngoscopy_.--there are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment. in extremely dyspneic patients, if the operator is not confident in his ability for a prompt and sure introduction of a bronchoscope, it may be wise to do a tracheotomy first. _instructions to the patient_.--before beginning endoscopy the patient should be told that he will feel a very disagreeable pressure on his neck and that he may feel as though he were about to choke. he must be gently but positively made to understand (1) that while the procedure is alarming, it is absolutely free from danger; (2) that you know just how it feels; (3) that you will not allow his breath to be shut off completely; (4) that he can help you and himself very much by paying close attention to breathing deeply and regularly; (5) and that he must not draw himself up rigidly as though "walking on ice," but must be easy and relaxed. _direct laryngoscopy. adult patient_.--before starting, every detail in regard to instrumental equipment and operating room assistants, (including an assistant to hold the arms and legs of the patient) must be complete. preparation of the patient and the technic of local anesthesia have been discussed in their respective chapters. the dorsally recumbent patient is draped with (not pinned in) a sterile sheet. the head, covered by sterile towels, is elevated, and slight extension is made at the occipitoatloid joint by the left hand of the first assistant. the bite block placed on the assistant's right thumb is inserted into the left angle of the patient's open mouth (see fig. 50). the laryngoscope must always and invariably be held in the left hand, and in such a manner that the greatest amount of traction is made at the swell of the horizontal bar of the handle, rather than on the vertical bar. the right hand is then free for the manipulation of forceps, and the insertion of the bronchoscope or other instrument. during introduction, the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth. the introduction of the direct laryngoscope and exposure of the larynx is best described in two stages. 1. exposure and identification of the epiglottis. 2. elevation of the epiglottis and all the tissues attached to the hyoid bone, so as to expose the larynx to direct view. _first stage_.--the spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. it was the german method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required, which exercise of force may be entirely avoided by crowding the tongue over to the left. when the posterior third stage of the tongue is reached, the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope. the epiglottis will then be seen to project into the endoscopic field, as seen in fig. 54. [fig. 54.--end of the first of direct laryngoscopy, recumbent adult patient. the epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis.] _second stage_.--the spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx, passed posterior to the epiglottis, and advanced about 1 cm. the larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope (fig. 55). particular care must be taken at this stage not to pry on the upper teeth; but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice. it is to be emphasized that while some pressure is necessary in the lifting motion, great force should never be used; the art is a gentle one. the first view is apt to find the larynx in state of spasm, and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis. usually little more is seen than the two rounded arytenoid masses, and, anterior to them, the ventricular bands in more or less close apposition hiding the cords (fig. 56). with deep general anesthesia or thorough local anesthesia the spasm may not be present. by asking the patient to take a deep breath and maintain steady breathing, or perhaps by requesting a phonatory effort, the larynx will open widely and the cords be revealed. if the anterior commissure of the larynx is not readily seen, the lifting motion and elevation of the head should be increased, and if there is still difficulty in exposing the anterior commissure the assistant holding the head should with the index finger externally on the neck depress the thyroid cartilage. if by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated. [fig. 55.--schema illustrating the technic of direct laryngoscopy on the recumbent patient. the motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone. the portion of the table indicated by the dotted line may be dropped or not, but the back of the head must never go lower than here shown, for direct laryngoscopy; and it is better to have it at least 10 cm. above the level of the table. the table may be used as a rest for the operator's left elbow to take the weight of the head. (note that in bronchoscopy and esophagoscopy the head section of the table must be dropped, so as to leave the head and neck of the patient out in the air, supported by the second assistant.)] [fig. 56.--endoscopic view at the end of the second stage of direct laryngoscopy. recumbent patient. larynx exposed waiting for larynx to relax its spasmodic contraction.] rules for direct laryngoscopy 1. the laryngoscope must always be held in the left hand, never in the right. 2. the operator's right index finger (never the left) should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth. 3. the patient's head must always be exactly in the middle line, not rotated to the right or left, nor bent over sidewise; and the entire head must be forward with extension at the occipitoatloid joint only. 4. the laryngoscope is inserted to the right side of the anterior two-thirds of the tongue, the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached. 5. the epiglottis must always be identified before any attempt is made to expose the larynx. 6. when first inserting the laryngoscope to find the epiglottis, great care should be taken not to insert too deeply lest the epiglottis be overridden and thus hidden. 7. after identification of the epiglottis, too deep insertion of the laryngoscope must be carefully avoided lest the spatula be inserted back of the arytenoids into the hypo-pharynx. 8. exposure of the larynx is accomplished by pulling forward the epiglottis and the tissues attached to the hyoid bone, and not by prying these tissues forward with the upper teeth as a fulcrum. 9. care must be taken to avoid mistaking the ary-epiglottic fold for the epiglottis itself. (most likely to occur as the result of rotation of the patient's head.) 10. the tube should not be retained too long in place, but should be removed and the patient permitted to swallow the accumulated saliva, which, if the laryngoscope is too long in place, will trickle down the trachea and cause cough. (swallowing is almost impossible while the laryngoscope is in position.) the secretions may be removed with the aspirator. 11. the patient must be instructed to breathe deeply and quietly without making a sound. [88] _difficulties of direct laryngoscopy_.--the larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. the spatula should glide slowly along the posterior third of the tongue until it reaches the glossoepiglottic fossa, while at the same time the tongue is lifted; when this is done the epiglottis will stand out in strong relief. the beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx. the elusiveness of the epiglottis and its tendency to retreat downward are very much accentuated in patients who have worn a tracheotomic cannula; and if still wearing it, the patient can wait indefinitely before opening his glottis. over extension of the patient's head is a frequent cause of difficulty. if the head is held high enough extension is not necessary, and the less the extension the less muscular tension there is in the anterior cervical muscles. only one arytenoid eminence may be seen. the right and the left look different. practice will facilitate identification, so that the endoscopist will at once know which way to look for the glottis. of the difficulties that pertain to the operator himself the greatest is lack of practice. he must learn to recognize the landmarks even though a high degree of spasm be present. the epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind's eye, for it is only on deep, relaxed inspiration that anything like a typical picture of the larynx will be seen. he must know also the right from the left arytenoid when only one is seen in order to know whether to move the lip of the laryngoscope to the right or the left for exposure of the interior of the larynx. _instruments for direct laryngoscopy_.--in undertaking direct laryngoscopy one must always be prepared for bronchoscopy, esophagoscopy, and tracheotomy, as well. preparations for bronchoscopy are necessary because the pathological condition may not be found in the larynx, and further search of the trachea or bronchi may be required. a foreign body in the larynx may be aspirated to a deeper location and could only be followed with the bronchoscope. sudden respiratory arrest might occur, from pathology or foreign body, necessitating the inserting of the bronchoscope for breathing purposes, and the insufflation of oxygen and amyl nitrite. trachectomy might be required for dyspnea or other reasons. it might be necessary to explore the esophagus for conditions associated with laryngeal lesions, as for instance a foreign body in the esophagus causing dyspnea by pressure. in short, when planning for direct laryngoscopy, bronchoscopy, or esophagoscopy, prepare for all three, and for tracheotomy. a properly done direct laryngoscopy would never precipitate a tracheotomy in an unanesthetized patient; but direct laryngoscopy has to deal so frequently with laryngeal stenosis, that routine preparation for tracheotomy a hundred unnecessary times is fully compensated for by the certainty of preparedness when the rare but urgent occasion arises. _direct laryngoscopy in children_.--the epiglottis in children is usually strongly curled, often omega shaped, and is very elusive and slippery. the larynx of a child is very freely movable in the neck during respiration and deglutition, and has a strong tendency to retreat downward during examination, and thus withdraw the epiglottis after the arytenoids have been exposed. in following down with the laryngoscope the speculum is prone to enter the hypopharynx. lifting in this location will expose the mouth of the esophagus and shut off the larynx, and may cause respiratory arrest. practice, however, will soon develop a technic and ability to recognize the landmarks in state of spasm, so that on exposing the approximated arytenoid eminences the endoscopist will maintain his position and wait for the larynx to open. the procedure should be done without any form of anesthesia for the following reasons: 1. anesthesia is unnecessary. 2. it is extremely dangerous in a dyspneic patient. 3. it is inadmissable in a patient with diphtheria. 4. if anesthesia is to be used, direct laryngoscopy will never reach its full degree of usefulness, because anesthesia makes a major procedure out of a minor one. 5. cocain in children is dangerous, and its application more annoying than the examination. _inducing a child to open its mouth (author's method)_.--the wounding of the child's mouth, gums, and lips, in the often inefficacious methods with gags, hemostats, raspatories, etcetera, are entirely unnecessary. the mouth of any child not unconscious can be opened quickly and without the slightest harm by passing a curved probe between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx. this will cause the child to gag, when its mouth invariably opens. [91] chapter viii--direct laryngoscopy (_continued_) _technic of laryngeal operations_.--preparation of the patient and anesthesia have been mentioned under their respective chapters. the prime essential of successful laryngeal operations is perfect mastery of continuous left-handed laryngeal exposure. the right hand must be equally trained in the manipulation of forceps, and the right eye to gauge depth. blood and secretions are best removed by a suction tube (fig. 9) inserted through the laryngoscope, or directly into the pharynx outside the laryngoscope. _for the removal of benign growths_ the author's papilloma forceps, fig. 29, or the laryngeal grasping forceps shown in fig. 17 will prove more satisfactory than any form of cutting forceps. these growths should be removed superficially flush with the normal structure. the crushing of the base incident to the plucking off of the growth causes its recession. by this conservative method damage to the cords and impairment of the voice are avoided. for growths in the anterior portion of the larynx, and in fact for the removal of most small benign growths, the anterior commissure laryngoscope is especially adapted. its shape allows its introduction into the vestibule of the larynx, and if desired it may be introduced through the glottic chink for the treatment of subglottic conditions. it will not infrequently be observed that a pedunculated subglottic growth which is found with difficulty will be pulled upward into view by the gauze swab introduced to remove secretions. the growth is then often held tightly between the approximated cords for a few seconds--perhaps long enough to grasp it with forceps. [92] _removal of growth from the laryngeal ventricle_.--after exposing the larynx in the usual manner, if the head is turned strongly to the right, the tip of the laryngoscope, directed from the right side of the mouth, may be used to lift the left ventricular hand and thus expose the ventricle, from which a growth may be removed in the usual manner (fig. 57). the right ventricle is exposed by working from the left side of the mouth. [fig. 57.-schema illustrating the lateral method of exposing a growth in the ventricle of morgagni, by bending the patient's head to the opposite side, while the second assistant externally fixes the larynx with his hand. m, patient's mouth; t, thyroid cartilage; r, right side; l, left. v, b, ventricular band. c, c, vocal cord. the circular drawing indicates the endoscopic view obtainable by this method. the tube, e, is dropped to the corner of the mouth, b, and the tube is inserted down to r. the lip of the spatula can then be used to lift the ventricular band so as to expose more of the ventricle. the drawing shows an unusually shallow ventricle.] _taking a laryngeal specimen for diagnosis_.--the diagnosis of carcinoma, sarcoma, and some other conditions can be made certain only by microscopic study of tissue removed from the growth. the specimen should be ample but will necessarily be small. if the suspected growth be small it should be removed entire, together with some of the basal tissues. if it is a large growth, and there are objections to its entire removal, the edge of the growth, including apparently normal as well as neoplastic tissue, is necessary. if it is a diffuse infiltrative process, a specimen should be taken from at least two locations. tissue for biopsy is to be taken with the punch forceps shown in fig. 28 or that in fig. 33. the forceps may be inserted through the tube or from the angle of the mouth; the "extubal" method (see fig. 58). [fig. 58.--schema illustrating removal of a tumor from the upper part of the larynx by the author's "extubal" method for large tumors. the large alligator basket punch forceps, f, is inserted from the right corner of the mouth and the jaws are placed over the tumor, t, under guidance of the eye looking through the laryngoscope, l. this method is not used for small tumors. it is excellent for amputation of the epiglottis with these same punch forceps or with the heavy snare.] _removal of large benign tumors above the cords_ may be done with the snare or with the large laryngeal punch forceps. both are used in the extubal method. _amputation of the epiglottis_ for palliation of odynophagia or dysphagia in tuberculous or malignant disease, is of benefit when the ulceration is confined to this region; though as to tuberculosis the author feels rather conservatingly inclined. early malignancy of the extreme tip can be cured by such means. the function of the epiglottis seems to be to split the food bolus and direct its portions laterally into the pyriform sinuses, rather than to take any important part in the closure of the larynx. following the removal of the epiglottis there is rarely complaint of food entering the larynx. the projecting portion of the epiglottis may be amputated with a heavy snare, or by means of the large laryngeal punch forceps (fig. 33). _endoscopic operations for laryngeal stenosis_.--web formations may be excised with sliding punch forceps, or if the web is due to contraction only, incision of the true band may allow its retraction. in some instances liberation of adhesions will favor the formation of adventitious vocal cords. a sharp anterior commissure is a large factor in good phonation. _endoscopic evisceration of the larynx_ will cure a few cases of laryngeal cicatricial stenosis, and should be tried before resorting to laryngostomy. a sliding punch forceps is used to remove all the tissue in the larynx out to the perichondrium, but care should be taken in cicatricial cases to avoid removing any part of either arytenoid cartilage. in cases of posticus paralysis the excision may include portions of the vocal processes of the arytenoids. ventriculocordectomy is preferable to evisceration. the ventricular floor is removed with punch forceps (fig. 33) first on one side, then after two months, on the other. _vocal results_.--a whispering voice can always be had as long as air can pass through the larynx, and this may be developed to a very loud penetrating stage whisper. if the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud, useful, though perhaps rough and inflexible voice. _galvano-cauterization_ is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria, when the stenosis produced prevents extubation or decannulation. the utmost caution should be used to avoid deep cauterizations; they are almost certain to set up perichondritis which will increase the stenosis. some of the most difficult cases that have come to the author have been previously cauterized too deeply. _galvano-cautery puncture_ of tuberculous infiltrations of the larynx at times yields excellent results in cases with mild pulmonary lesions, and has quite replaced the use of the curette, lactic acid, and other caustics. the direct method of exposing the larynx renders the application of the cautery point easy and accurate. in severely stenosed tuberculous larynges a tracheotomy should first be done, for though the reaction is slight it might be sufficient to close a narrowed glottis. the technic is the usual one for laryngeal operations. local anesthesia suffices. the larynx is exposed. the rheostat having been previously adjusted to heat the electrode to nearly white heat, the circuit is broken and the electrode introduced cold. when the point is in contact with the desired location the current is turned on and the point thrust in as deeply as desired. usually it should penetrate until a firm resistance is felt; but care must be used not to damage the cricoarytenoid joint. the circuit is broken at the instant of withdrawal. punctures should be made as nearly as possible perpendicular to the surface, so as to minimize the destruction of epithelium and thus lessen the reaction. a minute gray fibrous slough detaches itself in a few days. cautery puncture should be repeated every two or three weeks, selecting a new location each time, until the desired result is obtained. great caution, as mentioned above, must be used to avoid setting up perichondritis. many cases of laryngeal tuberculosis will recover as quickly by silence and a general antituberculous regime. _radium_, in form of capsules or of needles inserted in the tissues may be applied with great accuracy; but the author is strongly impressed with pyriform sinus applications by the freer method. _after-care of endolaryngeal operations_ includes careful cleansing of the teeth and mouth; and if the extrinsic area of the larynx is involved in the wound, sterile liquid food and water should be given for four days. the patient should be watched for complications by a special nurse who is familiar with the signs of laryngeal dyspnea (q.v.). _complications during endolaryngeal operations_ are rare. dyspnea may require tracheotomy. idiosyncrasy to cocain, or the sight or taste of blood may nauseate the patient and cause syncope. serious hemorrhage could occur only in a hemophile. the careless handling of a bite block might damage a frail tool or dental fixture. _complications after endolaryngeal operations_ are unusual. carelessness in asepsis has been known to cause cervical cellulitis. emphysema of the neck has occurred. edema of the larynx occasionally occurs, and might necessitate tracheotomy. serious bleeding after operation is very rare except in bleeders. hemorrhage within the larynx can be stopped by the introduction of a roll of gauze from above, tracheotomy having been previously performed. morphin subcutaneously administered, has a constricting action on the vessels which renders it of value in controlling hemorrhage. [97] chapter ix--introduction of the bronchoscope no one should do bronchoscopy until he is able to expose the glottis by left-handed direct laryngoscopy in less than one minute. when he has mastered this, one minute more should be sufficient to introduce the bronchoscope into the trachea. technic of bronchoscopy local anesthesia is usually employed in the adult. the patient is placed in the boyce position shown in fig. 51, with head and shoulders projecting over the edge of the table and supported by an assistant. the glottis is exposed by left-handed laryngoscopy. the instrument-assistant now inserts the distal end of the bronchoscope into the lumen of the laryngoscope, the handle being directed to the right in a horizontal position. the operator now grasps the bronchoscope, his eye is transferred from the laryngoscope to the bronchoscope, and the bronchoscope is advanced and so directed that a good view of the glottis is obtained. the slanted end of the bronchoscope should then be directed to the left, so as clearly to expose the left cord. in this position it will be found that the tip of the slanted end is in the center of the glottic chink and will slip readily into the trachea. no great force should be used, because if the bronchoscope does not go through readily, either the tube is too large a size or it is not correctly placed (fig. 60). normally, however, there is some slight resistance, which in cases of subglottic laryngitis may be considerable. the trained laryngologist will readily determine by sense of touch the degree of pressure necessary to overcome it. when the bronchoscope has been inserted to about the second or third tracheal ring, the heavy laryngoscope is removed by rotating the handle to the left, removing the slide, and withdrawing the instrument. care must be taken that the bronchoscope is not withdrawn or coughed out during the removal of the laryngoscope; this can be avoided by allowing the ocular end to rest against the gown-covered chest of the operator. if preferred the operator may train his instrumental assistant to take off the laryngoscope, while the operator devotes his attention to preventing the withdrawal of the bronchoscope by holding the handle with his right hand. at the moment of insertion of the bronchoscope through the glottis, an especially strong upward lift on the beak of the spatula will facilitate the passage. it is necessary to be certain that the axis of the bronchoscope corresponds to the axis of the trachea, in order to avoid injury to the subglottic tissue which might be followed by subglottic edema (fig. 47). if the subglottic region is already edematous and causes resistance, slight rotation to the laryngoscope, and bronchoscope will cause the bronchoscope to enter more easily. [fig. 59.--insufflation anesthesia with elsberg apparatus. anesthetist has exposed the larynx and is about to introduce the silk-woven catheter. note the full extension of the head on the table.] [fig. 60.--schema illustrating the introduction of the bronchoscope through the glottis, recumbent patient. the handle, h, is always horizontally to the right. when the glottis is first seen through the tube it should be centrally located as at k. at the next inspiration the end b, is moved horizontally to the left as shown by the dart, m, until the glottis shows at the right edge of the field, c. this means that the point of the lip, b, is at the median line, and it is then quickly (not violently) pushed through into the trachea. at this same moment or the instant before, the hyoid bone is given a quick additional lift with the tip of the laryngoscope.] [fig. 61.--schema illustrating oral bronchoscopy. the portion of the table here shown under the head is, in actual work, dropped all the way down perpendicularly. it appears in these drawings as a dotted line to emphasize the fact that the head must be above the level of the table during introduction of the bronchoscope into the trachea. a, exposure of larynx; b, bronchoscope introduced; c, slide removed; d, laryngoscope removed leaving bronchoscope alone in position.] _difficulties in the introduction of the bronchoscope_.--the beginner may enter the esophagus instead of the trachea: this might be a dangerous accident in a dyspneic case, for the tube could, by pressure on the trachea, cause respiratory arrest. a bronchoscope thus misplaced should be resterilized before introducing it into the air passages, for while the lower air passages are usually free from bacteria, the esophagus is a septic canal. if the given technic is carefully carried out the bronchoscope will not be contaminated with mouth secretions. the trachea is recognized as an open tube, with whitish rings, and the expiratory blast can be felt and tubular breathing heard; while if by mistake the bronchoscope has entered the gullet it will be observed that the cervical esophagus has collapsed walls. a puff of air may be felt and a fluttering sound heard when the tube is in the esophagus, but these lack the intensity of the tracheal blast. usually a free flow of secretion is met with in the esophagus. in diseased states the tracheal rings may not be visible because of swollen mucosa, or the trachea itself may be in partial collapse from external pressure. the true expiratory blast will, however, always be recognized when the tube is in the trachea. wide gagging of the mouth renders exposure of the larynx difficult. [fig. 62.--insertion of the bronchoscope. note direction of the trachea as indicated by the bronchoscope. note that the patient's head is held above the level of the table. the assistant's left hand should be at the patient's mouth holding the bite-block. this is removed and the assistant is on the wrong side of the table in the illustration in order not to hide the position of the operator's hands. note the handle of the bronchoscope is to the right.] [fig. 63.--the heavy laryngoscope has been removed leaving the light bronchoscope in position. the operator is inserting forceps. note how the left hand of the operator holds the tube lightly between the thumb and first two fingers of the left hand, while the last two fingers are hooked over the upper teeth of the patient "anchoring" the tube to prevent it moving in or out or otherwise changing the relation of the distal tube-mouth to a foreign body or a growth while forceps are being used. thus, also, any desired location of the tube can be maintained in systematic exploration. the assistant's left hand is dropped out of the way to show the operator's method. the assistant during bronchoscopy holds the bite-block like a thimble on the index finger of the left hand, and the assistant should be on the right side of the patient. he is here put wrongly on the left side so as not to hide the instruments and the manner of holding them.] _examination of the trachea and bronchi_.--all bronchial orifices must be identified _seriatim_; because this is the only way by which the bronchoscopist can know what part of the tree he is examining. appearances alone are not enough. it is the order in which they are exposed that enables the inexperienced operator to know the orifices. after the removal of the laryngoscope, the bronchoscope is to be held by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooking over the upper teeth, while the thumb and index finger hold the bronchoscope, clamping it to the teeth tightly or loosely as required (fig. 63). thus the tube may be anchored in any position, or at any depth, and the right hand which was directing the tube may be used for the manipulation of instruments. the grasp of the bronchoscope in the right hand should be similar to that of holding a pen, that is, the thumb, first, and second fingers, encircle the shaft of the tube. the bronchoscope should never be held by the handle (fig. 64) for this grasp does not allow of tactile sense transmission, is rigid, awkward, and renders rotation of the tube a wrist motion instead of but a gentle finger action. any secretion in the trachea is to be removed by sponge pumping before the bronchoscope is advanced. the inspection of the walls of the trachea is accomplished by weaving from side to side and, if necessary, up and down; the head being deflected as required during the search of the passages, so that the larynx be not made the fulcrum in the lever-like action. [fig. 64.--at a is shown an incorrect manner of holding the bronchoscope. the grasp is too rigid and the position of the hand is awkward. b, correct manner, the collar being held lightly between the finger and the thumb the thumb must not occlude the tube mouth.] _the fulcrum of the bronchoscopic lever is at the upper thoracic aperture; never at the larynx_.--disregard of this rule will cause subglottic edema and will limit the lateral motion of the tip of the bronchoscope. it is the function of the assistant to make the head and neck follow the direction of the proximal end of the bronchoscope and thus avoid any pressure on the larynx (see peroral endoscopy, fig. 135, p. 164). in passing down the trachea the following two rules must be kept in mind: 1. before attempting to enter either main bronchus the carina must be identified. 2. before entering either main bronchus the orifices of both should be identified and inspected. _the carina_ is identified as a sharp vertical spur (recumbent patient) at the distal end of the trachea, on either side of which are the openings of the main bronchi. as the carina is situated to the left of the midline of the trachea, the lip of the bronchoscope should be turned toward the left, and slight lateral pressure should be made on the left tracheal wall while the head of the patient is held slightly to the right. this will expose the left bronchial orifice and carina. _entering the bronchi_.--the lip of the bronchoscope should be turned in the direction of the bronchus to be explored, and the axis of the bronchoscope should be made to correspond as nearly as possible to the axis of this bronchus. the position of the lip is designated by the direction taken by the handle. upon entering the right bronchus, the handle of the bronchoscope is turned horizontally to the right, and at the same time the assistant deflects the head to the left. _the right upper-lobe bronchus_ is recognized by its vertical spur; the orifice is exposed by displacing the right lateral wall of the right main bronchus at the level of the carina. usually this orifice will be thus brought into view. if not the bronchoscope may be advanced downward 1 or 2 cm., carefully to avoid overriding. this branch is sometimes found coming off the trachea itself, and even if it does not, the overriding of the orifice is certain if the right bronchus is entered before search is made for the upper-lobe-bronchial orifice. the head must be moved strongly to the left in order to view the orifice. a lumen image of the right upper-lobe bronchus is not obtainable because of the sharp angles at which it is given off. _the left upper-lobe bronchus_ is entered by keeping the handle of the bronchoscope (and consequently the lip) to the left, and, by keeping the head of the patient strongly to the right as the bronchoscopist goes down the left main bronchus. this causes the lip of the bronchoscope to bear strongly on the left wall of the left main bronchus, consequently the left upper-lobe-bronchial orifice will not be overridden. the spur separating the upper-lobe-bronchial orifice from the stem bronchus is at an angle approximately from two to eight o'clock, as usually seen in the recumbent patient. a lumen image of a descending branch of the upper-lobe bronchus is often obtained, if the patient's head be borne strongly enough to the right. [fig. 65.--schema illustrating the entering of the anteriorly branching middle lobe bronchus. t, trachea; b, orifice of left main bronchus at bifurcation of trachea. the bronchoscope, s, is in the right main bronchus, pointing in the direction of the right inferior lobe bronchus, i. in order to cause the lip to enter the middle lobe bronchus, m, it is necessary to drop the head so that the bronchoscope in the trachea tt, will point properly to enable the lip of the tube mouth to enter the middle lobe bronchus, as it is seen to have done at ml.] branches of the stem bronchus in either lung are exposed, or their respective lumina presented, by manipulation of the lip of the bronchoscope, with movement of the head in the required direction. posterior branches require the head quite high. a large one in the left stem just below the left upper-lobe bronchus is often invaded by foreign bodies. anterior branches require lowering the head. the _middle-lobe bronchus_ is the largest of all anterior branches. its almost horizontal spur is brought into view by directing the lip of the bronchoscope upward, and dropping the head of the patient until the lip bears strongly on the anterior wall of the right bronchus (see fig. 65). [106] chapter x--introduction of the esophagoscope the esophagoscope is to be passed only with ocular guidance, never blindly with a mandrin or obturator, as was done before the bevel-ended esophagoscope was developed. blind introduction of the esophagoscope is equally as dangerous as blind bouginage. it is almost certain to cause over-riding of foreign bodies and disease. in either condition perforation of the esophagus is possible by pushing a sharp foreign body through the normal wall or by penetrating a wall weakened by disease. landmarks must be identified as reached, in order to know the locality reached. the secretions present form sufficient lubrication for the instrument. a clear conception of the endoscopic anatomy, the narrowings, direction, and changes of direction of the axis of the esophagus, are necessary. the services of a trained assistant to place the head in the proper sequential "high-low" positions are indispensible (figs. 52 and 70). introduction may be divided into four stages. 1. entering the right pyriform sinus. 2. passing the cricopharyngeus. 3. passing through the thoracic esophagus. 4. passing through the hiatus. the patient is placed in the boyce position as described in chapter vi. as previously stated, the esophagus in its upper portion follows the curves of the cervical and dorsal spine. it is necessary, therefore, to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head--the "high" position (figs. 66-71). [plate iii--esophagoscopic views from oil-color drawings from life, by the author: 1, direct view of the larynx and laryngopharynx in the dorsally recumbent patient, the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum. the spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands. posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition. the esophagoscope should be passed to the right of the median line into the right pyriform sinus, represented here by the right arm of the dark crescent. 2, the right pyriform sinus in the dorsally recumbent patient, the eminence at the upper left border, corresponds to the edge of the cricoid cartilage. 3, the cricopharyngeal constriction of the esophagus in the dorsally recumbent patient, the cricoid cartilage being lifted forward with the esophageal speculum. the lower (posterior) half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall. (compare fig. 10.) this view is not obtained with an esophagoscope. 4, passing through the right pyriform sinus with the esophagoscope; dorsally recumbent patient. the walls seem in tight apposition, and, at the edges of the slit-like lumen, bulge toward the observer. the direction of the axis of the slit varies, and in some instances it is like a rosette, depending on the degree of spasm. 5, cervical esophagus. the lumen is not so patulent during inspiration as lower down; and it closes completely during expiration. 6, thoracic esophagus; dorsally recumbent patient. the ridge crossing above the lumen corresponds to the left bronchus. it is seldom so prominent as in this patient, but can always be found if searched for. 7, the normal esophagus at the hiatus. this is often mistaken for the cardia by esophagoscopists. it is more truly a sphincter than the cardia itself. in the author's opinion there is no truly sphincteric action at the cardia. it is the failure of this hiatal sphincter to open as in the normal deglutitory cycle that produces the syndrome called "cardiospasm." 8, view in the stomach with the open-tube gastroscope. the form of the folds varies continually. 9, sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years. seen through the esophageal speculum, patient sitting. the lumen of the mouth of the esophagus, much encroached upon by the sarcomatous infiltration, is seen at the lower part of the circle. 10, coin (half-dollar) wedged in the upper third of the esophagus of a boy aged fourteen years. seen through the esophageal speculum, recumbent patient. forceps are retracting the posterior lip of the esophageal "mouth" preparatory to removal. 11, fungating squamous-celled epithelioma in a man of seventy-four years. fungations are not always present, and are often pale and edematous. 12, cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years. below tile upper stricture is seen a second stricture. an ulcer surrounded by an inflammatory areola and the granulation tissue together illustrates the etiology of cicatricial tissue. the fan-shaped scar is really almost linear, but it is viewed in perspective. patient was cured by esophagoscopic dilatation. 13, angioma of the esophagus in a man of forty years. the patient had hemorrhoids and varicose veins of the legs. 14, luetic ulcer of the esophagus 26 cm. from the upper teeth in a woman of thirty-eight years. two scars from healed ulcerations are seen in perspective on the anterior wall. branching vessels are seen in the livid areola of the ulcers. 15, tuberculosis of the esophagus in a man of thirty-four years. 16, leukoplakia of the esophagus near the hiatus in a man aged fifty-six years.] the hypopharynx tapers down to the gullet like a funnel, and the larynx is suspended in its lumen from the anterior wall. the larynx is attached only to the anterior wall, but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx, and particularly by its specialized portion--the cricopharyngeus muscle. a bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses, the recesses seen on either side of the larynx. but little of the food bolus passes posterior to the larynx during the act of swallowing. it is through the pyriform sinus that the esophagoscope is to be inserted, thereby following the natural food passage. to insert the esophagoscope in the midline, posterior to the arytenoids, requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall, or to both. the esophagoscope is steadied by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooked over the upper teeth, while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth. the right hand holds the tube in pen fashion at the collar of the handle, not by the handle. during introduction the handle is to be pointed upward toward the zenith. _stage i. entering the right pyriform sinus_.--the operator standing (as in fig. 66), inserts the esophagoscope along the right side of the tongue as far as and down the posterior pharyngeal wall. a lifting motion imparted to the tip of the esophagoscope by the left thumb will bring the rounded right arytenoid eminence into view (a, fig. 69). this is the landmark of the pyriform sinus, and care must be taken to avoid injury by hooking the tube mouth over it or its fellow. the tip of the tube should now be directed somewhat toward the midline, remembering the funnel shape of the hypopharynx. it will then be found to glide readily through the right pyriform sinus for 2 or 3 cm., when it comes to a full stop, and the lumen disappears. this is the spasmodically closed cricopharyngeal constriction. [fig. 66.--esophagoscopy by the author's "high-low" method. first stage. "high" position. finding the right pyriform sinus. in this and the second stage the patient's vertex is about 15 cm. above the level of the table.] _stage 2. passing the cricopharyngeus_ is the most difficult part of esophagoscopy, especially if the patient is unanesthetized. local anesthesia helps little, if at all. the handle of the esophagoscope is still pointing upward and consequently we are sure that the lip of the esophagoscope is directed anteriorly. force must not be used, but steady firm pressure against the tonically contracted cricopharyngeus is made, while at the same time the distal end of the esophagoscope is lifted by the left thumb. at the first inspiration a lumen will usually appear in the upper portion of the endoscopic field. the tip of the esophagoscope enters this lumen and the slanted end slides over the fold of the cricopharyngeus into the cervical esophagus. there is usually from 1 to 3 cm. of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers. [109] [fig. 67.--schematic illustration of the author's "high-low" method of esophagoscopy. in the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus, as shown above. the rose position is shown by way of accentuation.] [fig. 68.--schematic illustration of the anatomic basis for difficulty in introduction of the esophagoscope. the cricoid cartilage is pulled backward against the cervical spine, by the cricopharyngeus, so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe.] [fig. 69.--the upper illustration shows movements necessary for passing the cricopharyngeus. the lower illustration shows schematically the method of finding the pyriform sinus in the author's method of esophagoscopy. the large circle represents the cricoid cartilage. g, glottic chink, spasmodically closed; vb, ventricular band; a, right arytenoid eminence; p, right pyriform sinus, through which the tube is passed in the recumbent posture. the pyriform sinuses are the normal food passages.] _stage 3. passing through the thoracic esophagus_.--the thoracic esophagus will be seen to expand during inspiration and contract during expiration, due to the change in thoracic pressure. the esophagoscope usually glides easily through the thoracic esophagus if the patient's position is correct. after the levels of the aorta and left bronchus are passed the lumen of the esophagus seems to have a tendency to disappear anteriorly. the lumen must be kept in axial view and the head lowered as required for this purpose. _stage 4. passing through the hiatus esophageus_.--when the head is dropped, it must at the same time be moved horizontally to the right in order that the axis of the tube shall correspond to the axis of the lower third of the esophagus, which deviates to the left and turns anteriorly. the head and shoulders at this time will be found to be considerably below the plane of the table top (fig. 71). the hiatal constriction may assume the form of a slit or rosette. if the rosette or slit cannot be promptly found, as may be the case in various degrees of diffuse dilatation, the tube mouth must be shifted farther to the left and anteriorly. when the tube mouth is centered over the hiatal constriction moderately firm pressure continued for a short time will cause it to yield. then the tube, maintaining this same direction will, without further trouble glide into and through the abdominal esophagus. the cardia will not be noticed as a constriction, but its appearance will be announced by the rolling in of reddish gastric mucosal folds, and by a gush of fluid from the stomach. [fig. 70.--schematic illustration of the author's "high-low" method of esophagoscopy, fourth stage. passing the hiatus. the head is dropped from the position of the 1st and 2nd stages, cl, to the position t, and at the same time the head and shoulders are moved to the right (without rotation) which gives the necessary direction for passing the hiatus.] [fig. 71.--esophagoscopy by the author's "high-low" method. stage 4. passing the hiatus the patient's vertex is about 5 cm. below the top of the table.] _normal esophageal mucosa_ under proper illumination is glistening and of a yellowish or bluish pink. the folds are soft and velvety, rendering infiltration quickly noticeable. the cricoid cartilage shows white through the mucosa. the gastric mucosa is a darker pink than that of the esophagus and when actively secreting, its color in some cases tends toward crimson. _secretions_ in the esophagus are readily aspirated through the drainage canal by a negative pressure pump. food particles are best removed by "sponge pumping," or with forceps. should the drainage canal become obstructed positive pressure from the pump will clear the canal. _difficulties of esophagoscopy_.--the beginner may find the esophagoscope seemingly rigidly fixed, so that it can be neither introduced nor withdrawn. this usually results from a wedging of the tube in the dental angle, and is overcome by a wider opening of the jaws, or perhaps by easing up of the bite block, but most often by correcting the position of the patient's head. if the beginner cannot start the tube into the pyriform sinus in an adult, it is a good plan to expose the arytenoid eminence with the laryngoscope and then to insert the 7 mm. esophagoscope into the right pyriform sinus by direct vision. passing the cricopharyngeal and hiatal spasmodically contracted narrowings will prove the most trying part of esophagoscopy; but with the head properly held, and the tube properly placed and directed, patient waiting for relaxation of the spasm with gentle continuous pressure will usually expose the lumen ahead. in his first few esophagoscopies the novice had best use general anesthesia to avoid these difficulties and to accustom himself to the esophageal image. in the first favorable subject--an emaciated individual with no teeth--esophagoscopy without anesthesia should be tried. in cases of kyphosis it is a mistake to try to straighten the spine. the head should be held correspondingly higher at the beginning, and should be very slowly and cautiously lowered. once inserted, the esophagoscope should not be removed until the completion of the procedure, unless respiratory arrest demands it. occasionally in stenotic conditions the light may become covered by the upwelling of a flood of fluid, and it will be thought the light has gone out. as soon as the fluid has been aspirated the light will be found burning as brightly as before. if a lamp should fail it is unnecessary to remove the tube, as the light carrier and light can be withdrawn and quickly adjusted. a complete instrument equipment with proper selection of instruments for the particular case are necessary for smooth working. _ballooning esophagoscopy_.--by inserting the window plug shown in fig. 6 the esophagus may be inflated and studied in the distended state. the folds are thus smoothed out and constrictions rendered more marked. ether anesthesia is advocated by mosher. the danger of respiratory arrest from pressure, should the patient be dyspneic, is always present unless the anesthetic be given by the intratracheal method. if necessary to use forceps the window cap is removed. if the perforated rubber diaphragm cap be substituted the esophagus can be reballooned, but work is no longer ocularly guided. the fluoroscope may be used but is so misleading as to render perforation and false passage likely. _specular esophagoscopy_.--inspection of the hypopharynx and upper esophagus is readily made with the esophageal speculum shown in fig. 4. high lesions and foreign bodies lodged behind the larynx are thus discovered with ease, and such a condition as a retropharyngeal abscess which has burrowed downward is much less apt to be overlooked than with the esophagoscope. high strictures of the esophagus may be exposed and treated by direct visual bouginage until the lumen is sufficiently dilated to allow the passage of the esophagoscope for bouginage of the deeper strictures. _technic of specular esophagoscopy_.--recumbent patient. boyce position. the larynx is to be exposed as in direct laryngoscopy, the right pyriform sinus identified, the tip of the speculum inserted therein, and gently insinuated to the cricopharyngeal constriction. too great extension of the head is to be avoided--even slight flexion at the occipito-atloid joint may be found useful at times. moderate anterior or upward traction pulls the cricoid away from the posterior pharyngeal wall and the lumen of the esophagus opens above a crescentic fold (the cricopharyngeus). the speculum readily slides over this fold and enters the cervical esophagus. in searching for foreign bodies in the esophagus the speculum has the disadvantage of limited length, so that should the foreign body move downward it could not be followed. _complications following esophagoscopy_.--these are to be avoided in large measure by the exercise of gentleness, care, and skill that are acquired by practice. if the instructions herein given are followed, esophagoscopy is absolutely without mortality apart from the conditions for which it is done. injury to the crico-arytenoid joint may simulate recurrent paralysis. posticus paralysis may occur from recurrent or vagal pressure by a misdirected esophagoscope. these conditions usually recover but may persist. perforation of the esophageal wall may cause death from septic mediastinitis. the pleura may be entered,--pyopneumothorax will result and demand immediate thoracotomy and gastrostomy. aneurysm of the aorta may be ruptured. patients with tuberculosis, decompensating cardiovascular lesions, or other advanced organic disease, may have serious complications precipitated by esophagoscopy. _retrograde esophagoscopy_.--the first step is to get rid of the gastric secretions. there is always fluid in the stomach, and this keeps pouring out of the tube in a steady stream. fold after fold is emptied of fluid. once the stomach is empty, the search begins for the cardial opening. the best landmark is a mark with a dermal pencil on the skin at a point corresponding to the level of the hiatus esophageus. when it is desired to do a retrograde esophagoscopy and the gastrostomy is done for this special purpose, it is wise to have it very high. once the cardia is located and the esophagus entered, the remainder of the work is very easy. bouginage can be carried out from below the same as from above and may be of advantage in some cases. strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time. at retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia. the esophagoscope encounters only the diaphragmatic pinchcock which seems to be at the top of the stomach like the puckering string at the top of a bag. retrograde esophagoscopy is sometimes useful for "stringing" the esophagus in cases in which the patient is unable to swallow a string because he is too young or because of an epithelial scaling over of the upper entrance of the stricture. in such cases the smallest size of the author's filiform bougies (fig. 40) is inserted through the retrograde esophagoscope (fig. 43) and insinuated upward through the stricture. when the tip reaches the pharynx coughing, choking and gagging are noticed. the filiform end is brought out the mouth sufficiently far to attach a silk braided cord which is then pulled down and out of the gastrostomic opening. the braided silk "string" must be long enough so that the oral and the abdominal ends can be tied together to make it "endless;" but before doing so the oral end should be drawn through nose where it will be less annoying than in the mouth. the purpose of the "string" is to pull up the retrograde bougies (fig. 35) [117] chapter xi--acquiring skill endoscopic ability cannot be bought with the instruments. as with all mechanical procedures, facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers. as with learning to play a musical instrument, a fundamental knowledge of technic, positions, and landmarks is necessary, after which only continued manual practice makes for proficiency. for instance, efficient use of forceps requires that they be so familiar to the grasp that their use is automatic. endoscopy is a purely manual procedure, hence to know how is not enough: manual practice is necessary. even in the handling of the electrical equipment, practice in quickly locating trouble is as essential as theoretic knowledge. there is no mystery about electric lighting. no source of illumination other than electricity is possible for endoscopy. therefore a small amount of electrical knowledge, rendered practical by practice, is essential to maintain the simple lighting system in working order. it is an insult to the intelligence of the physician to say that he cannot master a simple problem of electric testing involving the locating of one or more of five possibilities. it is simply a matter of memorizing five tests. it is repeated for emphasis that a commercial current reduced by means of a rheostat should never be used as a source of current for endoscopy with any kind of instrument, because of the danger to the patient of a possible "grounding" of the circuit during the extensive moist contact of a metallic endoscopic tube in the mediastinum. the battery shown in fig. 8 should be used. the most frequent cause of trouble is the mistake of over-illuminating the lamps. _the lamp should not be over-illuminated to the dazzling whiteness usually used in flash lights_. excessive illumination alters the proper perception of the coloring of the mucosa, besides shortening the life of the lamps. the proper degree of brightness is obtained when, as the current is increased, the first change from yellow to white light is obtained. never turn up the rheostat without watching the lamp. _testing for electric defects_.--these tests should be made beforehand; not when about to commence introduction. if the first lamp lights up properly, use it with its light-carrier to test out the other cords. if the lamp lights up, but flickers, locate the trouble before attempting to do an endoscopy. if shaking the carrier cord-terminal produces flickering there may be a film of corrosion on the central contact of the light carrier that goes into the carrier cord-terminal. if the lamp fails to show a light, the trouble may be in one of five places which should be tested for in the following order and manner. 1. the lamp may not be firmly screwed into the light-carrier. withdraw the light-carrier and try screwing it in, though not too strongly, lest the central wire terminal in the lamp be bent over. 2. the light-carrier may be defective. 3. the cord may be defective or its terminals not tight in the binding posts. if screwing down the thumb nuts does not produce a light, test the light-carrier with lamp on the other cords. reserve cords in each pair of binding posts are for use instead of the defective cords. the two sets of cords from one pair of binding posts should not be used simultaneously. 4. the lamp may be defective. try another lamp. 5. the battery may be defective. take a cord and light-carrier with lamp that lights up, detaching the cord-terminals at the binding posts, and attach the terminals to the binding posts of the battery to be tested. _efficient use of forceps_ requires previous practice in handling of the forceps until it has become as natural and free from thought as the use of knife and fork. indeed the coordinate use of the bronchoscopic tube-mouth and the forceps very much resembles the use of knife and fork. yet only too often a practitioner will telegraph for a bronchoscope and forceps, and without any practice start in to remove an entangled or impacted foreign body from the tiny bronchi of a child. failure and mortality are almost inevitable. a few hundred hours spent in working out, on a bit of rubber tubing, the various mechanical problems given in the section on that subject will save lives and render easily successful many removals that would otherwise be impossible. it is often difficult for the beginner to judge the distance the forceps have been inserted into the tube. this difficulty is readily solved if upon inserting the forceps slowly into the tube, he observes that as the blades pass the light they become brightly illuminated. by this _light reflex_ it is known, therefore, that the forceps blades are at the tube-mouth, and distance from this point can be readily gauged. excellent practice may be had by picking up through the bronchoscope or esophagoscope black threads from a white background, then white threads from a black background, and finally white threads on a white background and black threads on a black background. this should be done first with the 9 mm. bronchoscope. it is to be remembered that the majority of foreign body accidents occur in children, with whom small tubes must be used; therefore, practice work, after say the first 100 hours, should be done with the 5 mm. bronchoscope and corresponding forceps rather than adult size tubes, so that the operator will be accustomed to work through a small calibre tube when the actual case presents itself. [120] _cadaver practice_.--the fundamental principles of peroral endoscopy are best taught on the cadaver. it is necessary that a specially prepared subject be had, in order to obtain the required degree of flexibility. injecting fluid of the following formula worked out by prof. j. parsons schaeffer for the bronchoscopic clinic courses, has proved very satisfactory: sodium carbonate--1 1/2 lbs. white arsenic--2 1/2 lbs. potassium nitrate--3 lbs. water--5 gal. boil until arsenic is dissolved. when cold add: carbolic acid 1500 c.c. glycerin 1250 c.c. alcohol (95%) 1250 c.c. for each body use about 3 gal. of fluid. the method of introduction of the endoscopic tube, and its various positions can be demonstrated and repeatedly practiced on the cadaver until a perfected technic is developed in both the operator and assistant who holds the head, and the one who passes the instruments to the operator. in no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically, and in no other way can the pupil be taught to avoid killing his patient. the danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality. laryngeal growths may be simulated, foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected. _practice on the rubber-tube manikin_.--this must be carried out in two ways. 1. general practice with all sorts of objects for the education of the eye and the fingers. 2. before undertaking a foreign body case, practice should be had with a duplicate of the foreign body. it is not possible to have a cadaver for daily practice, but fortunately the eye and fingers may be trained quite as effectually by simulating foreign body conditions in a small red rubber tube and solving these mechanical problems with the bronchoscope and forceps. the tubing may be placed on the desk and held by a small vise (fig. 72) so that at odd moments during the day or evening the fascinating work may be picked up and put aside without loss of time. complicated rubber manikins are of no value in the practice of introduction, and foreign body problems can be equally well studied in a piece of rubber tubing about 10 inches long. no endoscopist has enough practice on the living subject, because the cases are too infrequent and furthermore the tube is inserted for too short a space of time. practice on the rubber tube trains the eye to recognize objects and to gauge distance; it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired. before attempting the removal of a particular foreign body from a living patient, the anticipated problem should be simulated with a duplicate of the foreign body in a rubber tube. in this way the endoscopist may precede each case with a practical experience equivalent to any number of cases of precisely the same kind of foreign body. if the object cannot be removed from the rubber tube without violence, it is obvious that no attempt should be made on the patient until further practice has shown a definite method of harmless removal. during practice work the value of the beveled lip of the bronchoscope and esophagoscope in solving mechanical problems will be evidenced. with it alone, a foreign body may be turned into favorable positions for extraction, and folds can always be held out of the way. sufficient combined practice with the bronchoscope and the forceps enable the endoscopist easily to do things that at first seem impossible. it is to be remembered that lateral motion of the long slender tube-forceps cannot be controlled accurately by the handle, this is obtained by a change in position of the endoscopic tube, the object being so centered that it is grasped without side motion of the forceps. when necessary, the distal end of the forceps may be pushed laterally by the manipulation of the bronchoscope. [fig. 72.--a simple manikin. the weight of the small vise serves to steady the rubber tubing. by the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body, any mechanical problem can he simulated for solution or for practice, study of all possible presentations, etc.] _practice on the dog_.--having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube, experience should be had in the living lower air and food passages with their pulsatory, respiratory, bechic and deglutitory movements, and ever-present secretions. it is not only inhuman but impossible to obtain this experience on children. fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice. a small dog the size of a terrier (say 6 to 10 pounds in weight) should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight, given about 45 minutes before the time of practice. dogs stand large doses of morphin without apparent ill effect, so that repeated injection may be given in smaller dosage until the desired degree of relaxation results. the first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy. vomiting is soon followed by relaxation and stupor. the dog is normal and hungry in a few hours. dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal. other forms of anesthesia have been tried in my teaching, and none has proven so safe and satisfactory. phonation may be prevented during esophagoscopy by preventing approximation of the cords, through inserting a silk-woven cathether in the trachea. the larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy. a very comfortable and safe mouth gag is shown in fig. 73. great gentleness should be exercised, and no force should be used, for none is required in endoscopic work; and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child. he should remember he is not learning how to do endoscopy on the dog; but learning on the dog how safely to do bronchoscopy on a human being. the degree of resistance during introduction can be gauged and the color of the mucosa studied, while that interesting phenomenon, the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration, is readily observed and always forms subject for thought in its possible connection with pathological conditions. foreign body problems are now to be solved under these living conditions, and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least 100 foreign bodies from the dog without harming the animal. dogs have the faculty of easily ridding their air-passages of foreign objects, so that one need not be alarmed if a foreign body is lost during practice removal. it is to be remembered that dogs swallow very large objects with apparent ease. the dog's esophagus is relatively much larger than that of human beings. therefore a small dog (of six to eight pounds' weight) must be used for esophagoscopic practice, if practice is to be had with objects of the size usually encountered in human beings. the bronchi of a dog of this weight will be about the size of those of a child. [fig. 73.--author's mouth gag for use on the dog. the thumb-nut serves to prevent an uncomfortable degree of expansion of the gag. a bandage may be wound around the dog's jaws to prevent undue spread of the jaws.] _endoscopy on the human being_.--dog work offers but little practice in laryngoscopy. because of the slight angle at which the dog's head joins his spine, the larynx is in a direct line with the open mouth; hence little displacement of the anterior cervical tissues is necessary. moreover the interior of the larynx of the dog is quite different from that of the human larynx. the technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as, for instance, tonsillectomy, to see that the larynx and laryngopharynx are free of clots. to perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible; but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications.* diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases. no anesthesia, general or local, is required. much clinical material is neglected. all cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means. invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage. * dr. william frederick moore, of the bronchoscopic clinic, has recently collected statistics of 202 cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism (moore, w. f., pulmonary abscess. journ. am. med. assn., april 29, 1922, vol. 78, pp. 1279-1281). in acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought. aphorisms educate your eye and your fingers. be sure you are right, but not too sure. follow your judgment, never your impulse. cry over spilled milk enough to memorize how you spilled it. let your mistakes worry you enough to prevent repetition. let your left hand know what your right hand does and how to do it. nature helps, but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria. [126] chapter xii--foreign bodies in the air and food passages the air and food passages may be invaded by any foreign substance of solid, liquid or gaseous nature, from the animal, vegetable, or mineral kingdoms. its origin may be from within the body (blood, pus, secretion, broncholiths, sequestra, worms); introduced from without by way of the natural passages (aspirated or swallowed objects); or it may enter by penetration (bullet, dart, drainage tube from the neck). _prophylaxis_.--if one put into his mouth nothing but food, foreign body accidents would be rare. the habit of holding tacks, pins and whatnot in the mouth is quite universal and deplorable. children are prone to follow the bad example of their elders. no small objects such as safety pins, buttons, and coins should be left within a baby's reach; children should be watched and taught not to place things in their mouths. mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect, because the molar teeth are not erupted. it might be made a dictum that: "no child under 3 years of age should be allowed to eat nuts, unless ground finely as in peanut butter." digital efforts at removal of foreign bodies frequently force the object downward, or may hook it forward into the larynx, whereas if not meddled with digitally the intruder might be spat out. before general anesthesia the mouth should be searched for loose teeth, removable dentures, etc., and all unconscious individuals should be likewise examined. when working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments. [126] objects that have lodged in the esophagus, larynx, trachea, or bronchi should be endoscopically removed. _foreign bodies in the insane_.--foreign bodies may be introduced voluntarily and in great numbers by the insane. hysterical individuals may assert the presence of a foreign body, or may even volitionally swallow or aspirate objects. it is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence. such "cures" are ephemeral. _foreign bodies in the stomach_.--gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two. foreign bodies in very large numbers in the stomach, as in the insane, may be removed by gastrostomy. _the symptomatology of foreign bodies_ may be epitomized as given below; but it must be kept in mind, that certain symptoms may not be manifest immediately after intrusion, and others may persist for a time after the passage, removal, or expulsion of a foreign body. esophageal foreign body symptoms 1. there are no absolutely diagnostic symptoms. 2. dysphagia, however, is the most constant complaint, varying with the size of the foreign body, and the degree of inflammatory or spasmodic reaction produced. 3. pain may be caused by penetration of a sharp foreign body, by inflammation secondary thereto, by impaction of a large object, or by spasmodic closure of the hiatus esophageus. 4. the subjective sensation of foreign body is usually present, but cannot be relied upon as assuring the presence of a foreign body for this sensation often remains for a time after the passage onward of the intruder. 5. all of these symptoms may exist, often in the most intense degree, as the result of previous violent attempts at removal; and the foreign body may or may not be present. symptoms of laryngeal foreign body 1. initial laryngeal spasm followed by wheezing respiration, croupy cough, and varying degrees of impairment of phonation. 2. pain may be a symptom. if so, it is usually located in the laryngeal region, though in some cases it is referred to the ears. 3. the larynx may tolerate a thin, flat, foreign body for a relatively long period of time, a month or more; but the development of increasing dyspnea renders early removal imperative in the majority of cases. symptoms of tracheal and bronchial foreign body 1. tracheal foreign bodies are usually movable and their movements can usually be felt by the patient. 2. cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. in recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing. 3. sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body. 4. dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder. 5. dyspnea is usually absent in bronchial foreign bodies. 6. the respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive. 7. the asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. it is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it. 8. pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body. early symptoms of irritating foreign body such as a peanut kernel in the bronchus 1. initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. 2. a diffuse purulent laryngo-tracheo-bronchitis develops within 24 hours in children under 2 years. 3. fever, toxemia, cyanosis, dyspnea and paroxysmal cough are promptly shown. 4. the child is unable to cough up the thick mucilaginous pus through the swollen larynx and may "drown in its own secretions" unless the offender be removed. 5. "drowned lung," that is to say natural passages idled with pus and secretions, rapidly forms. 6. pulmonary abscess develops sooner than in case of mineral foreign bodies. 7. the older the child the less severe the reaction. symptoms of prolonged foreign body sojourn in the bronchus 1. the time of inhalation of a foreign body may be unknown or forgotten. 2. cough and purulent expectoration ultimately result, although there may be a delusive protracted symptomless interval. [130] 3. periodic attacks of fever, with chills and sweats, and followed by increased coughing and the expulsion of a large amount of purulent, usually more or less foul material, are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care. 4. emaciation, clubbing of the fingers and toes, night sweats, hemoptysis, in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude, even to the gain in weight by an out-door regime. 5. tubercle bacilli have never been found, in the cases at the bronchoscopic clinic, associated with foreign body in the bronchus.* in cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis. one point of difference was the almost invariably rapid recovery after removal of the foreign body. the statement in all of the text-books, that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown, hence the foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused with the true pulmonary tuberculosis of bacillary origin. 6. the subjective sensation of pain may allow the patient accurately to localize a foreign body. 7. foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum. 8. offensive odored sputum should always suggest bronchial foreign body; but absence of sputum, odorous or not, should not exclude foreign body. 9. sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating. [131] 10. complete obstruction of a bronchus is followed by rapid onset of symptoms. 11. the physical signs usually show limitation of expansion on the affected side, impairment of percussion, and lessened trans-mission or absence of breath-sounds distal to the foreign body. * the exceptional case has at last been encountered. a boy with a tack in the bronchus was found to have pulmonary tuberculosis. symptoms of gastric foreign body foreign body in the stomach ordinarily produces no symptoms. the roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis. diagnosis of foreign body in the air or food passages the questions arising are: i. is a foreign body present? 2. where is it located? 3. is a peroral endoscopic procedure indicated? 4. are there any contraindications to endoscopy? in order to answer these questions the definite routine given below is followed unvaryingly in the bronchoscopic clinic. 1. history. 2. complete physical examination, including mirror laryngoscopy. 3. roentgenologic study. 4. endoscopy. the history should note the date of, and should delve into the details of the accident; special note being made of the occurrence of laryngeal spasm, wheezing respiration heard by the patient or others (asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia, odynphagia, regurgitation, etc. the amount, character and odor of sputum are important. increasing amounts of purulent, foul-odored, sometimes blood-tinged sputum strongly suggest prolonged bronchial foreign body sojourn. the mode of onset of the persisting symptoms, whether immediately following the supposed accident or delayed in their occurrence, is to be noted. do attacks of sudden dyspnea and cyanosis occur? what has been the previous treatment and what attempts at removal have been made? the nature of the foreign body is to be determined, and if possible a duplicate thereof obtained. _general physical examination_ should be complete including inspection of the eyes, ears, nose, pharynx, and mirror inspection of the naso-pharynx and larynx. special attention is paid to the chest for the localization of the object. in order to discover conditions rendering endoscopy unusually hazardous, all parts of the body are to be examined. aneurysm of the aorta, excessive blood pressure, serious cardiac and renal conditions, the presence of a hernia and the existence of central nervous disease, as tabes dorsalis, should be at least known before attempting any endoscopic procedure. dysphagia might result from the pressure of an unknown aneurysm, the symptoms being attributed to a foreign body, and aortic aneurysm is a definite contraindication to esophagoscopy unless there be foreign body present also. there is no absolute contraindication to the endoscopic removal of a foreign body, though many conditions may render it wise to post-pone endoscopy. laryngeal crises of tabes might, because of their sudden onset, be thought due to foreign body. physical signs in esophageal foreign body there are no constant physical signs associated with uncomplicated impaction of a foreign body in the esophagus. should perforation of the cervical esophagus occur, subcutaneous emphysema, and perhaps cellulitis, may be found; while a perforation of the thoracic region causing mediastinitis is manifested by toxemia, fever, and rapid sinking. perforation of the pleura, with the development of pyopneumothorax, is manifested by the usual signs. it is to be emphasized that blind bouginage has no place in the diagnosis of any esophageal condition. the roentgenologist will give the information we desire without danger to the patient, and with far greater accuracy. foreign bodies in the larynx laryngeally lodged foreign bodies produce a wheezing respiration, the quality of which is peculiar to the larynx and is readily localized to this organ. if swelling or the size of the foreign body be sufficient to produce dyspnea, inspiratory indrawing of the suprasternal notch, supraclavicular fossae, costal interspaces and lower sternum will be present. cyanosis is only an accompaniment of suddenly produced dyspnea; the facies will therefore usually be anxious and pale, unless the patient is seen immediately after the aspiration of the foreign body. if labored breathing has been prolonged, and exhaustion threatened, the heart's action will be irregular and weak. the foreign body can be seen with the mirror, but a roentgenograph must nevertheless be made, for the object may be of another nature than was first thought. the roentgenograph will show its position, and from this knowledge the plan of removal can be formulated. for example, a straight pin may be so placed in the larynx that only a portion of its shaft will be visible, the roentgenogram will tell where the head and point are located, and which of these will be the more readily disengaged. (see chapter on mechanical problems.) physical signs of tracheal foreign body if fixed in the trachea the only objective sign of foreign body may be a wheezing respiration, the site of which may be localized with the stethoscope, by the intensity of the sound. movable foreign bodies may produce a palpatory thrill, and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear. the lungs will show equal aeration, but there may be marked dyspnea without the indrawing of the fossae, if the object be of large size and located below the manubrium. to the peculiar sound of the sudden subglottic, expiratory or bechic arrest of the foreign body the author has given the name "audible slap;" when felt by the thumb on the trachea he calls it the "palpatory thud." these signs can be produced by no condition other than the arrest of some substance by the subglottic taper. once heard and felt they are unmistakable. physical signs of bronchial foreign body in most cases there will be limitation of expansion on the invaded side, even though the foreign body is of such a shape as to cause no bronchial obstruction. it has been noted frequently in conjunction with the presence of such objects as a common straight pin in a small branch bronchus. this peculiar phenomenon was first noted by thomas mccrae in one of the author's cases and has since been abundantly corroborated by mccrae and others as one of the most constant physical signs. to understand the peculiar physical findings in these cases it is necessary to remember that the bronchi are not tubes of constant caliber; there occurs a dilatation during inspiration, and a contraction of the lumen during expiration; furthermore, the lumen may be narrowed by swollen mucosa if the foreign body be of an irritant nature. the signs vary with the degree of obstruction of the bronchus, and with the consequent degree of interference with aeration and drainage of the subjacent portion of the lung. we have three definite types which show practically constant signs in the earlier stages of foreign body invasion. 1. complete bronchial occlusion. 2. obstruction complete during expiration, but allowing the passage of air during the bronchial dilatation incident to inspiration, constituting an expiratory valve-like obstruction. 3. partial bronchial obstruction, allowing to-and-fro passage of air. 1. _complete bronchial obstruction_ is manifested by limitation of expansion, markedly impaired percussion note, particularly at the base, absence of breath-sounds, and rales on the invaded side. an atelectasis here exists; the air imprisoned in the lung is soon absorbed, and secretions rapidly accumulate. on the free side a compensatory emphysema is present. 2. _expiratory valve-like obstruction_.--the obstructed side shows marked limitation of expansion. percussion is of a tympanitic character. the duration of the vibrations may be shortened giving a muffled tympany. various grades and degrees of tympany may be noted. breath sounds are markedly diminished or absent. no rales are heard on the invaded side, although rales of all types may be present on the free side. in some cases it is possible to hear a short inspiratory sound. vocal resonance and fremitus are but little altered. the heart will be found displaced somewhat to the opposite side. these signs are explained by the passage of some air past the foreign body during inspiration with its trapping during expiration, so that there is air under pressure constantly maintained in the obstructed area. this type of obstruction is most frequently observed when the foreign body is of an organic nature such as nut kernels, beans, corn, seed, etc. the localized swelling about the irritating foreign body completes the expiratory obstruction. it may also be present with any foreign body whose size and shape are such as to occlude the lumen of the bronchus during its contracted expiratory phase. it was present in cases of pebbles, cylindrical metallic objects, thick tough balls of secretion etcetera. the valvular action is here produced most often by a change in the size of the valve seat and not by a movement of the foreign body plug. in other cases i have found at bronchoscopy, a regular ball-valve mechanism. pneumothorax is the only pathologic condition associated with signs similar to those of expiratory, valve-like bronchial obstruction by a foreign body. 3. _partial bronchial obstruction_ by an object such as a nail allows air to pass to and fro with some degree of retardation, and impairs the drainage of the subjacent lung. limitation of expansion will be found on the invaded side. the area below the foreign body will give an impaired percussion note. breath-sounds are diminished in the area of dullness, and vocal resonance and fremitus are impaired. rales are of great diagnostic import; the passage of air past the foreign body is accompanied by blowing, harsh breathing, and snoring; snapping rales are heard usually with greatest intensity posteriorly over the site of the foreign body (usually about the scapular angle). a knowledge of the topographical lung anatomy, the bronchial tree, and of endoscopic pathology* should enable the examiner of the chest to locate very accurately a bronchial foreign body by physical signs alone, for all the significant signs occur distal to the foreign body lodgment. * jackson, chevalier. pathology of foreign bodies in the air and food passages. mutter lecture, 1918. surgery, gynecology and obstetrics, march, 1919. also, by the same author, mechanism of the physical signs of foreign bodies in the lungs. proceedings of the college of physicians, philadelphia, 1922. _the asthmatoid wheeze_ has been found by the author a valuable confirmatory sign of bronchial foreign body. it is a wheezing heard by placing the observer's ear at the open mouth of the patient (not at the chest wall) during a prolonged forced expiration. thomas mccrae elicits this sign by placing the stethoscope bell at the patient's open mouth. the quality of the sound is dryer than that heard in asthma and the wheeze is clearest after all secretion has been removed by coughing. the mechanism of production is, probably, the passage of air by a foreign body which narrows the lumen of a large bronchus. as the foreign body works downward the wheeze lessens. the wheeze is often so loud as to be heard at some distance from the patient. it is of greatest value in the diagnosis of non-roentgenopaque foreign body but its absence in no way negates foreign body. its presence or absence should be recorded in every case. _prolonged bronchial obstruction_ by foreign body is followed by bronchiectasis and lung abscess usually in a lower lobe. the symptoms may with exactitude simulate tuberculosis, but this disease should be readily excluded by the basal, unilateral site of the lesion, absence of tubercle bacilli in the sputum, and roentgenographic study. chest examination in the foreign body cases reveals limitation of expansion, often some retraction, flat percussion note, and greatly diminished or absent breath-sounds over the site of the pulmonary lesion. rales vary with the amount of secretion present. these physical signs suggest empyema; and rib resection had been done before admission in a number of cases only to find the pleura normal. roentgenray study in foreign body cases _roentgenography_.--all cases of chest disease should have the benefit of a roentgenologic study to exclude bronchial foreign body as an etiological factor. negative opinions should never be based upon any plates except the best that the wonderful modern development of the art and science of roentgenology can produce. in doubtful cases, the negative opinion should not be conclusive until a roentgenologist of long experience in chest work, and especially in foreign body cases, has been called in consultation. even then there will be an occasional case calling for diagnostic bronchoscopy. antero-posterior and lateral roentgenograms should always be made. in an antero-posterior film a flat foreign body lying in the lateral body plane might be invisible in the shadow of the spine, heart, and great vessels; but would be revealed in the lateral view because of the greater edgewise density of the intruder and the absence of other confusing shadows. fluoroscopic examination will often discover the best angle from which to make a plate; but foreign bodies casting a very faint shadow on a plate may be totally invisible on the fluoroscopic screen. the value of a roentgenogram after the removal of a foreign body cannot be too strongly emphasized. it is evidence of removal and will exclude the presence of a second intruder which might have been overlooked in the first study. fluoroscopic study of the swallowing function with barium mixture, or a barium-filled capsule, will give the location of a nonroentgenopaque object (such as bone, meat, etc.) in the esophagus. if a flat or disc-shaped object located in the cervical region is seen to be lying in the lateral body plane, it will be found to be in the esophagus, for it assumed that position by passing down flatwise behind the larynx. if, however, the object is seen to be in the sagittal plane it must lie in the trachea. this position was necessary for it to pass through the glottic chink, and can be maintained because of the yielding of the posterior membranous wall of the trachea. the roentgenographic signs of expiratory-valve-like bronchial obstruction the roentgenray signs in expiratory valve-like obstruction of a bronchus are those of _an acute obstructive emphysema_ (fig. 74), namely, 1. greater transparency on the obstructed side (iglauer). 2. displacement of the heart to the free side (iglauer). 3. depression and flattening of the dome of the diaphragm on the invaded side (iglauer). 4. limitation of the diaphragmatic excursion on the obstructed side (manges). it is very important to note that, as discovered by manges, the differential emphysema occurs at the end of expiration and the plate must be exposed at that time, before inspiration starts. he also noted that at fluoroscopy the heart moved laterally toward the uninvaded side during expiration.* * dr. manges has developed such a high degree of skill in the fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive emphysema they produce that he has located peanut kernels and other vegetable substances with absolute accuracy and unfailing certainty in dozens of cases at the bronchoscopic clinic. [fig. 74--expiratory valve-like bronchial obstruction by non-radiopaque foreign body, producing an acute obstructive emphysema. peanut kernel in right main bronchus. note (a) depression of right diaphragm; (b) displacement of heart and mediastinum to left; (c) greater transparency of the invaded side. ray-plate made by willis f. manges.] _complete bronchial obstruction_ shows a density over the whole area the aeration and drainage of which has been cut off (fig. 75). pulmonary abscess formation and "drowned lung" (accumulated secretion in the bronchi and bronchioli) are shown by the definite shadows produced (fig. 76). [140] dense and metallic objects will usually be readily seen in the roentgenograms and fluoroscope, but many foreign bodies are of a nature which will produce no shadow; the roentgenologist should, therefore, be prepared to interpret the pulmonary pathology, and should not dismiss the case as negative for foreign body because one is not seen. even metallic objects are in rare cases exceedingly difficult to demonstrate. [fig. 75.--radiograph showing pathology resulting from complete obstruction of a bronchus with atelectasis and drowned lung resulting. foot of an alarm clock in left bronchus of 4 year old child. present 25 days. plate made by johnston and grier.] _positive films of the tracheo-bronchial tree as an aid to localization_.--in order to localize the bronchus invaded by a small foreign body the positive film is laid over the negative of the patient showing the foreign body. the shadow of the foreign body will then show through the overlying positive film. these positive films are made in twelve sizes, and the size selected should be that corresponding to the size of the patient as shown by the roentgenograph. the dome of the diaphragm and the dome of the pleura are taken as visceral landmarks for placing the positive films which have lines indicating these levels. if the shadow of the foreign body be faint it may be strengthened by an ink mark on the uncoated side of the plate. [fig. 76.--partial bronchial obstruction for long period of time pathology, bronchiectasis and pulmonary abscess, produced by the presence for 4 years of a nail in the left lung of a boy of 10 years] _bronchial mapping_ is readily accomplished by the author's method of endobronchial insufflation of a roentgenopaque inert powder such as bismuth subnitrate or subcarbonate (fig. 77). the roentgenopaque substance may be injected in a fluid mixture if preferred, but the walls are better outlined with the powder (fig. 77). [fig. 77.--roentgenogram showing the author's method of bronchial mapping or lung-mapping by the bronchoscopic introduction of opaque substances (in this instance powdered bismuth subnitrate) into the lung of the patient. plate made by david r. bowen. (illustration, strengthened for reproduction, is from author's article in american journal of roentgenology, oct., 1918.)] errors to avoid in suspected foreign body cases 1. do not reach for the foreign body with the fingers, lest the foreign body be thereby pushed into the larynx, or the larynx be thus traumatized. 2. do not hold up the patient by the heels, lest a tracheally lodged foreign body be dislodged and asphyxiate the patient by becoming jammed in the glottis. [143] 3. do not fail to have a roentgenogram made, if possible, whether the foreign body in question is of a kind dense to the ray or not. 4. do not fail to search endoscopically for a foreign body in all cases of doubt. 5. do not pass blindly an esophageal bougie, probang, or other instrument. 6. do not tell the patient he has no foreign body until after roentgenray examination, physical examination, indirect examination, and endoscopy have all proven negative. summary symptomatology and diagnosis of foreign bodies in the air and food passages _initial symptoms_ are choking, gagging, coughing, and wheezing, often followed by a symptomless interval. the foreign body may be in the larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil, pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may have been passed by bowel, coughed out or spat out, with or without the knowledge of the patient. initial choking, etcetera may have escaped notice, or may have been forgotten. _laryngeal foreign body_.--one or more of the following laryngeal symptoms may be present: hoarseness, croupy cough, aphonia, odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective sensation of foreign body. croupiness in foreign body cases, as in diphtheria, usually means subglottic swelling. obstructive foreign body may be quickly fatal by laryngeal impaction on aspiration, or on abortive bechic expulsion. lodgement of a non-obstructive foreign body may be followed by a symptomless interval. direct laryngoscopy for diagnosis is indicated in every child having laryngeal diphtheria without faucial membrane. (no anesthetic, general or local is needed.) in the presence of laryngeal symptoms, think of the following: 1. a foreign body in the larynx. 2. a foreign body loose or fixed in the trachea. 3. digital efforts at removal. 4. instrumentation. 5. overflow of food into the larynx from esophageal obstruction due to the foreign body. 6. esophagotracheal fistula from ulceration set up by a foreign body in the esophagus, followed by the leakage of food into the air-passages. 7. laryngeal symptoms may persist from the trauma of a foreign body that has passed on into the deeper air or food passages or that has been coughed or spat out. 8. laryngeal symptoms (hoarseness, croupiness, etcetera) may be due to digital or instrumental efforts at the removal of a foreign body that never was present. 9. laryngeal symptoms may be due to acute or chronic laryngitis, diphtheria, pertussis, infective laryngotracheitis, and many other diseases. 10. deductive decisions are dangerous. 11. if the roentgenray is negative, laryngoscopy (direct in children, indirect in adults) without anesthesia, general or local, is the only way to make a laryngeal diagnosis. 12. before doing a diagnostic laryngoscopy, preparation should be made for taking a swab-specimen and for bronchoscopy and esophagoscopy. _tracheal foreign body_.--(1) "audible slap," (2) "palpatory thud," and (3) "asthmatoid wheeze" are pathognomonic. the "tracheal flutter" has been observed by mccrae in a case of watermelon seed. cough, hoarseness, dyspnea, and cyanosis are often present. diagnosis is by roentgenray, auscultation, palpation, and bronchoscopy. listen long for "audible slap," best heard at open mouth during cough. the "asthmatoid wheeze" is heard with the ear or stethoscope bell (mccrae) at the patient's open mouth. history of initial choking, gagging, and wheezing is important if elicited, but is valueless negatively. _bronchial foreign body_.--initial symptoms are coughing, choking, asthmatoid wheeze, etc. noted above. there may be a history of these or of tooth extraction. at once, or after a symptomless interval, cough, blood-streaked sputum, metallic taste, or special odor of foreign body may be noted. non-obstructive metallic foreign bodies afford few symptoms and few signs for weeks or months. obstructive foreign bodies cause atelectasis, drowned lung, and eventually pulmonary abscess. lobar pneumonia is an exceedingly rare sequel. vegetable organic foreign bodies as peanut-kernels, beans, watermelon seeds, etcetera, cause at once violent laryngotracheobronchitis, with toxemia, cough and irregular fever, the gravity and severity being inversely to the age of the child. bones, animal shells and inorganic bodies after months or years produce changes which cause chills, fever, sweats, emaciation, clubbed fingers, incurved nails, cough, foul expectoration, hemoptysis, in fact, all the symptoms of chronic pulmonary sepsis, abscess, and bronchiectasis. these symptoms and some of the physical signs may suggest pulmonary tuberculosis, but the apices are normal and bacilli are absent from the sputum. every acute or chronic chest case calls for the exclusion of foreign body. _the physical signs_ vary with conditions present in different cases and at different times in the same case. secretions, normal and pathologic, may shift from one location to another; the foreign body may change its position admitting more, less, or no air, or it may shift to a new location in the same lung or even in the other lung. a recently aspirated pin may produce no signs at all. the signs of diagnostic importance are chiefly those of partial or complete bronchial obstruction, though a non-obstructive foreign body, a pin for instance, may cause limited expansion (mccrae) or, rarely, a peculiar rale or a peculiar auscultatory sound. the most nearly characteristic physical signs are: (1) limited expansion; (2) decreased vocal fremitus; (3) impaired percussion note; (4) diminished intensity of the breath-sounds distal to the foreign body. complete obstruction of a bronchus followed by drowned lung adds absence of vocal resonance and vocal fremitus, thus often leading to an erroneous diagnosis of empyema. varying grades of tympany are obtained over areas of obstructive or compensatory emphysema. with complete obstruction there may be tympany from the collapsed lung for a time. rales in case of complete obstruction are usually most intense on the uninvaded side. in partial obstruction they are most often found on the invaded side distal to the foreign body, especially posteriorly, and are most intense at the site corresponding to that of the foreign body. a foreign body at the bifurcation of the trachea may give signs in both lungs. early in a foreign body case, diminished expansion of one side, with dulness, may suggest pneumonia in the affected side; but absence of, or decreased, vocal resonance, and absence of typical tubular breathing should soon exclude this diagnosis. bronchial obstruction in pneumonia is exceedingly rare. memorize these signs suggestive of foreign body: 1. expansion--diminished. 2. percussion note--impaired (except in obstructive emphysema). 3. vocal fremitus--diminished. 4. breath sounds--diminished. the foregoing is only for memorizing, and must be considered in the light of the following fundamental note by prof. mccrae "there is no one description of physical signs which covers all cases. if the student will remember that complete obstruction of a bronchus leads to a shutting off of this area, there should be little difficulty in understanding the signs present. the diagnosis of empyema may be made, but the outline of the area of dulness, the fact that there is no shifting dulness, and the greater resistance which is present in empyema nearly always clear up any difficulty promptly. the absence of the frequent change in the voice sounds, so significant in an early small empyema, is of value. a large empyema should give no difficulty. if difficulty remains the use of the needle should be sufficient. in thickened pleura vocal fremitus is not entirely absent, and the breath-sounds can usually be heard, even if diminished. in case of partial obstruction of a bronchus, it is evident that air will still be present, hence the dulness may be only slight. the presence of air and secretion will probably result in the breath-sounds being somewhat harsh, and will cause a great variety of rales, principally coarse, and many of them bubbling. difficulty may be caused by signs in the other lung or in a lobe other than the one affected by the foreign body. if it is remembered that these signs are likely to be only on auscultation, and to consist largely in the presence of rales, while the signs in the area supplied by the affected bronchus will include those on inspection, palpation, and percussion, there should be little difficulty." _the roentgenray_ is the most valuable diagnostic means; but careful notation of physical signs by an expert should be made in all cases preferably without knowledge of ray findings. expert ray work will show all metallic foreign bodies and many of less density, such as teeth, bones, shells, buttons, etcetera. if the ray is negative, a diagnostic bronchoscopy should be done in all cases of unexplained bronchial obstruction. peanut kernels and watermelon seeds and, rarely, other foreign bodies in the bronchi produce obstructive emphysema of the invaded side. fluoroscopy shows the diaphragm flattened, depressed and of less excursion on the invaded side; at the end of expiration, the heart and the mediastinal wall move over toward the uninvaded side and the invaded lung becomes less dense than the uninvaded lung, from the trapping of the air by the expiratory, valve-like effect of obliteration of the "forceps spaces" that during inspiration afford air ingress between the foreign body and the swollen bronchial wall. this partial obstruction causes obstructive emphysema, which must be distinguished from compensatory emphysema, in which the ballooning is in the unobstructed lung, because its fellow is wholly out of function through complete "corking" of the main bronchus of the invaded side. _esophageal foreign body_.--after initial choking and gagging, or without these, there may be a subjective sense of a foreign body, constant or, more often, on swallowing. odynphagia and dysphagia or aphagia may or may not be present. pain, sub-sternal or extending to the back is sometimes present. hematemesis and fever may occur from the foreign body or from rough instrumentation. symptoms referable to the air-passages may be present due to: (1) overflow of the secretions on attempts to swallow through the obstructed esophagus; (2) erosion of the foreign body through from the esophagus into the trachea; or (3) trauma inflicted on the larynx during attempts at removal, digital or instrumental, the foreign body still being present or not. diagnosis is by the roentgenray, first without, then, if necessary, with a capsule filled with an opaque mixture. flat objects, like coins, always lie with their greatest diameter in the coronal plane of the body, when in the esophagus; in the sagittal plane, when in the trachea or larynx. lateral, anteroposterior, and sometimes also quartering roentgenograms are necessary. one taken laterally, low down on the neck but clear of the shoulder, will often show a bone or other semiopaque object invisible in the anteroposterior exposure. [149] chapter xiii--foreign bodies in the larynx and tracheobronchial tree the protective reflexes preventing the entrance of foreign bodies into the lower air passages are: (1) the laryngeal closing reflex and (2) the bechic reflex. laryngeal closing for normal swallowing consists chiefly in the tilting and the closure of the upper laryngeal orifice. the ventricular bands help but slightly; and the epiglottis and the vocal cords little, if at all. the gauntlet to be run by foreign bodies entering the tracheobronchial tree is composed of: 1. epiglottis. 2. upper laryngeal orifice. 3. ventricular bands. 4. vocal cords. 5. bechic blast. the epiglottis acts somewhat as a fender. the superior laryngeal aperture, composed of a pair of movable ridges of tissue, has almost a sphincteric action, in addition to a tilting movement. the ventricular bands can approximate under powerful stimuli. the vocal cords act similarly. the one defect in the efficiency of this barrier, is the tendency to take a deep inspiration preparatory to the cough excited by the contact of a foreign body. _site of lodgment_.--the majority of foreign bodies in the air passages occur in children. the right bronchus is more frequently invaded than the left because of the following factors: i. its greater diameter. 2. its lesser angle of deviation from the tracheal axis. 3. the situation of the carina to the left of the mid-line of the trachea. 4. the action of the trachealis muscle. 5. the greater volume of air going into the right bronchus on inspiration. the middle lobe bronchus is rarely invaded by foreign body, and, fortunately, in less than one per cent of the cases is the object in an upper lobe bronchus. _spontaneous expulsion of foreign bodies from the air passages_. a large, light, foreign body in the larynx or trachea may occasionally be coughed out, but the frequent newspaper accounts of the sudden death of children known to have aspirated objects should teach us never to wait for this occurrence. the cause of death in these cases is usually the impaction of a large foreign body in the glottis producing sudden asphyxiation, and in a certain proportion of these cases the impaction has occurred on the reverse journey, when cough forced the intruder upward from below. the danger of subglottic impaction renders it imperative that attempts to aid spontaneous expulsion by inverting the patient should be discouraged. sharp objects, such as pins, are rarely coughed out. the tendency of all foreign bodies is to migrate down and out to the periphery as their size and shape will allow. most of the reported cases of bechic expulsion of bronchially lodged foreign bodies have occurred after a prolonged sojourn of the object, associated which much lung pathology; and in some cases the object has been carried out along with an accumulation of pus suddenly liberated from an abscess cavity, and expelled by cough. this is a rare sequence compared to the usual formation of fibrous stricture above the foreign body that prevents the possibility of bechic expulsion. to delay bronchoscopy with the hope of such a solution of the problem is comparable to the former dependence on nature for the cure of appendiceal abscess. we do our full duty when we tell the patient or parents that while the foreign body may be coughed up, it is very dangerous to wait; and, further, that the difficulty of removal usually increases with the time the foreign body is allowed to remain in the air passages. _mortality and morbidity of bronchoscopy_ vary directly with the degree of skill and experience of the operator, and the conditions for which the endoscopies are performed. the simple insertion of the bronchoscope is devoid of harm if carefully done. the danger lies in misdirected efforts at removal of the intruder and in repeating bronchoscopies in children at too frequent intervals, or in prolonging the procedure unduly. in children under one year endoscopy should be limited to twenty minutes, and should not be repeated sooner than one week after, unless urgently indicated. a child of 5 years will bear 40 to 60 minutes work, while the adult offers no unvarying time limit. more can be ultimately accomplished, and less reaction will follow short endoscopies repeated at proper intervals than in one long procedure. _indications for bronchoscopy for suspected foreign body_ may be thus summarized: 1. the appearance of a suspicious shadow in the radiograph, in the line of a bronchus. 2. in any case in which lung symptoms followed a clear history of the patient having choked on a foreign body. 3. in any case showing signs of obstruction in the trachea or of a bronchus. 4. in suspected bronchiectasis. 5. symptoms of pulmonary tuberculosis with sputum constantly negative for tubercle bacilli. if the physical signs are at the base, particularly the right base, the indication becomes very strong even in the absence of any foreign body circumstance in the history. 6. in all cases of doubt, bronchoscopy should be done anyway. there is no absolute _contraindication to bronchoscopy for foreign bodies_. extreme exhaustion or reaction from previous efforts at removal may call for delay for recuperation, but pulmonary abscess and even the rarer complications, bronchopneumonia and gangrene of the lung, are improved by the early removal of the foreign body. _choice of time to do bronchoscopy for foreign body_.--the difficulties of removal usually increase from the time of aspiration of the object. it tends to work downward and outward, while the mucosa becomes edematous, partly closing over the foreign body, and even completely obliterating the lumen of smaller bronchi. later, granulation tissue and the formation of stricture further hide the object. the patient's health deteriorates with the onset of pulmonary pathology, and renders him a less favorable subject for bronchoscopy. organic foreign bodies, which produce early and intense inflammatory reaction and are liable to swell, call for prompt bronchoscopy. when a bronchus is completely obstructed by the bulk of the foreign body itself immediate removal is urgently demanded to prevent serious lung changes, resulting from atelectasis and want of drainage. in short, removal of the foreign body should be accomplished as soon as possible after its entrance. this, however, does not justify hasty, ill-planned, and poorly equipped bronchoscopy, which in most cases is doomed to failure in removal of the object. the bronchoscopist should not permit himself to be stampeded into a bronchoscopy late at night, when he is fatigued after a hard day's work. _bronchoscopic finding of a foreign body_ is not especially difficult if the aspiration has been recent. if secondary processes have developed, or the object be small and in a bronchus too small to admit the tube-mouth, considerable experience may be necessary to discover it. there is usually inflammatory reaction around the orifice of the invaded bronchus, which in a measure serves to localize the intruder. we must not forget, however, that objects may have moved to another location, and also that the irritation may have been the result of previous efforts at removal. care must be exercised not to mistake the sharp, shining, interbronchial spurs for bright thin objects like new pins just aspirated; after a few days pins become blackened. if these spurs be torn pneumothorax may ensue. if a number of small bronchi are to be searched, the bronchoscope must be brought into the line of the axis of the bronchus to be examined, and any intervening tissue gently pushed aside with the lip of the bronchoscope. blind probing for exploration is very dangerous unless carefully done. the straight forceps, introduced closed, form the best probe and are ready for grasping if the object is felt. once the bronchoscope has been introduced, it should not be withdrawn until the procedure is completed. the light carrier alone may be removed from its canal if the illumination be faulty. complications and after-effects of bronchoscopy all foreign body cases should be watched day and night by special nurses until all danger of complications is passed. complications are rare after careful work, but if they do occur, they may require immediate attention. this applies especially to the subglottic edema associated with arachidic bronchitis in children under 2 years of age. _general reaction_.--there is usually no elevation in temperature following a short bronchoscopy for the removal of a recently lodged metallic foreign body. if, however, an inflammatory condition of the bronchi existed previous to the bronchoscopy, as for instance the intense diffuse, purulent laryngotracheobronchitis associated with the aspiration of nut kernels, or in the presence of pulmonary abscess from long retained foreign bodies, a moderate temporary rise of temperature may be expected. these cases almost always have had irregular fever before bronchoscopy. disturbance of the epithelium in the presence of pus without abscess usually permits enough absorption to elevate the temperature slightly for a few days. _surgical shock_ in its true form has never followed a carefully performed and time-limited bronchoscopy. severe fatigue resulting in deep sleep may be seen in children after prolonged work. _local reaction_ is ordinarily noted by slight laryngeal congestion causing some hoarseness and disappearing in a few days. if dyspnea occur it is usually due to (1) drowning of the patient in his own secretions. (2) subglottic edema. (3) laryngeal edema. _drowning of the patient in his own secretions_.--the accumulation of secretions in the bronchi due to faulty bechic powers and seen most frequently in children, is quickly relievable by bronchoscopic sponge-pumping or aspiration through the tracheotomic wound, in cases in which the tracheotomy may be deemed necessary. in other cases, the aspirating bronchoscope with side drainage canal (fig. 1, e) may be used through the larynx. frequent peroral passage of the bronchoscope for this purpose is contraindicated only in case of children under 3 years of age, because of the likelihood of provoking subglottic edema. in such cases instead of inserting a bronchoscope the aspirating tube (fig. 9) should be inserted through the direct laryngoscope, or a low tracheotomy should be done. _supraglottic edema_ is rarely responsible for dyspnea except when associated with advanced nephritis. _subglottic edema_ is a complication rarely seen except in children under 3 years of age. they have a peculiar histologic structure in this region, as is shown by logan turner. even at the predisposing age subglottic edema is a very unusual sequence to bronchoscopy if this region was previously normal. the passage of a bronchoscope through an already inflamed subglottic area is liable to be followed by a temporary increase in the swelling. if the foreign body be associated with but slight amount of secretion, the child can usually obtain sufficient air through the temporarily narrowed lumen. if, however, as in cases of arachidic bronchitis, large amounts of purulent secretion must be expelled, it will be found in certain cases that the decreased glottic lumen and impaired laryngeal motility will render tracheotomy necessary to drain the lungs and prevent drowning in the retained secretions. subglottic edema occurring in a previously normal larynx may result from: 1. the use of over-sized tubes. 2. prolonged bronchoscopy. 3. faulty position of the patient, the axis of the tube not being in that of the trachea. 4. trauma from undue force or improper direction in the insertion of the bronchoscope. 5. the manipulation of instruments. 6. trauma inflicted in the extraction of the foreign body. _diagnosis_ must be made without waiting for cyanosis which may never appear. pallor, restlessness, startled awakening after a few minutes sleep, occurring in a child with croupy cough, indrawing around the clavicles, in the intercostal spaces, at the suprasternal notch and at the epigastrium, call for tracheotomy which should always be low. such a case should not be left unwatched. the child will become exhausted in its fight for air and will give up and die. the respiratory rate naturally increases because of air hunger, accumulating secretions that cannot be expelled because of impaired glottic motility give signs wrongly interpreted as pneumonia. many children whose lives could have been saved by tracheotomy have died under this erroneous diagnosis. _treatment_.--intubation is not so safe because the secretions cannot easily be expelled through the tube and postintubational stenosis may be produced. low tracheotomy, the tracheal incision always below the second ring, is the safest and best method of treatment. [156] chapter xiv--removal of foreign bodies from the larynx _symptoms and diagnosis_.--the history of a sudden choking attack followed by impairment of voice, wheezing, and more or less dyspnea can be usually elicited. laryngeal diphtheria is the condition most frequently thought of when these symptoms are present, and antitoxin is rightly given while waiting for a positive diagnosis. extreme dyspnea may render tracheotomy urgently demanded before any attempts at diagnosis are made. further consideration of the symptomatology and diagnosis of laryngeal foreign body will be found on pages 128, 133 and 143. _preliminary examination_.--in the adult, mirror examination of the larynx should be done, the patient being placed in the recumbent position. whenever time permits roentgenograms, lateral and anteroposterior, should be made, the lateral one as low in the neck as possible. one might think this an unnecessary procedure because of the visibility of the larynx in the mirror; but a child's larynx cannot usually be indirectly examined, and even in the adult a pin may be so situated that neither head nor point is visible, only a portion of the shaft being seen. the roentgenogram will give accurate information as to the position, and will thus allow a planning of the best method for removal of the foreign body. a bone in the larynx usually is visible in a good roentgenogram. accurate diagnosis in children is made by direct laryngoscopy without anesthesia, but direct laryngoscopy should not be done until one is prepared to remove a foreign body if found, to follow it into the bronchus and remove it if it should be dislodged and aspirated, and to do tracheotomy if sudden respiratory arrest occur. [157] _technic of removal of foreign bodies from the larynx_.--the patient is to be placed in the author's position, shown in fig. 53. no general anesthesia should be given, and the application of local anesthesia is usually unnecessary and further, is liable to dislodge and push down the foreign body.* because of the risk of loss downward it is best to seize the foreign body as soon as seen; then to determine how best to disimpact it. the fundamental principles are that a pointed object must either have its point protected by the forceps grasp or be brought out point trailing, and that a flat object must be so rotated that its plane corresponds to the sagittal plane of the glottic chink. the laryngeal grasping forceps (fig. 53) will be found the most useful, although the alligator rotation forceps (fig. 31) may occasionally be required. * in adolescents or adults a few drops of a 4 per cent solution of cocain applied to the laryngopharynx with an atomizer or a dropper will afford the minimum risk of dislodgement; but the author's personal preference is for no anesthesia, general or local. [158] chapter xv--mechanical problems of bronchoscopic foreign body extraction* * for more extensive consideration of mechanical problems than is here possible the reader is referred to the bibliography, page 311, especially reference numbers 1, 11, 37 and 56. the endoscopic extraction of a foreign body is a mechanical problem pure and simple, and must be studied from this viewpoint. hasty, ill-equipped, ill-planned, or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal, is never justifiable. while the lodgement of an organic foreign body (such as a nut kernel) in the bronchus calls for prompt removal and might be included under the list of emergency operations, time is always available for complete preparation, for thorough study of the patient, and localization of the intruder. the patient is better off with the foreign body in the lung than if in its removal a mediastinitis, rupture into the pleura, or tearing of a thoracic blood vessel has resulted. the motto of the endoscopist should be "i will do no harm." if no harm be inflicted, any number of bronchoscopies can be done at suitable intervals, and eventually success will be achieved, whereas if mortality results, all opportunity ceases. the first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes; (1) anteroposterior, (2) lateral, and (3) the plane corresponding to the greatest plane of the foreign body. the next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to, and try to simulate the probable position shown by the ray, so as to get an idea of the bronchoscopic appearance of the probable presentation. then the duplicate foreign body is turned into as many different positions as possible, so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient. for each of these presentations a method of disimpaction, disengagement, disentanglement or version and seizure is worked out, according to the kind of foreign body. prepared by this practice and the radiographic study, the bronchoscope is introduced into the patient. the location of the foreign body is approached slowly and carefully to avoid overriding or displacement. a _study of the presentation_ is as necessary for the bronchoscopist as for the obstetrician. it should be made with a view to determining the following points: 1. the relation of the presenting part to the surrounding tissues. 2. the probable position of the unseen portion, as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study, and by inspection of the ray plate upside down on view in front of the bronchoscopist. 3. the version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement. 4. the best instruments to use, and which to use first, as, hook, pincloser, forceps, etc. 5. the presence and position of the "forceps spaces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion space" for any other instrument. until all of these points are determined it is a grave error to insert any kind of instrument. if possible even swabbing of the foreign body should be avoided by swabbing out the bronchus, when necessary, before the region of the intruder is reached. when the operator has determined the instrument to be used, and the method of using it, the instrument is cautiously inserted, under guidance of the eye. [160] _the lip of the bronchoscope_ is one of the most valuable aids in the solution of foreign-body problems. with it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps; edematous mucosa may be displaced, angles straightened and space made at the side of the foreign body for the forceps' jaw. it forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body. with the bronchoscopic lip and the forceps or other instrument inserted through the tube, the bronchoscopist has bimanual, eye-guided control, which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork, will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments. _the relation of the tube mouth and foreign body_ is of vital importance. generally considered, the tube mouth should be as near the foreign body as possible, and the object must be placed in the center of the bronchoscopic field, so that the ends of the open jaws of the forceps will pass sufficiently far over the object. but little lateral control is had of the long instruments inserted through the tube; sidewise motion is obtained by a shifting of the end of the bronchoscope. when the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping, it is important that this position be maintained by anchoring the tube to the upper teeth with the left, third, and fourth fingers hooked over the patient's upper alveolus (fig. 63) _the light reflex on the forceps_.--it is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. on slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. it is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. this assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination. _hooks_ are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed. a right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (bib. 11, p. 311). _the use of forceps in endoscopic foreign body extraction_.--two different strengths of forceps are supplied, as will be seen in the list in chapter 1. the regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. for more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. spring-opposed forceps render any delicacy of touch impossible. forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. these fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in fig. 78. it is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. the impulse to seize the object as soon as it is discovered must be strongly resisted. a careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. the most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open v, a sufficient distance to afford a good grasp. the blades are then closed and the foreign body is drawn against the tube mouth. few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together. [fig. 78.--proper hold of forceps. the right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. all traction is made with the index finger, the ring fingers being used only to open and close the forceps. if any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.] _anchoring the foreign body against the tube mouth_.--if withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. this is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in fig. 79. the left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis. [fig. 79--method of anchoring the foreign body against the tube mouth after the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube, the other fingers of the left hand encircle the tube. withdrawal is then done with the left hand; the fingers of the right hand maintaining closure of the forceps.] [164] _bringing the foreign body through the glottis_.--stripping of the foreign body from the forceps at the glottis may be due to: 1. not keeping the object against the tube mouth as just mentioned. 2. not bringing the greatest diameter of the foreign body into the sagittal plane of the glottic chink. 3. faulty application of the forceps on the foreign body. 4. mechanically imperfect forceps. should the foreign body be lost at the glottis it may, if large become impacted and threaten asphyxia. prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps. the object may be dropped or expelled into the pharynx and be swallowed. it may even be coughed into the naso-pharynx or it may be re-aspirated. in the latter event the bronchoscope is to be re-inserted and the trachea carefully searched. care must be used not to override the object. if much inflammatory reaction has occurred in the first invaded bronchus, temporarily suspending the aerating function of the corresponding lung, reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus, by reason of the greater inspiratory volume of air entering that side. this may produce sudden death by blocking the only aerating organ. _extraction of pins, needles and similar long pointed objects_.--when searching for such objects especial care must be taken not to override them. pins are almost always found point upward, and the dictum can therefore be made, "search not for the pin, but for the point of the pin." if the point be found free, it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube. it may then be seized with the forceps and withdrawn. should the pin be grasped by the shaft, it is almost certain to turn crosswise of the tube mouth, where one pull may cause the point to perforate, enormously increasing the difficulties by transfixation, and perhaps resulting fatally (fig. 80). [fig. 80.--schematic illustration of a serious phase of the error of hastily seizing a transfixed pin near its middle, when first seen as at m. traction with the forceps in the direction of the dart in schema b will rip open the esophagus or bronchus inflicting fatal trauma, and probably the pin will be stripped off at the glottic or the cricopharyngeal level, respectively. the point of the pin must be disembedded and gotten into the tube mouth as at a, to make forceps traction safe.] [fig. 81.--schema illustrating the mechanical problem of extracting a pin, a large part of whose shaft is buried in the bronchial wall, b. the pin must be pushed downward and if the orifice of the branches, c, d, are too small to admit the head of the pin some other orifice (as at a) must be found by palpation (not by violent pushing) to admit the head, so that the pin can be pushed downward permitting the point to emerge (e). the point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps, as shown at f.] _inward rotation method_.--when the point is found to be buried in the mucosa, the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps, then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees. the point is thus disengaged, and the shaft of the pin is brought parallel with that of the forceps, after which the point may be drawn into the tube mouth. the lips added to the side-curved forceps by my assistant dr. gabriel tucker i now use exclusively for this inward rotation method. they are invaluable in preventing the escape of the pin during the manipulation. a hook is sometimes useful in disengaging a buried point. the method of its use is illustrated in fig. 82. [fig. 82.--mechanical problem of pin, needle, tack or nail with embedded point. if the forceps are pulled upon the pin point will be buried still deeper. the side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube. if the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above the side curved forceps may be used instead of the hook for freeing the point, the author's "inward rotation" method. the very best instrument for the purpose is the forceps devised by my assistant, dr. gabriel tucker (fig. 21). the lips prevent all risk of losing the pin from the grasp, and at the same time bring the long axis of the pin parallel to that of the bronchoscope.] pins are very prone to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration. at other times, pins not dropping so deeply may show the point only during expiration or cough, at which times the bronchi are shortened. in such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible; the forceps are now inserted, opened, and the next emergence watched for, the point being grasped as soon as seen. _extraction of tacks, nails and large headed foreign bodies from the tracheobronchial tree_.--in cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. the author's inward-rotation method when executed with the tucker forceps is ideal. the large head, however, presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis (fig. 83). the extraction problems of tacks are illustrated in figs. 84, 85, and 86. nails, stick pins, and various tacks are dealt with in the same manner by the author's "inward rotation" method. _hollow metallic bodies_ presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in figs 23 and 25, or its edge may be grasped by the regular side-grasping forceps. the latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps; but with care it is the best method. should the closed end be uppermost, however, it may be necessary to insert a hook beyond the object, and to coax it upward to a point where it may be turned for grasping and removal with forceps. [fig. 83.--"mushroom anchor" problem of the upholstery tack. if the tack has not been _in situ_ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma, _provided_ axis-traction only be used. if the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor. otherwise traction may rupture the bronchial wall. the stenotic tissue in cases of a few months' sojourn maybe composed of granulations, in which case axis-traction will safely withdraw it. the point of a tack rarely projects freely into the lumen as here shown. more often it is buried in the wall.] [168] [fig. 84.-schema illustrating the "mushroom anchor" problem of the brass headed upholstery tack. at a the tack is shown with the head bedded in swollen mucosa. the bronchoscopist, looking through the bronchoscope, e, considering himself lucky to have found the point of the tack, seizes it and starts to withdraw it, making traction as shown by the dart in drawing b. the head of the tack catches below a chondrial ring and rips in, tearing its way through the bronchial wall (d) causing death by mediastinal emphysema. this accident is still more likely to occur if, as often happens, the tack-head is lodged in the orifice of the upper lobe bronchus, f. but if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction, as shown at c, the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage. if necessary, in addition, the lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, h. if the swollen mucosa, h, has been replaced by fibrous tissue from many months' sojourn of the tack, the stenosis may require dilatation with the divulsor.] [fig. 85.--problem of the upholstery tack with buried point. if pulled upon, the imminent perforation of the mediastinum, as shown at a will be completed, the bronchus will be torn and death will follow even if the tack be removed, which is of doubtful possibility. the proper method is gently to close the side curved forceps on the shank of the tack near the head, push downward as shown by the dart, in b, until the point emerges. then the forceps are rotated to bring the point of the tack away from the bronchial wall.] [169] _removal of open safety pins from the trachea and bronchi_.-removal of a closed safety pin presents no difficulty if it is grasped at one or the other end. a grasp in the middle produces a "toggle and ring" action which would prevent extraction. when the safety pin is _open with the point downward_ care must be exercised not to override it with the bronchoscope or to push the point through the wall. the spring or near end is to be grasped with the side-curved or the rotation forceps (figs. 19, 20 and 31) and pulled into the bronchoscope, thus closing the pin. an open safety pin lodged point up presents an entirely different and a very difficult problem. if traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced. the pin may be closed with the pin-closer as illustrated in fig. 37, and then removed with forceps. arrowsmith's pin-closer is excellent. another method (fig. 87) consists in bringing the point of the safety pin into the bronchoscope, after disengaging the point with the side curved forceps, by the author's "inward rotation" method. the forceps-jaws (fig. 21) devised recently by my assistant, dr. gabriel tucker, are ideal for this maneuver. as the point is now protected, the spring, seen just off the tube mouth, is best grasped with the rotation forceps, which afford the securest hold. the keeper and its shaft are outside the bronchoscope, but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin. care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly, for the reason that the base of the glottic triangle is posterior, and that the posterior wall of the larynx is membranous above the cricoid cartilage, and will yield. a small safety-pin may be removed by version, the point being turned into a branch bronchial orifice. no one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin. this practice should be carried out by anyone expecting to do endoscopy, because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body. then, when a safety pin case is encountered, the bronchoscopist will be prepared to cope with its difficulties, and he will be able to determine which of the methods will be best suited to his personal equation in the particular case. [fig. 86.--schema illustrating the "upper-lobe-bronchus problem," combined with the "mushroom-anchor" problem and the author's method for their solution. the patient being recumbent, the bronchoscopist looking down the right main bronchus, m, sees the point of the tack projecting from the right upper-lobe-bronchus, a. he seizes the point with the side-curved forceps; then slides down the bronchoscope to the position shown dotted at b. next he pushes the bronchoscopic tube-mouth downward and medianward, simultaneously moving the patient's head to the right, thus swinging the bronchoscopic level on its fulcrum, and dragging the tack downward and inward out of its bed, to the position, 1). traction, as shown at c, will then safely and easily withdraw the tack. a very small bronchoscope is essential. the lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over, and the lip must be brought close to the tack just before the prying-pushing movement. s, right stem-bronchus.] [fig. 87.--one method of dealing with an open safety pin without closing it.] _removal of double pointed tacks_.--if the tack or staple be small, and lodged in a relatively large trachea a version may be done. that is, the staple may be turned over with the hook or rotation forceps and brought out with the points trailing. with a long staple in a child's trachea the best method is to "coax" the intruder along gently under ocular guidance, never making traction enough to bury the point deeply, and lifting the point with the hook whenever it shows any inclination to enter the wall. great care and dexterity are required to get the intruder through the glottis. in certain locations, one or both points may be turned into branch bronchi as illustrated in fig. 88, or over the carina into the opposite main bronchus. another method is to get both points into the tube-mouth. this may be favored, as demonstrated by my assistant, dr. gabriel tucker, by tilting the staple so as to get both points into the longest diameter of the tube-mouth. in some cases i have squeezed the bronchoscope in a vise to create an oval tube-mouth. in other cases i have used expanding forceps with grooved blades. [fig. 88.-schema illustrating podalic version of bronchially-lodged staples or double-pointed tacks. h, bronchoscope. a, swollen mucosa covering points of staple. at e the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices, b, c. traction being made in the direction of the dart (f), by means of the rotation forceps, and counterpressure being made with the bronchoscopic lip on the points of the staple, the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind (k).] _the extraction of tightly fitting foreign bodies from the bronchi. annular edema_.--such objects as marbles, pebbles, corks, etc., are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter. the air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. a ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. a forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body; but usually the attempt to apply forceps when there are no spaces between the presenting part of the foreign body and the bronchial wall, will result only in pushing the foreign body deeper.* a better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point, so that a hook may be introduced below the foreign body, which then can be worked up to a wider place where forceps may be applied (fig. 89). sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted. for this the unslanted tube-mouth is used. * the author's new ball forceps are very successful with ball-bearing balls and marbles. [fig. 89.--schema illustrating the use of the lip of the bronchoscope in disimpaction of foreign bodies. a and b show an annular edema above the foreign body, f. at c the edematous mucosa is being repressed by the lip of the tube mouth, permitting insinuation of the hook, h, past one side of the foreign body, which is then withdrawn to a convenient place for application of the forceps. this repression by the lip is often used for purposes other than the insertion of hooks. the lip of the esophagoscope can be used in the same way.] _extraction of soft friable foreign bodies from the tracheobronchial tree_.--the difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps space. there is usually in these cases an abundance of purulent secretion which further hinders the work. the great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view, must always be kept in mind. extremely delicate forceps with rather broad blades are required for this work. the fenestrated "peanut" forceps are best for large pieces in the large bronchi. the operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal, yet not so firmly as to crush them. nipping off an edge by not inserting the forceps far enough is also to be avoided. small fragments under 2 mm. in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping. it is, however, never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled, for these may be aspirated into small bronchi, and cause multiple abscesses. a hook may be found useful in dealing with round, friable, foreign bodies; and in some cases the mechanical spoon or safety-pin closer may be used to advantage. the foreign body is then brought close to, but not crushed against the tube mouth. [174] _removal of animal objects from the tracheobronchial tree_ is readily accomplished with the side-curved forceps. leeches are not uncommon intruders in european countries. small insects are usually coughed out. worms and larvae may be found. cocaine or salt solution will cause a leech to loosen its hold. _foreign bodies in the upper-lobe bronchi_ are fortunately not common. if the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps (fig. 90), guided by the collaboration of the fluoroscopist. these forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus. full-curved coil-spring hooks will reach high, but must be used with the utmost caution, and the method of their disengagement must be practiced beforehand. _penetrating projectiles_.--foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus (see bibliography, 43) [fig. 90.--schematic illustration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. t, trachea; ul, upper-lobe bronchus; lb, left bronchus; sb, stem bronchus. these forceps are made to extend around 180 degrees.] rules for endoscopic foreign body extraction 1. never endoscope a foreign body case unprepared, with the idea of taking a preliminary look. 2. approach carefully the suspected location of a foreign body, so as not to override any portion of it. [175] 3. avoid grasping a foreign body hastily as soon as seen. 4. the shape, size and position of a foreign body, and its relations to surrounding structures, should be studied before attempting to apply the forceps. (exception cited in rule 10.) 5. preliminary study of a foreign body should be from a distance. 6. as the first grasp of the forceps is the best, it should be well planned beforehand so as to seize the proper part of the intruder. 7. with all long foreign bodies the motto should be "search, not for the foreign body, but for its nearer end." with pins, needles, and the like, with point upward, _search always for the point_. try to see it first. 8. remember that a long foreign body grasped near the middle becomes, mechanically speaking, a "toggle and ring." 9. remember that the mortality to follow failure to remove a foreign body does not justify probably fatal violence during its removal. 10. _laryngeally lodged_ foreign bodies, because of the likelihood of dislodgment and loss, may be seized by any part first presented, and plan of withdrawal can be determined afterward. 11. for similar reasons, laryngeal cases should be dealt with only in the author's position (fig. 53). 12. an esophagoscopy may be needed in a bronchoscopic case, or a bronchoscopy in an esophageal case. in every case both kinds of tubes should be sterile and ready before starting. it is the unexpected that happens in foreign body endoscopy. 13. do not pull on a foreign body unless it is properly grasped to come away readily without trauma. then do not pull hard. 14. do no harm, if you cannot remove the foreign body. 15. full-curved hooks are to be used in the bronchi with greatest caution, if used at all, lest they catch inextricably in branch bronchi. [176] 16. don't force a foreign body downward. coax it back. the deeper it gets the greater your difficulties. 17. the watchword of the bronchoscopist should be, "if i can do no good, i will at least do no harm." _fluoroscopic bronchoscopy_ is so deceptively easy from a superficial, theoretical, point of view that it has been used unsuccessfully in cases easily handled in the regular endoscopic way with the eye at the proximal tube-mouth. in a collected series of cases by various operators the object was removed in 66.7 per cent with a mortality of 41.6 per cent. in the problem of a pin located out of the field of bronchoscopic vision, the fluoroscopist will yield invaluable aid. an extremely delicate forceps is to be inserted closed into the invaded bronchus, the grasp on the object being confirmed by the fluoroscopist. it is to be kept in mind that while the object itself may be in the grasp of the forceps, the fluoroscope will not show whether there may not be included in the forceps' grasp a bronchial spur or other tissue, the tearing of which may be fatal. therefore traction must not be sufficient to lacerate tissue. if the foreign body does not come readily it must be released, and a new grasp may then be taken. all of the cautions in faulty seizure already mentioned, apply with particular force to fluoroscopic bronchoscopy. the fluoroscope is of aid in finding foreign bodies held in abscess cavities. the fluoroscope should show both the lateral and anteroposterior planes. to accomplish this quickly, two coolidge tubes and two screens are necessary. fluoroscopic bronchoscopy, because of its high mortality and low percentage of successes, should be tried only after regular, ocularly guided, peroral bronchoscopy has failed, and only by those who have had experience in ocularly guided bronchoscopy. [177] chapter xvi--foreign bodies in the bronchi for prolonged periods the sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis, pulmonary abscess, and fibrous changes. the symptoms of tuberculosis may all be presented, but tubercle bacilli have never been found associated with any of the many cases that have come to the bronchoscopic clinic.* the history of repeated attacks of malaise, fever, chills, and sweats lasting for a few days and terminated by the expulsion of an amount of foul pus, suggests the intermittent drainage of an abscess cavity, and special study should be made to eliminate foreign body as the cause of the condition, in all such cases, whether there is any history of a foreign body accident or not. bronchoscopy for diagnosis is to be done unless the etiology can be definitely proven by other means. in all cases of chronic chest disease foreign body should be eliminated as a matter of routine. * one exception has recently come to the clinic. 12 _the time of aspiration of a foreign body_ may be unknown, having possibly occurred in infancy, during narcosis, or the object may even enter the lower air passages without the patient being aware of the accident, as happened with a particularly intelligent business man who unknowingly aspirated the tip of an atomizer while spraying his throat. in many other cases the accident had been forgotten. in still others, in spite of the patient's statement of a conviction that the trouble was due to a foreign body he had aspirated, the physician did not consider it worthy of sufficient consideration to warrant a roentgenray examination. it is curious to note the various opinions held in regard to the gravity of the presence of a bronchial foreign body. one patient was told by his physician that the presence of a staple in his bronchus was an impossibility, for he would not have lived five minutes after the accident. others consider the presence of a foreign body in the bronchus as comparatively harmless, in spite of the repeated reports of invalidism and fatality in the medical literature of centuries. the older authorities state that all cases of prolonged bronchial foreign body sojourn died from phthisis pulmonalis, and it is still the opinion of some practitioners that the presence of a foreign body in the lung predisposes to the development of true tuberculosis. with the dissemination of knowledge regarding the possibility of bronchial foreign body, and the marvellous success in their removal by bronchoscopy, the cases of prolonged foreign body sojourn should decrease in number. it should be the recognized rule, and not the exception, that all chest conditions, acute or chronic, should have the benefit of roentgenographic study, even apart from the possibility of foreign body. often even with the clear history of foreign-body aspiration, both patient and physician are deluded by a relatively long period of quiescence in which no symptoms are apparent. this symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum, finally by bronchiectasis and pulmonary abscess, chronic sepsis, and invalidism. _pathology_.--if the foreign body completely obstructs a main bronchus, preventing both aeration and drainage, such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months, or even in a few weeks, in the case of irritating foreign bodies such as peanut kernels and soft rubber. very minute, inorganic foreign bodies may become encysted as in anthracosis. large objects, however, do not become encysted. the object is drawn down by gravity and aspirated into the smallest bronchus it can enter. later the negative pressure below from absorption of air impacts it still further. swelling of the bronchial mucosa from irritation plus infection completes the occlusion of the bronchus. retention of secretions and bacterial decomposition thereof produces first a "drowned lung" (natural passages full of pus); then sloughing or ulceration in the tissues plus the pressure of the pus, causes bronchiectasis; further destruction of the cartilaginous rings results in true abscess formation below the foreign body. the productive inflammation at the site of lodgement of the foreign body results in cicatricial contraction and the formation of a stricture at the top of the cavity, in which the foreign body is usually held. the abscess may extend to the periphery and rupture into the pleural cavity. it may drain intermittently into a bronchus. certain irritating foreign bodies, such as soft rubber, may produce gangrenous bronchitis and multiple abscesses. for observations on pathology (see bibliography, 38). _prognosis_.--if the foreign body be not removed, the resulting chronic sepsis or pulmonary hemorrhage will prove fatal. removal of the foreign body usually results in complete recovery without further local treatment. occasionally, secondary dilatation of a bronchial stricture may be required. all cases will need, besides removal of the foreign body, an antituberculous regimen, and offer a good prognosis if this be followed. _treatment_.--bronchoscopy should be done in all cases of chronic pulmonary abscess and bronchiectasis even though radiographic study reveals no shadow of foreign body. the patient by assuming a posture with the head lowered is urged to expel spontaneously all the pus possible, before the bronchoscopy. the aspirating bronchoscope (fig. 2, e) is often useful in cases where large amounts of secretion may be anticipated. granulations may require removal with forceps and sponging. disturbed granulations result in bleeding which further hampers the operation; therefore, they should not be touched until ready to apply the forceps, unless it is impossible to study the presentation without disturbing them. for this reason secretions hiding a foreign body should be removed with the aspirating tube (fig. 9) rather than by swabbing or sponge-pumping, when the bronchoscopic tube-mouth is close to the foreign body. it is inadvisable, however, to insert a forceps into a mass of granulations to grope blindly for a foreign body, with no knowledge of the presentation, the forceps spaces, or the location of branch-bronchial orifices into which one blade of the forceps may go. dilatation of a stricture may be necessary, and may be accomplished by the forms of bronchial dilators shown in fig. 25. the hollow type of dilator is to be used in cases in which the foreign body is held in the stricture (fig. 83). this dilator may be pushed down over the stem of such an object as a tack, and the stricture dilated without the risk of pushing the object downward. it is only rarely, however, that the point of a tack is free. dense cicatricial tissue may require incision or excision. _internal bronchotomy_ is doubtless, a very dangerous procedure, though no fatalities have occurred in any of the three cases in the bronchoscopic clinic. it is advisable only as a last resort. [181] chapter xvii--unsuccessful bronchoscopy for foreign bodies the limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. when localization by means of transparent films, fluoroscopy, and endobronchial bismuth insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane. with foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. at the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. the nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. the blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility. the possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote; and the lesions established may result fatally even after the expulsion of the object. pulmonary abscess formation and rupture into the pleura should not be awaited, for the foreign body does not often follow the pus into the pleural cavity. it remains in the lung, held in a bed of granulation tissue. furthermore, to await the development is to subject the patient to a prolonged and perhaps fatal sepsis, or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process. the recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy, so that this operation is to be considered when bronchoscopy has failed. bronchoscopy can be considered as having failed, for the time being, when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it; but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today. before considering thoracotomy months of study of the mechanical problem are advisable. it is probable that any foreign body of appreciable size that has gone down the natural passages can be brought back the same way. in the event of a foreign body reaching the pleura, either with or without pus, it should be removed immediately by pleuroscopy or by thoracotomy, without waiting for adhesive pleuritis. the problem may be summarized thus: 1. large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy. 2. the development of bronchoscopy having subsequently solved the problems presented by previous failures, it seems probable that by patient developmental endeavor, any foreign body of appreciable size that has gone down through the natural passages, can be bronchoscopically removed the same way, provided fatal trauma is avoided. at the author's bronchoscopic clinics 98.7 per cent of foreign bodies have been removed. chapter xviii--foreign bodies in the esophagus _etiology_.--the lodgement of foreign bodies in the esophagus is influenced by: 1. the shape of the foreign body (disc-shaped, pointed, irregular). 2. resiliency of the object (safety pins). 3. the size of the foreign body. 4. narrowing of the esophagus, spasmodic or organic, normal, or pathologic. 5. paralysis of the normal esophageal propulsory mechanism. the lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature; a large bolus of food, poorly masticated and hurriedly swallowed, may, however, become impacted in a perfectly normal esophagus. carelessness is the cause of over 80 per cent of the foreign bodies in the esophagus (see bibliography, 29). _site of lodgement_.--almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax. a physiologic narrowing is present at this level, produced in part by muscular contraction, and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture. if dislodged from this position the foreign body usually passes downward to be arrested at the next narrowing or to pass into the stomach. the esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold. such, however, is almost never the case. the cricopharyngeus muscle functionates in starting the foreign body downward as if it were food; but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor. _symptoms_.--_dysphagia_ is the most frequent complaint in cases of esophageally lodged foreign bodies. a very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-passages by food arrested by the foreign body. _dyspnea_ may be present if the foreign body is large enough to compress the trachea. _cough_ may be excited by reflex irritation, overflow of secretions into the larynx, or by perforation of the posterior tracheal wall, traumatic or ulcerative, allowing leakage of food or secretion into the trachea. (see chapter xii for discussion of symptomatology and diagnosis.) _prognosis_.--a foreign body lodged in the esophagus may prove quickly fatal from _hemorrhage_ due to perforation of a large vessel; from _asphyxia_ by pressure on the trachea; or from _perforation_ and _septic mediastinitis_. slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia. sooner or later, if not removed, the foreign body causes death. it may be tolerated for a long period of time, causing abscess, cervical cellulitis, fistulous tracts, and ultimately extreme stenosis from cicatricial contraction. perichondritis of the laryngeal or tracheal cartilages may follow, and result in laryngeal stenosis requiring tracheotomy. the damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal. if the foreign body becomes dislodged and moves downward, the danger of intestinal perforation is encountered. the _prognosis_, therefore, must be guarded so long as the intruder remains in the body. _treatment_.--it is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie. sounding the esophagus with bougies to determine the level of the obstruction, or to palpate the nature of the foreign body, is unnecessary and dangerous. esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus, except for urgent reasons. the level of the stenosis, and usually the nature of the foreign body, can thus be decided. blind instrumentation is dangerous, and in view of the safety and success of esophagoscopy, reprehensible. if for any reason removal should be delayed, bismuth sub-nitrate, gramme 0.6, should be given dry on the tongue every four hours. it will adhere to the denuded surfaces. the addition of calomel, gramme 0.003, for a few doses will increase the antiseptic action. should swallowing be painful, gramme 0.2 of orthoform or anesthesin will be helpful. emetics are inefficient and dangerous. holding the patient up by the heels is rarely, if ever, successful if the foreign body is in the esophagus. in the reported cases the intruder was probably in the pharynx. _external esophagotomy_ for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists. it has been the observation in the bronchoscopic clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way, unless it has already perforated the esophageal wall, in which event it is no longer a case of foreign body in the esophagus. the mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent, while that of esophagoscopy is less than two per cent, if the foreign body has not already set up a serious complication before the esophagoscopy. furthermore, external esophagotomy can be successful only with objects lodged in the cervical esophagus and, moreover, it has happened that after the esophagus has been opened, the foreign body could not be found because of dislodgement and passage downward during the relaxation of the general anesthesia. should this occur during esophagoscopy, the foreign body can be followed with the esophagoscope, and even if it is not overtaken and removed, no risk has been incurred. esophagoscopy is the one method of removal worthy of serious consideration. should it repeatedly fail in the hands of two skillful endoscopists, which will be very rarely, if ever, then external operation is to be considered in cervically lodged foreign bodies. [187] chapter xix--esophagoscopy for foreign body _indications_.--esophagoscopy is demanded in every case in which a foreign body is known to be, or suspected of being, in the esophagus. _contraindications_.--there is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies, even in the presence of aneurism, serious cardiovascular disease, hypertension or the like, although these conditions would render the procedure inadvisable. should the patient be in bad condition from previous ill-advised or blind attempts at extraction, endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved. it is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the passage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient. moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false passage into the mediastinum or overriding the foreign body is great. water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. the esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder: rx. anesthesin...gramme 0.12 bismuth subnitrate...gramme 0.6 calomel, gramme 0.006 to 0.003 may be added to each powder for a few doses to increase the antiseptic effect. if the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done. this will give time for nature to repair the damage and render the removal of the object more certain and less hazardous. perforation of the esophagus by the foreign body, or by blind instrumentation, is a contraindication to esophagoscopy. it is manifested by such signs as subcutaneous emphysema, swelling of the neck, fever, irritability, increase in pulsatory and respiratory rates, and pain in the neck or chest. gaseous emphysema is present in some cases, and denotes a dangerous infection. esophagoscopy should be postponed and the treatment mentioned at the end of this chapter instituted. after the subsidence of all symptoms other than esophageal, esophagoscopy may be done safely. pleural perforation is manifested by the usual signs of pneumothorax, and will be demonstrated in the roentgenogram. esophagoscopic extraction of foreign bodies it is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look. everything likely to be needed for extraction of the intruder should be sterile and ready at hand. furthermore, all required instruments for laryngoscopy, bronchoscopy or tracheotomy should be prepared as a matter of routine, however rarely they may be needed. sponging should be done cautiously lest the foreign body be hidden in secretions or food accumulation, and dislodged. small food masses often lodge above the foreign body and are best removed with forceps. the folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. if the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great. _"overriding" or failure to find a foreign body known to be present_ is explained by the collapsed walls and folds covering the object, since the esophagoscope cannot be of sufficient size to smooth out these folds, and still be of small enough diameter to pass the constricted points of the esophagus noted in the chapter on anatomy. objects are often hidden just distal to the cricopharyngeal fold, which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object, so that the contact at the side of the tube is not felt as the tube passes over the foreign body (fig. 91). the chief factors in overriding an esophageal foreign body are: 1. the chute-like effect of the plica cricopharyngeus. 2. the chute-like effect of other folds. 3. the lurking of the foreign body in the unexplored pyriform sinus. 4. the use of an esophagoscope of small diameter. 5. the obscuration of the intruder by secretion or food debris. 6. the obscuration of the intruder by its penetration of the esophageal wall. 7. the obscuration of the intruder by inflammatory sequelae. [fig. 91.--illustrating the hiding of a coin by the folding downward of the plica cricopharyngeus. the muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has passed over the foreign body. other folds may in rare instances act similarly in hiding a foreign body from view. this overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall.] _the esophageal speculum for the removal of foreign bodies_ is useful when the object is not more than 2 cm. below the cricoid in a child, and 3 cm. in the adult. the fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found. the author's down-jaw forceps (fig. 22) are very useful to reach down back of the cricopharyngeal fold, because of the often small posterior forceps space. the speculum has the disadvantage of not allowing deeper search should the foreign body move downward. in infants, the child's size laryngoscope may be used as an esophageal speculum. general anesthesia is not only unnecessary but dangerous, because of the dyspnea created by the endoscopic tube. local anesthesia is unnecessary as well as dangerous in children; and its application is likely to dislodge the foreign body unless used as a troche. forbes esophageal speculum is excellent. mechanical problems of esophagoscopic removal of foreign bodies the bronchoscopic problems considered in the previous chapter should be studied. _the extraction of transfixed foreign bodies_ presents much the same problem as those in the bronchi, though there is no limit here to the distance an object may be pushed down to free the point. thin, sharp foreign bodies such as bones, dentures, pins, safety-pins, etcetera, are often found to lie crosswise in the esophagus, and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made (fig. 92). should the intruder be grasped in the center and traction exerted, serious and perhaps fatal trauma might ensue. [191] [fig. 92.--the problem of the horizontally transfixed foreign body in the esophagus. the point, d, had caught as the bone, a, was being swallowed. the end, e, was forced down to c, by food or by blind attempts at pushing the bone downward. the wall, f, should be laterally displaced to j, with the esophagoscope, permitting the forceps to grasp the end, m, of the bone. traction in the direction of the dart will disimpact the bone and permit it to rotate. the rotation forceps are used as at k.] [fig. 93.--solution of the mechanical problem of the broad foreign body having a sharp point by version. if withdrawn with plain forceps as applied at a, the point b, will rip open the esophageal wall. if grasped at c, the point, d, will rotate in the direction of f and will trail harmlessly. to permit this version the rotation forceps are used as at h. on this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal.] the extraction of broad, flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in fig. 93. _extraction of open safety-pins from the esophagus_.--an open safety pin with the point down offers no particular mechanical difficulty in removal. great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. the coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. an open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. a roentgenogram should always be made in the plane showing the widest spread of the pin. it is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. it may be best to close the safety pin with the safety-pin closer, as illustrated in fig. 37. for this purpose arrowsmith's closer is excellent. in other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. the rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. the sense of touch will aid the sense of sight in the execution of this maneuver (fig. 87). when the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. in certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. this, however, is a dangerous method and applicable in but few cases. it is better to disengage the point by downward and inward rotation with the tucker forceps. _version of a safety pin_.--a safety pin of very small size may be turned over in a direction that will cause the point to trail. an advancing point will puncture. this is a dangerous procedure with a large safety pin. _endogastric version_.--a very useful and comparatively safe method is illustrated in figs. 94 and 95. in the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus passed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost. it can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. only very small safety-pins can be withdrawn through the esophagoscope. _spatula-protected method_.--safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. the keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. instruments and foreign body are then removed together. often the pin point will catch in the light-chamber where it is very safely lodged. if the pin be then pulled upon it will straighten out and may be withdrawn through the tube. [fig. 94.--endogastric version. one of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach, where they are turned and removed. the first illustration (a) shows the rotation forceps before seizing pin by the ring of the spring end. (forceps jaws are shown opening in the wrong diameter.) at b is shown the pin seized in the ring by the points of the forceps. at c is shown the pin carried into the stomach and about to be rotated by withdrawal. d, the withdrawal of the pin into the esophagoscope which will thereby close it. if withdrawn by flat-jawed forceps as at f, the esophageal wall would be fatally lacerated.] _double pointed tacks and staples_, when lodged point upward, must be turned so that the points trail on removal. this may be done by carrying them into the stomach and turning them, as described under safety-pins. _the extraction of foreign bodies of very large size_ from the esophagus is greatly facilitated by the use of general anesthesia, which relaxes the spasmodic contractions of the esophagus often occurring when attempt is made to withdraw the foreign body. general anesthesia, though entirely unnecessary for introduction of the esophagoscope, in any case may be used if the body is large, sharp, and rough, in order to prevent laceration through the muscular contractions otherwise incident to withdrawal.* in exceptional cases it may be necessary to comminute a large foreign body such as a tooth plate. a large smooth foreign body may be difficult to seize with forceps. in this case the mechanical spoon or the author's safety-pin closer may be used. * it must always be remembered that large foreign bodies are very prone to cause dyspnea that renders general anesthesia exceedingly dangerous especially in children. [fig. 95.--lateral roentgenogram of a safety-pin in a child aged 11 months, demonstrating the esophageal location of the pin in this case and the great value of the lateral roentgenogram in the localization of foreign bodies. the pin was removed by the author's method of endogastric version. (plate made by george c. johnston )] _the extraction of meat and other foods from the esophagus_ at the level of the upper thoracic aperture is usually readily accomplished with the esophageal speculum and forceps. in certain cases the mechanical spoon will be found useful. should the bolus of food be lodged at the lower level the esophagoscope will be required. _extraction of foreign bodies from the strictured esophagus_.--foreign bodies of relatively small size will lodge in a strictured esophagus. removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body passing the first one lodges at the second. still more difficult is the case when the second stricture is considerably below the first, and not concentric. under these circumstances it is best to divulse the upper stricture mechanically, when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body. _prolonged sojourn of foreign bodies in the esophagus_, while not so common as in the bronchi is by no means of rare occurrence. following their removal, stricture of greater or less extent is almost certain to follow from contraction of the fibrous-tissue produced by the foreign body. _fluoroscopic esophagoscopy_ is a questionable procedure, for the esophagus can be explored throughout by sight. in cases in which it is suspected that a foreign body, such as pin, has partially escaped from the esophagus, the fluoroscope may aid in a detailed search to determine its location, but under no circumstances should it be the guide for the application of forceps, because the transparent but vital tissues are almost certain to be included in the grasp. [197] complications and dangers of esophagoscopy for foreign bodies. asphyxia from the pressure of the foreign body, or the foreign body plus the esophagoscope, is a possibility (fig. 91). faulty position of the patient, especially a low position of the head, with faulty direction of the esophagoscope may cause the tube mouth to press the membranous tracheo-esophageal wall into the trachea, so as temporarily to occlude the tracheal lumen, creating a very dangerous situation in a patient under general anesthesia. prompt introduction of a bronchoscope, with oxygen and amyl nitrite insufflation and artificial respiration, may be necessary to save life. the danger is greater, of course, with chloroform than with ether anesthesia. cocain poisoning may occur in those having an idiosyncrasy to the drug. cocain should never be used with children, and is of little use in esophagoscopy in adults. its application is more annoying and requires more time than the esophagoscopic removal of the foreign bodies without local anesthesia. traumatic esophagitis, septic mediastinitis, cervical cellulitis, and, most dangerous, gangrenous esophagitis may be present, caused by the foreign body itself or ill-advised efforts at removal. perforation of the esophagus with the esophagoscope is rare, in skillful hands, if the esophageal wall is sound. the esophageal wall, however, may be weakened by ulceration, malignant disease, or trauma, so that the possibility of making a false passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening. to avoid entering a false passage previously created, is often exceedingly difficult, and usually it is better to wait for obliterative adhesive inflammation to seal the tissue layers together. _treatment_.--acute esophagitis calls for rest in bed, sterile liquid food, and the administration of bismuth powder mentioned in the paragraph on contraindications. an ice bag applied to the neck may afford some relief. the mouth should be hourly cleansed with the following solution: dakin's solution 1 part cinnamon water 5 parts. emphysema unaccompanied by pyogenic processes usually requires no treatment, though an occasional case may require punctures of the skin to liberate the air. gaseous emphysema and pus formation urgently demand early external drainage, preferably behind the sternomastoid. should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable. prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected. foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae. in the serious degrees of esophageal trauma, particularly if the pleura be perforated, gastrostomy is indicated to afford rest of the esophagus, and for alimentation. a duodenal feeding tube may be placed through an esophagoscope passed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly passed stomach tube would be very likely to enter, with probably dangerous results. [199] chapter xx--pleuroscopy _foreign bodies in the pleural cavity_ should be immediately removed. the esophageal speculum inserted through a small intercostal incision makes an excellent pleuroscope, its spatular tip being of particular value in moving the lung out of the way. this otherwise dark cavity is thus brilliantly illuminated without the necessity of making a large flap resection, an important factor in those cases in which there is no infection present. the pleura and wound may be immediately closed without drainage, if the pleura is not infected. excessive plus pressure or pus may require reopening. in one case in which the author removed a foreign body by pleuroscopy, healing was by first intention and the lung filled in a few days. drainage tubes that have slipped up into the empyemic cavity are foreign bodies. they are readily removed with the retrograde esophagoscope even through the smallest fistula. the aspirating canal keeps a clear field while searching for the drain. _pleuroscopy for disease_.--most pleural diseases require a large external opening for drainage, and even here the pleuroscope may be of some use in exploring the cavities. usually there are many adhesions and careful ray study may reveal one or more the breaking up of which will improve drainage to such an extent as to cure an empyema of long standing. repeated severing of adhesions, aspiration and sometimes incision of the thickened visceral pleura may be necessary. the author is so strongly imbued with the idea that local examination under full illumination has so revolutionized the surgery of every region of the body to which it has been applied, that every accessible region should be thus studied. the pleural cavity is quite accessible with or without rib-resection, and there is practically no risk in careful pleuroscopy. [201] chapter xxi--benign growths in the larynx benign growths in the larynx are easily and accurately removable by direct laryngoscopy; but perhaps no method has been more often misused and followed by most unfortunate results. it should always be remembered that benign growths are benign, and that hence they do not justify the radical work demanded in dealing with malignancy. the larynx should be worked upon with the same delicacy and respect for the normal tissues that are customary in dealing with the eye. _granulomata in the larynx_, while not true neoplasms, require extirpation in some instances. _vocal nodules_, when other methods of cure such as vocal rest, various vocal exercises, etcetera have failed may require surgical excision. this may be done with the laryngeal tissue forceps or with the author's vocal nodule forceps. sessile vocal nodules may be cured by touching them with a fine galvanocautery point, but all work on the vocal cords must be done with extreme caution and nicety. it is exceedingly easy to ruin a fine voice. _fibromata_, often of inflammatory genesis, are best removed with the laryngeal grasping forceps, though the small laryngeal punch or tissue forceps may be used. if very large, they may be amputated with the snare, the base being treated with galvanocautery though this is seldom advisable. strong traction should be avoided as likely to do irreparable injury to the laryngeal motility. _cystomata_ may get well after simple excision or galvanopuncture of a part of the wall of the sac, but complete extirpation of the sac is often required for cure. the same is true of _adenomata._ [202] angiomata, if extensive and deeply seated, may require deep excision, but usually cure results from superficial removal. usually no cauterization of the vessels at the base is necessary, either to arrest hemorrhage or to lessen the tendency to recurrence. a diffuse telangiectasis, should it require treatment, may be gently touched with a needle-pointed galvanocaustic electrode at a number of sittings. the galvanonocautery is a dangerous method to use in the larynx. radium offers the best results in this latter form of angioma, applied either internally or to the neck. _lymphoma, enchondroma and osteoma_, if not too extensively involving the laryngeal walls, may be excised with basket punch forceps, but lymphoma is probably better treated by radium.* _true myxomata and lipomata_ are very rare. _amyloid tumors_ are occasionally met with, and are very resistant to treatment. _aberrant thyroid tumors_ do not require very radical excision of normal base, but should be removed as completely as possible. in a general way, it may be stated that with benign growths in the larynx the best functional results are obtained by superficial rather than radical, deep extirpation, remembering that it is easier to remove tissue than to replace it, and that cicatrices impair or ruin the voice and may cause stenosis. * in a case reported by delavan a complete cure with perfect restoration of voice resulted from radium after i had failed to cure by operative methods. (proceedings american laryngological association, 1921.) [203] chapter xxii--benign growths in the larynx (continued) papillomata of the larynx in children of all benign growths in the larynx papilloma is the most frequent. it may occur at any age of childhood and may even be congenital. the outstanding fact which necessarily influences our treatment is the tendency to recurrences, followed eventually in practically all cases by a tendency to disappearance. in the author's opinion multiple papillomata constitute a benign, self-limited disease. there are two classes of cases. 1. those in which the growth gets well spontaneously, or with slight treatment, surgically or otherwise; and, 2, those not readily amenable to any form of treatment, recurrences appearing persistently at the old sites, and in entirely new locations. in the author's opinion these two classes of case represent not two different kinds of growths, but stages in the disease. those that get well after a single removal are near the end of the disease. papillomata are of inflammatory origin and are not true neoplasms in the strictest sense. _methods of treatment_.--irritating applications probably provoke recurrences, because the growths are of inflammatory origin. formerly laryngostomy was recommended as a last resort when all other means had failed. the excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. thyrotomy for papillomata is mentioned only to be condemned. fulguration has been satisfactory in the hands of some, disappointing to others. it is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. in my experience, however, i have never seen a cure of papillomata which could be attributed to the radiation. i have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. in other most unfortunate cases i have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. possibly the disastrous results were due to overdosage; but i feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. in cancer we have an infiltrating process that has no limits short of life itself. _endolaryngeal extirpation_ of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility. if, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway. obstructed respiration introduces into general anesthesia an enormous element of danger. concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the bronchoscopic clinic, that repeated superficial removals with blunt non-cutting forceps (see chapter i) will so modify the soil as to make it unfavorable for repullulation. the removals are superficial and do not include the subjacent normal tissue. radical removal of a papilloma situated, for instance, on the left ventricular band or cord, can in no way prevent the subsequent occurrence of a similar growth at a different site, as upon the epiglottis, or even in the fauces. furthermore, radical removal of the basal tissues is certain to impair the phonatory function. excellent results as to voice and freedom from recurrence have always followed repeated superficial removal. the time required has been months or a year or two. only rarely has a cure followed a single extirpation. if the child is but slightly dyspneic, the obstructing part of the growth is first removed without anesthesia, general or local; the remaining fungations are extirpated subsequently at a number of brief seances. the child is thus not terrified, soon loses dread of the removals, and appreciates the relief. should the child be very dyspneic when first seen, a low tracheotomy is immediately done, and after an interim of ten days, laryngoscopic removal of the growth is begun. tracheotomy probably has a beneficial effect on the disease. tracheal growths require the insertion of the bronchoscope for their removal. _papillomata in the larynx of adults_ are, on the whole, much more amenable to treatment than similar growths in children. tracheotomy is very rarely required, and the tendency to recurrence is less marked. many are cured by a single extirpation. the best results are obtained by removal of the growths with the laryngeal grasping-forceps, taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue. radical resection or cauterization of the base is unwise because of the probable impairment of the voice, or cicatricial stenosis, without in anyway insuring against repullulation. the papillomata are so soft that they give no sensation of traction to the forceps. they can readily be "scalped" off without any impairment of the sound tissues, by the use of the author's papilloma forceps (fig. 29). cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning. a gentle hand might be trusted with the cup forceps (fig. 32, large size.) sir felix semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths. therefore, no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths. indeed there is much clinical evidence elsewhere in the body, and more than a little such evidence as to the larynx, to warrant the removal of benign growths, repeated if necessary, as a prophylactic of cancer (bibliography, 19). [207] chapter xxiii--benign growths primary in the tracheobronchial tree extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. true primary growths of the tracheobronchial tree, though not frequent, are by no means rare. these primary growths include primary papillomata and fibromata as the most frequent, aberrant thyroid, lipomata, adenomata, granulomata and amyloid tumors. chondromata and osteochondromata may be benign but are prone to develop malignancy, and by sarcomatous or other changes, even metaplasia. edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered. _symptoms of benign tumors of the tracheobronchial tree_.--cough, wheezing respiration, and dyspnea, varying in degree with the size of the tumor, indicate obstruction of the airway. associated with defective aeration will be the signs of deficient drainage of secretions. roentgenray examination may show the shadow of enchondromata or osteomata, and will also show variations in aeration should the tumor be in a bronchus. _bronchoscopic removal of benign growths_ is readily accomplished with the endoscopic punch forceps shown in figs. 28 and 33. quick action may be necessary should a large tumor producing great dyspnea be encountered, for the dyspnea is apt to be increased by the congestion, cough, and increased respiration and spasm incidental to the presence of the bronchoscope in the trachea. general anesthesia, as in all cases showing dyspnea, is contraindicated. the risks of hemorrhage following removal are very slight, provided fungations on an aneurismal erosion be not mistaken for a tumor. multiple papillomata when very numerous are best removed by the author's "coring" method. this consists in the insertion of an aspirating bronchoscope with the mechanical aspirator working at full negative pressure. the papillomata are removed like coring an apple; though the rounded edge of the bronchoscope does not even scratch the tracheal mucosa. many of the papillomata are taken off by the holes in the bronchoscope. aspiration of the detached papillomata into the lungs is prevented by the corking of the tube-mouth with the mass of papillomata held by the negative pressure at the canal inlet orifice. chapter xxiv--benign neoplasms of the esophagus as a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen, but true benign tumors of the esophagus are rare affections. keloidal changes in scar tissue may occur. cases of retention, epithelial and dermoid cysts have been observed; and there are isolated reports of the finding of papillomata, fibromata, lipomata, myomata and adenomata. the removal of these is readily accomplished with the tissue forceps (fig. 28), if the growths are small and projecting into the esophageal lumen. the determination of the advisability of the removal of keloidal scars would require careful consideration of the particular case, and the same may be said of very large growths of any kind. the extreme thinness of the esophageal walls must be always in the mind of the esophagoscopist if he would avoid disaster. [210] chapter xxv--endoscopy in malignant disease of the larynx the general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. the facility, accuracy and thoroughness afforded by skilled, direct, laryngeal operation offers a means of lessening the incidence of cancer. to a much greater extent the facility, accuracy, and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis. well-planned, careful, external operation (laryngofissure) followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx; and it is a cure only in those intrinsic cases in which the growth is small, and is located in the anterior two-thirds of the intrinsic area. by limiting operations strictly to this class of case, eighty-five per cent of cures may be obtained.* in determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached. it is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method, for the reason that the full extent of the growth cannot be appreciated when viewed only from above, and the necessary radical removal cannot be accurately or completely accomplished. * the author's results in laryngofissure have recently fallen to 79 per cent of relative cures by thyrochondrotomy. _malignant disease of the epiglottis_, in those rare cases where the lesion is strictly limited to the tip is, however, an exception. if amputation of the epiglottis will give a sufficiently wide removal, this may be done en masse with a heavy snare, and has resulted in complete cure. very small growths may be removed sufficiently widely with the punch forceps (fig. 33); but piece meal removal of malignancy is to be avoided. _differential diagnosis of laryngeal growths in the larynx of adults_.--determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities, namely, 1. lues. 2. tuberculosis, including lupus. 3. scleroma. 4. malignant neoplasm. in the bronchoscopic clinic the following is the routine procedure: 1. a wassermann test is made. if negative, and there remains a suspicion of lues, a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks; during which time no potassium iodid is given, lest its reaction upon the larynx cause an edema necessitating tracheotomy. if no improvement is noticed lues is excluded. if the wassermann is positive, malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury, because, for instance, a leutic or tuberculous patient may have cancer; a tuberculous patient may have lues; or a leutic patient, tuberculosis. 2. pulmonary tuberculosis is excluded by the usual means. if present the laryngeal lesion may or may not be tuberculous; if the laryngoscopic appearances are doubtful a specimen is taken. lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty. 3. in all cases in which the diagnosis is not clear a specimen is taken. this is readily accomplished by direct laryngoscopy under local anesthesia, using the regular laryngoscope or the anterior commissure laryngoscope. the best forceps in case of large growths are the alligator punch forceps (fig. 33). smaller growths require tissue forceps (fig. 28). in case of small growths, it is best to remove the entire growth; but without any attempt at radical extirpation of the base; because, if the growth prove benign it is unnecessary; if malignant, it is insufficient. _inspection of the party wall in cases of suspected laryngeal malignancy_.--when taking a specimen the party wall should be inspected by passing a laryngoscope or, if necessary, an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus. if this region shows infiltration, all hope of cure by operation, however radical, should be abandoned. _radium and the therapeutic roentgenray_ have given good results, but not such as would warrant their exclusive use in any case of malignancy in the larynx operable by laryngofissure. with inoperable cases, excellent palliative results are obtained. in some cases an almost complete disappearance of the growth has occurred, but ultimately there has been recurrence. the method of application of the radium, dosage, and its screening, are best determined by the radiologist in consultation with the laryngologist. radium may be applied externally to the neck, or suspended in the larynx; radium-containing needles may be buried in the growth, or the emanations, imprisoned in glass pearls or capillary tubes, may be inserted deeply into the growth by means of a small trocar and cannula. for all of these procedures direct laryngoscopy affords a ready means of accurate application. tracheotomy is necessary however, because of the reactionary swelling, which may be so great as to close completely the narrowed glottic chink. where this is the case, the endolaryngeal application of the radium may be made by inserting the container through the tracheotomic wound, and anchoring it to the cannula. the author is much impressed with freer's method of radiation from the pyriform sinus in such cases as those in which external radiation alone is deemed insufficient. the work of drs. d. bryson delavan and douglass m. quick forms one of the most important contributions to the subject of the treatment of radium by cancer. (see proceedings of the american laryngological association, 1922; also proceedings of the tenth international otological congress, paris, 1922.) [214] chapter xxvi--bronchoscopy in malignant growths of the trachea the trachea is often secondarily invaded by malignancy of the esophagus, thyroid gland, peritracheal or peribronchial glands. primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy. peritracheal or peribronchial malignancy may produce a compressive stenosis covered with normal mucosa. endoscopically, the wall is seen to bulge in from one side causing a crescentic picture, or compression of opposite walls may cause a "scabbard" or pear shaped lumen. endotracheal and endobronchial malignancy ulcerate early, and are characterized by the bronchoscopic view of a bleeding mass of fungating tissue bathed in pus and secretion, usually foul. the diagnosis in these cases rests upon the exclusion of lues, and is rendered certain by the removal of a specimen for biopsy. sarcoma and carcinoma of the thyroid when perforating the trachea may become pedunculated. in such cases aberrant non-pathologic thyroid must be excluded by biopsy. endothelioma of the trachea or bronchus may also assume a pedunculated form, but is more often sessile. _treatment_.--pedunculated malignant growths are readily removed with snare or punch forceps. cure has resulted in one case of the author following bronchoscopic removal of an endothelioma from the bronchus; and a limited carcinoma of the bronchus has been reported cured by bronchoscopic removal, with cauterization of the base. most of the cases, however, will be subjects for palliative tracheotomy and radium therapy. it will be found necessary in many of the cases to employ the author's long, cane-shaped tracheal cannula (fig. 104, a), in order to pipe the air down to one or both bronchi past the projecting neoplasm. it has recently been demonstrated that following the intravenous injection of a suspension of the insoluble salt, radium sulphate, that the suspended particles are held in the capillaries of the lung for a period of one year. intravenous injections of a watery suspension, and endobronchial injections of a suspension of radium sulphate in oil, have had definite beneficial action. while as yet, no relatively permanent cures of pulmonary malignancy have been obtained, the amelioration and steady improvement noted in the technic of radium therapy are so encouraging that every inoperable case should be thus treated, if the disease is not in a hopelessly advanced stage. in a case under the care of dr. robert m. lukens at the bronchoscopic clinic, a primary epithelioma of the trachea was retarded for 2 years by the use of radium applied by dr. william s. newcomet, radium-therapist, and miss katherine e. schaeffer, technician. [216] chapter xxvii--malignant disease of the esophagus cancer of the esophagus is a more prevalent disease than is commonly thought. in the male it usually develops during the fourth and fifth decades of life. there is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors. in the female the condition often occurs at an earlier age than in the male, and tends to run a more protracted course, preceeded in some cases by years of precancerous dysphagia. squamous-celled epithelioma is the most frequent type of neoplasm. in the lower third of the esophagus, cylindric cell carcinoma may be found associated with a like lesion in the stomach. sarcoma of the esophagus is relatively rare (bibliography 1, p. 449). the sites of the lesion are those of physiologic narrowing of the esophagus. the middle third is most frequently involved; and the lower third, near the cardia, comes next in frequency. cancer of the lower third of the esophagus preponderates in men, while cancer of the upper orifice is, curiously, more prevalent in women. the lesion is usually single, but multiple lesions, resulting from implantation metastases have been observed (bibliography 1, p. 391). bronchoesophageal fistula from extension is not uncommon. _symptoms_.--malignant disease of the esophagus is rarely seen early, because of the absence, or mildness, of the symptoms. dysphagia, the one common symptom of all esophageal disease, is often ignored by the patient until it becomes so marked as to prevent the taking of solid food; therefore, the onset may have the similitude of abruptness. any well masticated solid food can be swallowed through a lumen 5 millimeters in diameter. the inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia. when the stenosis becomes so severe that the fluid intake is limited, rapid decline occurs from water starvation. pain is usually a late symptom of the disease. it may be of an aching character and referred to the vertebral region or to the neck; or it may only accompany the act of swallowing. blood-streaked, regurgitated material, and the presence of odor, are late manifestations of ulceration and secondary infection. in some cases, constant oozing of blood from the ulcerated area adds greatly to the cachexia. if the recurrent laryngeal nerves are involved, unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough, dyspnea, aphonia, and possibly septic pneumonia. _diagnosis_.--it has been estimated that 70 per cent of stenoses of the esophagus in adults are malignant in nature. this should stimulate the early and careful investigation of every case of dysphagia. when all cases of persistent dysphagia, however slight, are endoscopically studied, precancerous lesions may be discovered and treated, and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal. luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests, supplemented in rare instances by biopsy. aneurysm of the aorta must in all cases of dysphagia be excluded, for the dilated aorta may be the sole cause of the condition, and its presence contraindicates esophagoscopy because of the liability of rupture. foreign body is to be excluded by history and roentgenographic study. spasmodic stenosis of the esophagus may or may not have a malignant origin. esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain. it is to be especially remembered, however, that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth. fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue. _the esophagoscopic appearances of malignant disease_, varying with the stage and site of origin of the growth, may present as follows:- 1. submucosal infiltration covered by perfectly normal membrane, usually associated with more or less bulging of the esophageal wall, and very often with hardness and infiltration. 2. leucoplakia. 3. ulceration projecting but little above the surface at the edges. 4. rounded nodular masses grouped in mulberry-like form, either dark or light red in color. 5. polypoid masses. 6. cauliflower fungations. in considering the esophagoscopic appearances of cancer, it is necessary to remember that after ulceration has set in, the cancerous process may have engrafted upon it, and upon its neighborhood, the results of inflammation due to the mixed infections. cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane. the significant signs at this early stage are: 1. absence of one or more of the normal radial creases between the folds. 2. asymmetry of the inspiratory enlargement of lumen. 3. sensation of hardness of the wall on palpation with the tube. 4. the involved wall will not readily be made to wrinkle when pushed upon with the tube mouth. in all the later forms of lesions the two characteristics are (a) the readiness with which oozing of blood occurs; and (b) the sense of rigidity, or fixation, of the involved area as palpated with the esophagoscope, in contrast to the normally supple esophageal wall. esophageal dilatation above a malignant lesion is rarely great, because the stenosis is seldom severely obstructive until late in the course of the disease. _treatment_.--the present 100 per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study. the relief or circumvention of the dysphagia requires early measures to prevent food and water starvation. _bouginage_ of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability, and is attended with the great risk of perforating the weakened esophageal wall. _esophageal intubation_ may serve for a time to delay gastrostomy but it cannot supplant it, nor obviate the necessity for its ultimate performance. the charters-symonds or guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope. the tube must be changed every week or two for cleaning, and duplicate tubes must be ready for immediate reinsertion. eventually, a smaller, and then a still smaller tube are needed, until finally none can be introduced; though in some cases the tube can be kept in the soft mass of fungations until the patient has died of hemorrhage, exhaustion, complications or intercurrent disease. _gastrostomy_ is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst. the operation should be done before inanition has made serious inroads. as in the case of tracheotomy, we always preach doing it early, and always do it late. if postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach. _radiotherapy_.--radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. no permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. the combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases. the dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. two fundamental points are to be considered, however. the radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. the dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. if the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. it is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (fig. 95) drs. henry k. pancoast, george e. pfahler and william s. newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer. [221] chapter xxviii--direct laryngoscopy in diseases of the larynx the diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. no anesthetic, local or general, should be used, for the practised endoscopist can complete the examination within a minute of time and without pain to the patient. the technic for doing this should be acquired by every laryngologist. anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria, and especially because of the dyspnea so frequently present in laryngeal disease. to attempt general anesthesia in a dyspneic case is to invite disaster (see tracheotomy). it is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa, so that the first glance should include an estimation of the color of the mucosa, which, as a result of the engorgement, deepens with the prolongation of the direct laryngoscopy. _chronic subglottic edema_, often the result of perichondritis, may require linear cauterization at various times, to reduce its bulk, after the underlying cause has been removed. _perichondritis and abscess_, and their sequelae are to be treated on the accepted surgical precepts. they may be due to trauma, lues, tuberculosis, enteric fever, pneumonia, influenza, etc. _tuberculosis of the larynx_ calls for conservatism in the application of surgery. ulceration limited to the epiglottis may justify amputation of the projecting portion or excision of only the ulcerated area. in either case, rapid healing may be expected, and relief from the odynphagia is sometimes prompt. amputation of the epiglottis is, however, not to be done if ulceration in other portions of the larynx coexist. the removal of tuberculomata is sometimes indicated, and the excision of limited ulcerative lesions situated elsewhere than on the epiglottis may be curative. these measures as well as the galvanocautery are easily executed by the facile operator; but their advisability should always be considered from a conservative viewpoint. they are rarely justifiable until after months of absolute silence and a general antituberculous regime have failed of benefit. _galvanopuncture_ for laryngeal tuberculosis has yielded excellent results in reducing the large pyriform edematous swellings of the aryepiglottic folds when ulceration has not yet developed. deep punctures at nearly a white heat, made perpendicular to the surface, are best. care must be exercised not to injure the cricoarytenoid joint. fungating ulcerations may in some cases be made to cicatrize by superficial cauterization. excessive reactions sometimes follow, so that a light application should be made at the first treatment. _congenital laryngeal stridor_ is produced by an exaggeration of the infantile type of larynx. the epiglottis will be found long and tapering, its lateral margins rolled backward so as to meet and form a cylinder above. the upper edges of the aryepiglottic folds are approximated, leaving a narrow chink. the lack of firmness in these folds and the loose tissue in the posterior portion of the larynx, favors the drawing inward of the laryngeal aperture by the inspiratory blast. the vibration of the margins of this aperture produces the inspiratory stridor. diagnosis is quickly made by the inspection of the larynx with the infant diagnostic laryngoscope. no anesthetic, general or local, is needed. stridorous respiration may also be due to the presence of laryngeal papillomata, laryngeal spasm, thymic compression, congenital web, or an abnormal inspiratory bulging into the trachea of the posterior membranous tracheo-esophageal wall. the term "congenital laryngeal stridor" should be limited to the first described condition of exaggerated infantile larynx. _treatment of congenital laryngeal stridor_ should be directed to the relief of dyspnea, and to increasing the nutrition and development of the infant. the insertion of a bronchoscope will temporarily relieve an urgent dyspneic attack precipitated by examination; but this rarely happens if the examination is not unduly prolonged. tracheotomy may be needed to prevent asphyxia or exhaustion from loss of sleep; but very few cases require anything but attention to nutrition and hygiene. recovery can be expected with development of the laryngeal structures. _congenital webs of the larynx_ require incision or excision, or perhaps simply bouginage. congenital goiter and congenital laryngeal paralysis, both of which may cause stertorous breathing, are considered in connection with other forms of stenosis of the air passages. _aphonia_ due to cicatricial webs of the larynx may be cured by plastic operations that reform the cords, with a clean, sharp anterior commissure, which is a necessity for clear phonation. the laryngeal scissors and the long slender punch are often more useful for these operations than the knife. [224] chapter xxix--bronchoscopy in diseases of the trachea and bronchi _the indications for bronchoscopy in disease_ are becoming increasingly numerous. among the more important may be mentioned: 1. bronchiectasis. 2. chronic pulmonary abscess. 3. unexplained dyspnea. 4. dyspnea unrelieved by tracheotomy calls for bronchoscopic search for deeper obstruction. 5. paralysis of the recurrent laryngeal nerve, the cause of which is not positively known. 6. obscure thoracic disease. 7. unexplained hemoptysis. 8. unexplained cough. 9. unexplained expectoration. _contraindications to bronchoscopy in disease_ do not exist if the bronchoscopy is really needed. serious organic disease such as aneurysm, hypertension, advanced cardiac disease, might render bronchoscopy inadvisable except for the removal of foreign bodies. _bronchoscopic appearances in disease_.--the first look should note the color of the bronchial mucosa, due allowance being made for the pressure of tubal contact, secretions, and the engorgement incident to continued cough. the carina trachealis normally moves slowly forward as well as downward during deep inspiration, returning quickly during expiration. impaired movement of the carina indicates peritracheal and peribronchial pathology, the fixation being greatest in advanced cancer. in children and in the smaller tubes of the adult, the lengthening and dilatation of the bronchi during inspiration, and their shortening and contraction during expiration are readily seen. _anomalies of the tracheobronchial tree_.--tracheobronchial anomalies are relatively rare. congenital esophagotracheal and esophagobronchial fistulae are occasionally seen, and cases of cervicotracheal fistulae have been reported. congenital webs and diverticula of the trachea are cited infrequently. laryngoptosis and deviation of the trachea may be congenital. substernal goitre, aneurysm, malignant growths, and various mediastinal adenopathies may displace the trachea from its normal course. the emphysematous chest fixed in the deep voluntary inspiratory position produces in some cases an elevation of the superior thoracic aperture simulating laryngoptosis (bibliography r, pp. 468, 594). _compression stenosis of the trachea and bronchi_.--compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. less frequently, enlarged mediastinal tuberculous, leukemic, leutic or hodgkin's glands compress the airway. the left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle. compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing. the endoscopic picture of compression stenosis is that of an elliptical or scabbard-shaped lumen when the bronchus is at rest or during inspiration. concentric funnel-like compression stenosis, while rare, may be produced by annular growths. _treatment of compression stenoses of the trachea_.--if the thymus be at fault, rapid amelioration of symptoms follows roentgenray or radium therapy. tracheotomy and the insertion of the long cane-shaped cannula (fig. 104) past the compressed area is required in the cases caused by conditions less amenable to treatment than thymic enlargement. permanent cure depends upon the removability of the compressive mass. should the bronchi be so compressed by a benign condition as to prevent escape of secretions from the subjacent air passages, bronchial intubation tubes may be inserted, and, if necessary, worn constantly. they should be removed weekly for cleansing and oftener if obstructed. _influenzal laryngotracheobronchitis_.--influenzal infection, not always by the same organism, sweeps over the population, attacking the air passages in a violent and quite characteristic way. bronchoscopy shows the influenzal infection to be characterized by intense reddening and swelling of the mucosa. in some cases the swelling is so great as to necessitate tracheotomy, or intubation of the larynx; and if the edema involve the bronchi, occlusion may be fatal. hemorrhagic spots and superficial erosions are commonly seen, and a thick, tenacious exudate, difficult of expectoration, lies in patches in the trachea. infants may asphyxiate from accumulation of this secretion which they are unable to expel. the differential diagnosis from diphtheria is sometimes difficult. the absence of true membrane and the failure to find diphtheria bacilli in smears taken from the trachea are of aid but are not infallible. in doubtful cases, the administration of diphtheria antitoxin is a wise precaution pending the establishment of a definite diagnosis. the pseudomembrane sometimes present in influenzal tracheobronchitis is thinner and less pulpy than that of the earlier stages of diphtheria. the casts of the later stages do not occur in influenzal tracheobronchitis (bibliography i, p. 480). _edematous tracheobronchitis_.--this is chiefly observed in children. the most frequently encountered form is the epidemic disease to which the name "influenza" has been given (q.v. supra). the only noticeable difference between the epidemic and the sporadic cases is in the more general susceptibility to the infective agent, which gives the influenzal form an appearance of being more virulently infective. possibly the sporadic form is simply the attack of children not immunized by a previous attack during an epidemic. there is another form of edematous tracheobronchitis often of great severity and grave prognosis, that results from the aspiration of irritating liquids or vapors, or of certain organic substances such as peanut kernels, watermelon seeds, etcetera. tracheotomy should be done if marked dyspnea be present. secretions can then be easily removed and medication in the form of oily solutions be instilled at will into the trachea. in the bronchoscopic clinic many children have been kept alive for days, and their lives finally saved by aspiration of thick, tough, sometimes clotted and crusted secretions, with the aspirating tube (fig. 10). it is better in these cases not to pass the bronchoscope repeatedly. if, however, evidences of obstruction remain, after aspiration, it is necessary to see the nature of the obstruction and relieve it by removal, dilatation, or bronchial intubation as the case may require. it is all a matter of "plumbing" i.e., clearing out the "pipes," and maintaining a patulous airway. _tracheobronchial diphtheria_.--urgent dyspnea in diphtheria when no membrane and but slight lessening of the laryngeal airway is seen, calls for bronchoscopy. many lives have been saved by the bronchoscopic removal of membrane obstructing the trachea or bronchi. in the early stages, pulpy masses looking like "mother" of vinegar are very obstructive. later casts of membrane may simulate foreign bodies. the local application of diphtheria antitoxin to the trachea and bronchi has also been recommended. a preparation free from a chemical irritant should be selected. _abscess of the lung_.--if of foreign-body origin, pulmonary abscess almost invariably heals after the removal of the object and a regime of fresh air and rest, without local measures of any kind. acute pulmonary abscess from other causes may require bronchoscopic drainage and gentle dilatation of the swollen and narrowed bronchi leading to it. some of these bronchi are practically fistulae. obstructive granulations should be removed with crushing, not biting forceps. the regular foreign-body forceps are best for this purpose. caution should be used as to removal of the granulations with which the abscess "cavity" is filled in chronic cases. the term "abscess" is usually loosely applied to the condition of drowned lung in which the pus has accumulated in natural passages, and in which there is neither a new wall nor a breaking down of normal walls. chronic lung-abscess is often successfully treated by weekly bronchoscopic lavage with 20 cc. or more of a warm, normal salt solution, a 1:1000 watery potassium permanganate solution, or a weak iodine solution as in the following formula: rx. monochlorphenol (merck) .12 lugol's solution 8.00 normal salt solution 500. perhaps the best procedure is to precede medicinal applications by the clearing out of the purulent secretions by aspiration with the aspirating bronchoscope and the independent aspirating tube, the latter being inserted into passages too small to enter with the bronchoscope, and the endobronchial instillation of from 10 to 30 cc. of the medicament. the following have been used: argyrol, 1 per cent watery solution; silvol, 1 per cent watery solution; iodoform, oil emulsion 10 per cent; guaiacol, 10 per cent solution in paraffine oil; gomenol, 20 per cent solution in oil; or a bismuth subnitrate suspension in oil. robert m. lukens and william f. moore of the bronchoscopic clinic report excellent results in post-tonsillectomy abscesses from one tenth of one per cent phenol in normal salt solution with the addition of 2 per cent lugol's solution. chlorinated solutions are irritating, and if used, require copious dilution. liquid petrolatum with a little oil of eucalyptus has been most often the medium. _gangrene of the lung_.--pulmonary gangrene has been followed by recovery after the endobronchial injection of oily solutions of gomenol and guaiacol (guisez). the injections are readily made through the laryngoscope without the insertion of a bronchoscope. a silk woven catheter may be used with an ordinary glass syringe or a long-nozzled laryngeal syringe, or a bronchoscopic syringe may be used. _lung-mapping_ by a roentgenogram taken promptly after the bronchoscopic insufflation of bismuth subnitrate powder or the injection of a suspension of bismuth in liquid petrolatum is advisable in most cases of pulmonary abscess before beginning any kind of treatment. _bronchial stenosis_.--stenosis of one or more bronchi results at times from cicatricial contraction following secondary infection of leutic, tuberculous or traumatic lesions. the narrowing resulting from foreign body traumatism rarely requires secondary dilatation after the foreign body has been removed. tuberculous bronchial stenoses rarely require local treatment, but are easily dilated when necessary. luetic cicatricial stenosis may require repeated dilatation, or even bronchial intubation. endobronchial neoplasms may cause a subjacent bronchiectasis, and superjacent stenosis; the latter may require dilatation. cicatricial stenoses of the bronchi are readily recognizable by the scarred wall and the absence of rings at or near the narrowing. _bronchiectasis_.--in most cases of bronchiectasis there are strong indications for a bronchoscopic diagnosis, to eliminate such conditions as foreign body, cicatricial bronchial stenosis, or endobronchial neoplasm as etiologic factors. in the idiopathic types considerable benefit has resulted from the endobronchial lavage and endobronchial oily injections mentioned under lung abscess. it is probable that if bronchoscopic study were carried out in every case, definite causes for many so-called "idiopathic" cases would be discovered. lung-mapping as elsewhere herein explained is invaluable in the study of bronchiectasis. _bronchial asthma_ affords a large field for bronchoscopic study. as yet, sufficient data to afford any definite conclusions even as to the endoscopic picture of this disease have not been accumulated. of the cases seen in the bronchoscopic clinic some showed no abnormality of the bronchi in the intervals between attacks, others a chronic bronchitis. in cases studied bronchoscopically during an attack, the bronchi were found filled with bubbling secretions and the mucosa was somewhat cyanotic in color. the bronchial lumen was narrowed only as much as it would be, with the same degree of cough, in any patient not subject to asthma. the secretions were removed and the attack quickly subsided; but no influence on the recurrence of attacks was observed. it is essential that the bronchoscopic studies be made, as were these, without anesthesia, local or general, for it is known that the application of cocain or adrenalin to the larynx, or even in the nose, will, with some patients, stop the attack. when done without local anesthesia, allowance must be made for the reaction to the presence of the tube. in those cases in which other means have failed to give relief, the endobronchial application of novocain and adrenalin, orthoform, propaesin or anesthesin emulsion may be tried. cures have been reported by this treatment. argentic nitrate applied at weekly intervals has proven very efficient in some cases. associated infective disease of the bronchial mucosa brings with it the questions of immunity, allergy, anaphylaxis, and vaccine therapy; and the often present defective metabolism has to be considered. _autodrownage_.--autodrownage is the name given by the author to the drowning of the patient in his own secretions. tracheobronchial secretions in excess of the amount required to moisten the inspired air, become, in certain cases, a mechanical menace to life, unless removed. the cough reflex, forced expiration, and ciliary action, normally remove the excess. when these mechanisms are impaired, as in profound asthenia, laryngeal paralysis, laryngeal or tracheal stenosis, etc.; and especially when in addition to a mild degree of glottic stenosis or impaired laryngeal mobility, the secretions become excessive, the accumulation may literally drown the patient in his own secretions. this is illustrated frequently in influenza and arachidic bronchitis. infants cannot expectorate, and their cough reflex is exceedingly ineffective in raising secretion to the pharynx; furthermore they are easily exhausted by bechic efforts; so that age may be cited as one of the most frequent etiologic factors in the condition of autodrownage. bronchoscopic sponge-pumping (_q.v._) and bronchoscopic aspiration are quite efficient and can save any patient not afflicted with conditions that are fatal by other pathologic processes. _lues of the tracheobronchial tree_.--compared to laryngeal involvement, syphilis of the tracheobronchial tree is relatively rare. the lesions may be gummatous, ulcerative, or inflammatory, or there may be compressive granulomatous masses. hemoptysis may have its origin from a luetic ulceration. excision of fungations or of a portion of the margin of the ulceration for biopsy is advisable. the wassermann and therapeutic tests, and the elimination of tuberculosis will be required for confirmation. luetic stenoses are referred to above. _tuberculosis of the tracheobronchial tree_.--the bronchoscopic study of tuberculosis is very interesting, but only a few cases justify bronchoscopy. the subglottic infiltrations from extensions of laryngeal disease are usually of edematous appearance, though they are much more firm than in ordinary inflammatory edema. ulcerations in this region are rare, except as direct extensions of ulceration above the cord. the trachea is relatively rarely involved in tuberculosis, but we may have in the trachea the pale swelling of the early stage of a perichondritis, or the later ulceration and all the phenomena following the mixed pyogenic infections. these same conditions may exist in the bronchi. in a number of instances, the entire lumen of the bronchus was occluded by cheesy pus and debris of a peribronchial gland which had eroded through. as a rule, the mucosa of tuberculosis is pale, and the pallor is accentuated by the rather bluish streak of vessels, where these are visible. erosion through of peri-bronchial or peri-tracheal lymph masses may be associated with granulation tissue, usually of pale color, but occasionally reddish; and sometimes oozing of blood is noticed. a most common picture in tuberculosis is a broadening of the carina, which may be so marked as to obliterate the carina and to bulge inward, producing deformed lumina in both bronchi. sometimes the lumina are crescentic, the concavity of the crescent being internal, that is, toward the median line. absence of the normal anterior and downward movement of the carina on deep inspiration is almost pathognomonic of a mass at the bifurcation, and such a mass is usually tuberculous, though it may be malignant, and, very rarely, luetic. the only lesion visible in a tuberculous case may be cicatrices from healed processes. in a number of cases there has been a discharge of pus coming from the upper-lobe bronchus. [fig. 96.--the author's tampons for pulmonary hemostasis by bronchoscopic tamponade. the folded gauze is 10 cm. long; the braided silk cord 60 cm. long.] _hemoptysis_.--in cases not demonstrably tuberculous, hemoptysis may require bronchoscopic examination to determine the origin. varices or unsuspected luetic, malignant, or tuberculous lesions may be found to be the cause. it is mechanically easy to pack off one bronchus with the author's packs (fig. 96) introduced through the bronchoscope, but the advisability of doing so requires further clinical tests. _angioneurotic edema_.--angioneurotic edema manifests itself by a pale or red swollen mucosa producing stenosis of the lumen. the temporary character of the lesion and its appearance in other regions confirm the diagnosis. _scleroma of the trachea_ is characterized by infiltration of the tracheal mucosa, which greatly narrows the lumen. the infiltration may be limited in area and produce a single stricture, or it may involve the entire trachea and even close a bronchial orifice. drying and crusting of secretions renders the stenosis still more distressing. this disease is but rarely encountered in america but is not infrequent in some parts of europe. treatment consists in the prevention of crusts and their removal. limited stenotic areas may yield to bronchoscopic bouginage. urgent dyspnea calls for tracheotomy. radium and roentgenray therapy have been advised, and cure has been reported by intravenous salvarsan treatment (see article by s. shelton watkins, on scleroma in surg. gynecol. and obst., july, 1921, p. 47). _atrophic tracheitis_, with symptoms quite similar to atrophic rhinitis is a not unusual accompaniment of the nasal condition. it may also exist without nasal involvement. on tracheoscopy the mucosa is thinned, pale and dry, and is covered with patches of thick mucilaginous secretion and crusts. decomposition of secretion produces tracheal "ozena," while the accumulated crusts give rise to the sensation of a foreign body and may seriously interfere with respiration, making bronchoscopic removal imperative. the associated development of tracheal nodular enchondromata has been described. the internal administration of iodine and the intratracheal injection of bland oily solutions of menthol, guaiacol, or gomenol are helpful. [235] chapter xxx--diseases of the esophagus the more frequent causes of the one common symptom of esophageal disease, dysphagia, are included in the list given below. to avoid elaboration and to obtain maximum usefulness as a reminder, overlapping has not been eliminated. 1. anomalies. 2. esophagitis, acute. 3. esophagitis, chronic. 4. erosion. 5. ulceration. 6. trauma. 7. stricture, congenital. 8. stricture, spasmodic, including cramp of the diaphragmatic pinchcock. 9. stricture, inflammatory. 10. stricture, cicatricial. 11. dilatation, local. 12. dilatation, diffuse. 13. diverticulum. 14. compression stenosis. 15. mediastinal tumor. 16. mediastinal abscess. 17. mediastinal glandular mass. 18. aneurysm. 19. malignant neoplasm. 20. benign neoplasm. 21. tuberculosis. 22. lues. 23. actinomycosis. 24. varix. 25. angioneurotic edema. 26. hysteria. 27. functional antiperistalsis. 28. paralysis. 29. foreign body in (a) pharynx, (b) larynx, (c) trachea, (d) esophagus. [236] _diagnosis_.--the swallowing function can be studied only with the fluoroscope; esophagoscopy for diagnosis, should therefore always be preceded by a fluoroscopic study of deglutition with a barium or other opaque mixture and examination of the thoracic organs to eliminate external pressure on the esophagus as the cause of stenosis. complete physical examination and wassermann reaction are further routine preliminaries to any esophagoscopy. special laboratory tests are done as may be indicated. the physical examination is meant to include a careful examination of the lips, tongue, palate, pharynx, and a mirror examination of the larynx when age permits. _indications for esophagoscopy in disease_.--any persistent abnormal sensation or disturbance of function of the esophagus calls for esophagoscopy. vague stomach symptoms may prove to be esophageal in origin, for vomiting is often a complaint when the patient really regurgitates. _contraindications to esophagoscopy_.--in the presence of aneurysm, advanced organic disease, extensive esophageal varicosities, acute necrotic or corrosive esophagitis, esophagoscopy should not be done except for urgent reasons, such as the lodgment of a foreign body; and in this case the esophagoscopy may be postponed, if necessary, unless the patient is unable to swallow fluids. esophagoscopy should be deferred, in cases of acute esophagitis from swallowing of caustics, until sloughing has ceased and healing has strengthened the weak places. the extremes of age are not contraindications to esophagoscopy. a number of newborn infants have been esophagoscoped by the author; and he has removed foreign bodies from patients over 80 years of age. _water starvation_ makes the patient a very bad surgical subject, and is a distinct contraindication to esophagoscopy. water must be supplied by means of proctoclysis and hypodermoclysis before any endoscopic or surgical procedure is attempted. if the esophageal stenosis is not readily and quickly remediable, gastrostomy should be done immediately. _rectal feeding_ will supply water for a limited time, but for nutrient purposes rectal alimentation is dangerously inefficient. _preliminary examination of the pharynx and larynx with tongue depressor_ should always precede esophagoscopy, for any purpose, because the symptoms may be due to laryngeal or pharyngeal disease that might be overlooked in passing the esophagoscope. a high degree of esophageal stenosis results in retention in the suprajacent esophagus of the fluids which normally are continually flowing downward. the pyriform sinuses in these cases are seen with the laryngeal mirror to be filled with frothy secretion (jackson's sign of esophageal stenosis) and this secretion may sometimes be seen trickling into the larynx. this overflow into the larynx and lower air passages is often the cause of pulmonary symptoms, which are thus strictly secondary to the esophageal disease. anomalies of the esophagus _congenital esophagotracheal fistulae_ are the most frequent of the embryonic developmental errors of this organ. septic pneumonia from the entrance of fluids into the lungs usually causes death within a few weeks. _imperforate esophagus_ usually shows an upper esophageal segment ending in a blind pouch. a lower segment is usually present and may be connected with the upper segment by a fistula. _congenital stricture_ of the esophagus may be single or multiple, and may be thin and weblike, or it may extend over a third or more of the length of the esophagus. it may not become manifest until solids are added to the child's diet; often not for many months. the lodgment of an unusually large bolus of unmasticated food may set up an esophagitis the swelling of which may completely close the lumen of the congenitally narrow esophagus. it is not uncommon to meet with cases of adults who have "never swallowed as well as other people," and in whom cicatricial and spasmodic stenosis can be excluded by esophagoscopy, which demonstrates an obvious narrowing of the esophageal lumen. these cases are doubtless congenital. _webs in the upper third of the esophagus_ are best determined by the passage of a large esophagoscope which puts the esophagus on the stretch. the webs may be broken by the insertion of a closed alligator forceps, which is then withdrawn with opened blades. better still is the dilator shown in fig. 26. this retrograde dilatation is relatively safe. a silk-woven esophagoscopic bougie or the metallic tracheal bougie may be used, with proper caution. subsequent dilatation for a few times will be required to prevent a reproduction of the stenosis. _treatment of esophageal anomalies_.--gastrostomy is required in the imperforate cases. esophagoscopic bouginage is very successful in the cure of all cases of congenital stenosis. any sort of lumen can be enlarged so any well masticated food can be swallowed. careful esophagoscopic work with the bougies (fig. 40) will ultimately cure with little or no risk of mortality. any form of rapid dilatation is dangerous. congenital stenosis, if not an absolute atresia, yields more readily to esophagoscopic bouginage than cicatricial stenosis. rupture and trauma of the esophagus these may be spontaneous or may ensue from the passage of an instrument, or foreign body, or of both combined, as exemplified in the blind attempts to remove a foreign body or to push it downwards. digestion of the esophagus and perforation may result from the stagnation of regurgitated gastric juice therein. this condition sometimes occurs in profound toxic and debilitated states. rupture of the thoracic esophagus produces profound shock, fever, mediastinal emphysema, and rapid sinking. pneumothorax and empyema follow perforation into the pleural cavity. rupture of the cervical esophagus is usually followed by cervical emphysema and cervical abscess, both of which often burrow into the mediastinum along the fascial layers of the neck. lesser degrees of trauma produce esophagitis usually accompanied by fever and painful and difficult swallowing. the treatment of traumatic esophagitis consists in rest in bed, sterile liquid food, and the administration of bismuth subnitrate (about one gramme in an adult), dry on the tongue every 4 hours. rupture of the esophagus requires immediate gastrostomy to put the esophagus at rest and supply necessary alimentation. thoracotomy for drainage is required when the pleural cavity has been involved, not only for pleural secretions, but for the constant and copious esophageal leakage. it is not ordinarily realized how much normal salivary drainage passes down the esophagus. the customary treatment of shock is to be applied. no attempt should be made to remove a foreign body until the traumatic lesions have healed. this may require a number of weeks. decision as to when to remove the intruder is determined by esophagoscopic inspection. subcutaneous emphysema does not require puncture unless gaseous, or unless pus forms. in the latter event free external drainage becomes imperative. acute esophagitis this is usually of traumatic or cauterant origin. if severe or extensive, all the symptoms described under "rupture of the esophagus" may be present. the endoscopic appearances are unmistakable to anyone familiar with the appearance of mucosal inflammations. the pale, bluish pink color of the normal mucosa is replaced by a deep-red velvety swollen appearance in which individual vessels are invisible. after exudation of serum into the tissues, the color may be paler and in some instances a typical edema may be seen. this may diminish the lumen temporarily. folds of swollen mucosa crowd into the lumen if the inflammation is intense. these folds are sometimes demonstrable in the roentgenogram by the bismuth or barium in the creases between which the prominence of the folds show as islands as beautifully demonstrated by david r. bowen in one of the author's cases. if the inflammation is due to corrosives, a grayish exudate may be visible early, sloughs later. ulceration of the esophagus superficial erosions of the esophagus are by no means an uncommon accompaniment of the stagnation of food and secretions. from the irritation they produce, spastic stenosis may occur, thus constituting a vicious circle; the spasm of the esophagus increases the stagnation which in turn results in further inflammation and ultimate ulceration. healing of such ulcers may result in cicatricial contraction and organic stenosis. ulceration may follow trauma by instrument, foreign body, or corrosive. differential diagnosis of ulcer of the esophagus _simple ulcer_ requires the exclusion of lues, tuberculosis, epithelioma, endothelioma, sarcoma, and actinomycosis. simple ulcer of the esophagus is usually associated with stenosis, spastic or organic. _luetic ulcers_ commonly show a surrounding inflammatory areola, and they usually have thickened elevated edges, generally free from granulation tissue, with a pasty center not bleeding readily when sponged. the wassermann reaction may contribute to the diagnosis; but if negative, a thorough and prolonged test with mercury is imperative. it must be remembered that a person with lues may have a simple, mixed, or malignant ulceration of the esophagus, or the three lesions may even be combined. it may be in some cases possible to demonstrate the treponema pallidum in scrapings taken from the ulcer. the single _tuberculous ulcer_ is usually pale, superficial, and granular in base. if it is a continuation from more extensive extra-esophageal tuberculous ulceration, pale cauliflower granulations may be present. slight cicatrices may be seen. tuberculosis in other organs can almost always be demonstrated by roentgenographic, physical, or laboratory studies. tuberculin tests and animal injection with an emulsion of a specimen of tissue may be required. the specimen must be taken very superficially to avoid risk of perforation. _sarcomatous ulcers_ do not differ materially in appearance from those of carcinoma, but they are much more rare. _carcinomatous ulcer_ is usually characterized by the very vascular bright red zone, raised edges, fungations, granulation tissue that bleeds freely on the lightest touch, and above all, it is almost invariably situated on an infiltrated base which communicates a feeling of hardness to the pressure of sponges or the esophagoscope itself. a scar may be from the healing of an ulcer from stasis, or one of specific or precancerous character. it may be a cancerous process developing on the site of a scar, so that the presence of scar tissue does not absolutely negative malignancy. as a rule, however, scars are absent in cancer of the esophagus. the firm and sometimes prominent ridge of the crossing of the left bronchus must not be mistaken for infiltration, and the esophagoscopist must be familiar with the normal rigidity of the cricopharyngeus. [242] mixed infection gives to all esophageal ulceration a certain uniformity of appearance, so that laboratory studies of smears or histologic and bacteriologic study of tissue specimens taken from fungations or thickened edges are often required to confirm the endoscopic diagnosis. if the edges are thin and flat, the taking of a specimen involves some risk; fungations can be removed without risk; so can nodules, but care must be taken that projecting folds are not mistaken for nodules. it is always wise to push the therapeutic test with potassium iodid and especially mercury in any case of esophageal ulceration unassociated with stasis. _treatment of acute and subacute inflammation and ulceration of the esophagus_.--bismuth subnitrate in doses of about one gramme, given dry on the tongue and swallowed without water, has a local antiseptic and protective action. its antiseptic power may be enhanced by the addition of calomel to the powder, in such amount as may be tolerated by the bowels. if pain be present the combination of a grain or two of anesthesin or orthoform with the bismuth will be grateful. the local application of argyrol in 25 per cent watery solution is also of great value. the mouth and teeth are to be kept clean with a mouth wash of dakin's solution, 1 part, to peppermint water, 6 parts. the esophagus must be placed at rest as far as possible by liquid diet or, if need be, by gastrostomy. chronic esophagitis this is usually a result of stagnation of food or secretion, and will be considered under spasmodic stenosis and diffuse dilatation of the esophagus. a very marked case with local distress and pain extending through to the back was seen by the author in consultation with dr. john b. wright who had made the diagnosis. the patient was a sufferer from ankylostomiasis. [243] compression stenosis of the esophagus the esophagus may be narrowed by the pressure of any periesophageal disease or anomaly. the lesions most frequently found are: 1. goiter, cervical or thoracic. 2. malignancy of any of the intrathoracic viscera. 3. aneurysm. 4. cardiac and aortic enlargement. 5. lymphadenopathies. hodgkins' disease. leukemia. lues. tuberculosis. simple infective adenitis. 6. lordosis. 7. enlargement of the left hepatic lobe. endoscopically, compression stenosis of the esophagus is manifested by a slit-like crevice which occupies the place of the lumen and which does not open up readily before the advancing tube. the long axis of the slit is almost always at right angles to the compressive mass, if the esophageal wall be uninvolved. the covering mucosa may be normal or it may show signs of chronic inflammation. malignant compressions are characterized by their hardness when palpated with the tube. associated pressure on the recurrent laryngeal nerve often makes laryngeal paralysis coexistent. the nature of the compressive mass will require for its determination the aid of the roentgenologist, internist, and clinical laboratory. compression by the enlarged left auricle has been observed a number of times. the presence of aneurysm is a distinct contraindication to esophagoscopy for diagnosis except in case of suspected foreign body. _treatment of compressive stenosis of the esophagus_ depends upon the nature of the compressive lesion and is without the realm of endoscopy. in uncertain cases potassium iodid, and especially mercury, should always be given a thorough and prolonged trial; an occasional cure will result. esophageal intubation is indicated in all conditions except aneurysm. gastrostomy should be done early when necessary. diffuse dilatation of the esophagus this is practically always due to stagnation ectasia, which is invariably associated with either organic or "spasmodic" stricture, existing at the time of observation or at some time prior thereto. the dilating effect of the repeatedly accumulated food results in a permanent enlargement, so that the esophagus acts as the reservoir of a large funnel with a very small opening. when food is swallowed the esophagus fills, and the contents trickle slowly through the opening. gases due to fermentation increase the distension and cause substernal pressure, discomfort, and belching. a very large dilatation of the thoracic esophagus indicates spastic stenosis. cicatricial stenoses do not result in such large dilatations and the dilatation above a malignant stenosis is usually slight, probably because of its relatively shorter duration. the _treatment of diffuse esophageal dilatation_ consists in dilating the "diaphragmatic pinchcock" that is, the hiatal esophagus. chronic esophagitis is to be controlled by esophageal lavage, the regulation of the diet to liquefiable foods and the administration of bismuth subnitrate. the patient can be taught to do the lavage. the local esophagoscopic application of a small quantity of a 25 per cent watery solution of argyrol may be required for the static esophagitis. the redundancy probably never disappears; but functional and subjective cures are usually obtainable. [245] chapter xxxi--diseases of the esophagus (_continued_) spasmodic stenosis of the esophagus _etiology_.--the functional activity of the esophagus is dependent upon reflex action. the food is propulsed in a peristaltic wave by the same mechanism as, and through an innervation (auerbach and meissner plexus) similar to that which controls intestinal movements. the vagus also is directly concerned with the deglutitory act, for swallowing is impossible if both vagi are cut. anything which unduly disturbs this reflex arc may serve as an exciting cause of spasmodic stenosis. bolting of food, superficial erosions, local esophageal disease, or a small foreign body, may produce spasmodic stenosis. spasm secondary to disease of the stomach, liver, gall bladder, appendix, or other abdominal organ is clinically well recognized. a perpetuating cause in established cases is undoubtedly "nerve cell habit," and in many cases there is an underlying neurotic factor. shock as an exciting cause has been well exemplified by the number of cases of phrenospasm developing in soldiers during the world war. _cricopharyngeal spasmodic stenosis_ usually presents the subjective symptom of difficulty in starting the bolus of food downward. once started, the food passes into the stomach unimpeded. regurgitation, if it occurs, is immediate. the condition consists in a tonic contraction, ahead of the bolus, of the circular fibers of the inferior constrictor known as the cricopharyngeus muscle, or in a failure of this muscle to relax so as to allow the bolus to pass. in either case the disorder may be secondary to an organic lesion. local malignant disease or foreign bodies may be the cause. globus hystericus, "lump in the throat," and the sense of constriction and choking during emotion are due to the same spasmodic condition. _diagnosis_.--at esophagoscopy there will be found marked exaggeration of the usual spasm which occurs at the cricopharyngeus during the introduction of the tube. the lumen may assume various shapes, or be so tightly closed that the folds form a mammilliform projection in the center. if the spasm gradually yields, and a full-sized esophagoscope passes without further resistance, it may be stated that the esophagus is of normal calibre, and a diagnosis of spasmodic stenosis can be made. considerable experience is required to distinguish between normal and pathologic spasm in an unanesthetized individual. to the less experienced esophagoscopist, examination under ether anesthesia is recommended. deep anesthesia will relax the normal cricopharyngeal reflex closure as well as any abnormal spasm, thus assisting in the differentiation between an organic stricture and one of functional character. under deep general anesthesia, however, it is impossible to differentiate between the normal reflex and a spasmodic condition, since both are abolished. many cases of intermittent esophageal stenosis supposed to be spasmodic are due to organic narrowness of lumen plus lodgement of food, obstructive in itself and in the esophagitis resulting from its presence. the organic narrowing, congenital or pathologic, is readily recognizable esophagoscopically. _treatment_.--the fundamental cause of the disturbance of the reflex should be searched for, and treated according to its nature. purely functional cases are often cured by the passage of a large esophagoscope. recurrences may require similar treatment. [247] functional hiatal stenosis. hiatal esophagismus. phrenospasm, diaphragmatic pinchcock stenosis. (so-called cardiospasm) there is no sphincteric muscular arrangement at the cardiac orifice of the esophagus, so that spasmodic stenosis at this level is not possible and the term cardiospasm is, therefore, a misnomer. it was first demonstrated by the author that in so-called cardiospasm the functional closure of the esophagus occurred at the diaphragmatic level, and that it was due to the "diaphragmatic pinchcock." anatomical studies have corroborated this finding by demonstrating a definite sphincteric mechanism consisting of muscle bands springing from the crura of the diaphragm and surrounding the esophagus at the under surface of the hiatus. an inspection of the cadaveric diaphragm from below will demonstrate an arrangement like double shears admirably adapted to this "pinchcock" action. further confirmation is the fact that all dilatation of the esophagus incident to spasm at its lower extremity is situated above the diaphragm. in passing it may be stated that the pinchcock action, plus the kinking of the esophagus normally prevents regurgitation when a man with a full stomach "stands on his head" or inverts his body. for the upward escape of food from the stomach an involuntary co-ordinated antiperistaltic cycle is necessary. the dilatation resulting from phrenospasm may reach great size (fig. 96a), and the capacity of the sac may be as much as two liters. while the esophagus is usually dilated, the stomach on the other hand is often contracted, largely from lack of distention by food, but possibly also because of a spastic state due to the same causes as the phrenospasm. recently mosher has demonstrated that hepatic abnormality may furnish an organic cause in many cases formerly considered spasmodic. the _symptoms of hiatal esophagismus_ are variable in degree. substernal distress, with a feeling of fullness and pressure followed by eructations of gas and regurgitation of food within a period of a quarter of an hour to several hours after eating, are present. if the esophageal dilatation be great, regurgitation may occur only after an accumulation of several days, when large quantities of stale food will be expelled. the general nutrition is impaired, and there is usually the history of weight loss to a certain level at which it is maintained with but slight variation. this is explained by the trickling of liquified food from the esophageal reservoir into the stomach as the spasm intermittently relaxes, this occurring usually before a serious state of inanition supervenes. at times the hiatal spasms are extremely violent and painful, the pain being referred from the xiphoid region to the back, or upward into the neck. patients are often conscious of the times of patulency of the esophagus; they will know the esophagus to be open and will eat without hesitation, or will refuse food with the certain knowledge that it will not pass into the stomach. periods of remission of symptoms for months and years are noted. the neurotic character of the lesion in some cases is evidenced by the occasionally sudden and startling cures following a single dilatation, as well as by the tendency to relapse when the individual is subject to what is for him undue nervous tension. in a very few cases, with patients of rather a stolid type, all neurotic tendencies seem to be absent. the _diagnosis of hiatal esophagismus_ requires the exclusion of local organic esophageal lesions. in the typical case with marked dilatation, the esophagoscopic findings are diagnostic. a white, pasty, macerated mucosa, and normally contracted hiatus esophageus which when found permits the large esophagoscope to pass into the stomach, will be recognized as characteristic by anyone who has seen the condition. in the cases with but little esophageal distension the diagnosis is confirmed by the constancy of the obstruction to a barium mixture at the phrenic level, while at esophagoscopy the usual resistance at the hiatus esophageus is found not to be increased, and no other local lesion is found as the esophagoscope enters the stomach. it is the failure of the diaphragmatic pinchcock to open, as in the normal deglutitory cycle, rather than a spasmodic tightness, that obstructs the food. the presence of organic stenosis at the hiatus may remove the case altogether from the spasmodic class, or a cicatricial or infiltrated narrowing may be the result of static esophagitis. a compressive stenosis due to hepatic abnormality may simulate spasmodic stenosis as shown by mosher, who believes that 75 per cent of so-called cardiospasms are organic. _treatment of hiatal esophagismus (so-called cardiospasm)_ consists in the over-dilatation of the "diaphragmatic pinchcock" or hiatus esophageus, and in proper remedial measures for the removal of the underlying neurosis. the simple passage of the esophagoscope suffices to cure some cases. further dilatation by endoscopic guidance may be obtained by the introduction of mosher's divulsor through the esophagoscope, by which accurate placement is obtained. the distension should not usually exceed 25 mm. numerous water and air bags have been devised for stretching the hiatus, and excellent results have been obtained by their use. possibly some of the cures have been due to the dilatation of organic lesions, or to the crowding back of an enlarged malposed, or otherwise abnormal left lobe of the liver, which mosher has shown to be an etiologic factor. certain cases prove very obstinate of cure, and require esophageal lavage for the esophagitis, and feedings through the stomach tube to increase nutrition and to dilate the contracted stomach. gastrostomy for feeding rarely becomes necessary, for a stomach tube can always be placed with the esophagoscope if it will not pass otherwise. retrograde dilatation with the fingers through a gastrostomy opening has been done, but seems hardly warranted in view of the excellent results obtainable from above. instructions should be given concerning the proper mastication of food, and during treatment the frequent partaking of small quantities of liquid foods is recommended. liquids and foods should be neither hot nor cold. the neurologist should be consulted in cases deemed neurotic. [96a.-functional hiatal stenosis. cramp of the diaphragmatic pinchcock (so-called cardiospasm).] endocrine imbalance should be investigated and treated, as urged by macnab. _esophageal antiperistalsis_ is the name given by the author to a heretofore undescribed disease associated with regurgitation of food from the esophagus, the food not having reached the stomach. it may be continuous or paroxysmal and may be of so serious a degree as to threaten starvation. the best treatment in severe cases is gastrostomy to put the esophagus at rest. milder cases get well under liquid diet, rest in bed, endocrine therapy, cure of associated abdominal disease, etcetera. [251] chapter xxxii--diseases of the esophagus (_continued_) cicatricial stenosis of the esophagus _etiology_.--the accidental swallowing of caustic alkali in solutions of lye or proprietary washing and cleansing powders, is the most frequent cause of cicatricial stenosis. commercial lye preparations are about 95 per cent sodium hydroxide. the cleansing and washing powders contain from eight to fifty per cent of caustic alkali, usually soda ash, and are sold by grocers everywhere. the labels on their containers not only give no warning of the dangerous nature of the contents nor antidotal advice, but have such directly misleading statements as : "will not injure the most delicate fabric," "will not injure the hands," etc. utensils used to measure or dissolve the powders are afterward used for drinking, without rinsing, and thus the residue of the powder remaining is swallowed in strong solution. at other times solutions of lye are drunk in mistake for water, coffee, or wine. these entirely preventable accidents would be rare if they were as conspicuously labelled "poison" as is required by law in the case of these and any other poisons, when sold by druggists. the necessity for such labelling is even greater with the lye preparations because they go into the kitchen, whereas the drugs go to the medicine shelf, out of the reach of children. "household ammonia," "salts of tartar" (potassium carbonate), "washing soda" (sodium carbonate), mercuric chloride, and strong acids are also, though less frequently, the cause of cicatricial esophageal stricture. tuberculosis, lues, scarlet fever, diphtheria, enteric fever and pyogenic conditions may produce ulceration followed by cicatrices of the esophagus. spasmodic stenosis with its consequent esophagitis and erosions, and, later, secondary pyogenic infection, may result in serious cicatrices. peptic ulcer of the lower esophagus may be a cause. the prolonged sojourn of a foreign body is likely to result in cicatricial narrowing. [fig. 97.--schematic illustration of a series of eccentric strictures with interstrictural sacculations, in the esophagus of a boy aged four years. the strictures were divulsed seriatim from above downward with the divulsor, the esophageal wall, d, being moved sidewise to the position of the dotted line by means of a small esophagoscope inserted through the upper stricture, a, after divulsion of the latter.] _location of cicatricial esophageal strictures_.--the strictures are often multiple and their lumina are rarely either central or concentric (fig. 97). in order of frequency the sites of cicatricial stenosis are: 1. at the crossing of the left bronchus; 2. in the region of the cricopharyngeus; 3. at the hiatal level. stricture at the cardia has rarely been encountered in the bronchoscopic clinic. stenosis of the pylorus has been noted, but is rare. _prognosis_.--spontaneous recovery from cicatricial stenosis probably never occurs, and the mortality of untreated small lumen strictures is very high. blind methods of dilatation are almost certain to result in death from perforation of the esophageal wall, because some pressure is necessary to dilate a stricture, and the point of the bougie, not being under guidance of the eye, is certain at sometime or other to be engaged in a pocket instead of in the stricture. pressure then results in perforation of the bottom of the pocket (fig. 98). this accident is contributed to by dilatation with the wrinkled, scarred floor which usually develops above the stricture. rapid divulsion and internal esophagotomy are mechanically very easily and accurately done through the esophagoscope, and would yield a few prompt cures; but the mortality would be very high. under certain circumstances, to be explained below, gentle divulsion of the proximal one of a series of strictures has to be done. with proper precautions and a gentle hand, the risk is slight. under esophagoscopic bouginage the prognosis is favorable as to ultimate cure, the duration of the treatment varying with the number of strictures, the tightness, and the extent of the fibrous tissue-changes in the esophageal wall. mortality from the endoscopic procedure is almost nil, and if gastrostomy is done early in the tightly stenosed cases, ultimate cure may be confidently expected with careful though prolonged treatment. [fig. 98.--schema illustrating the mechanism of perforation by blind bouginage. on encountering resilient resistance the operator, having a false conception, pushes on the bougie. perforation results because in reality the bougie is in a pocket of the suprastrictural eccentric dilatation.] _symptoms_.--dysphagia, regurgitation, distress after eating, and loss of weight, vary with the degree of the stenosis. the intermittency of the symptoms is sometimes confusing, for the lodgment of relatively large particles of food often simulates a spasmodic stenosis, and in fact there is often an element of spasm which holds the foreign body in the strictured area until it relaxes. static esophagitis results in a swelling of the esophageal walls and a narrowing of the lumen, so that swallowing is more or less troublesome until the esophagitis subsides. _esophagoscopic appearances of cicatricial stenosis_.--the color of the cicatricial area is usually paler than the normal mucosa. the scars may be very white and elevated, or they may be flush with the normal mucosa, or even depressed. occasionally the cicatrix is annular, but more often it is eccentric and involves only a part of the circumference of the wall. if the amount of scar tissue is small, the lumen maintains its mobility; opens and closes during respiration, cough, and vomiturition. between two strictures there is often a pouch containing food remnants. it is rarely possible to see the lumen of the second stricture, because it is usually eccentric to the first. stagnation of food results in superjacent dilatation and esophagitis. erosions and ulcerations which follow the stagnation esophagitis increase the cicatricial stenosis in their healing. _differential diagnosis_.--when the underlying condition is masked by inflammation and ulceration, these lesions must be removed by frequent lavage, the administration of bismuth subnitrate with the occasional addition of calomel powder, and the limitation of the diet to strained liquids. the cicatricial nature of the stenosis can then be studied to better advantage. in most cases the cicatrices are unmistakably conspicuous. spasmodic stenoses are differentiated by the absence of cicatrices and the yielding of the stenosis to gentle but continuous pressure of the esophagoscope. while it is possible that spasmodic stenosis may supplement cicatricial stenosis, it is certainly exceedingly rare. nearly all of the occasions in which a temporary increase of the stenosis in a cicatricial case is attributed to an element of spasm, the real cause of the intermittency is not spasm but obstruction caused by food. this occurs in three ways: 1. actual "corking" of the strictured lumen by a fragment of food, in which case intermittency may be due to partial regurgitation of the "corking" mass with subsequent sinking tightly into the stricture. 2. the "cork" may dissolve and pass on through to be later replaced by another. 3. reactionary swelling of the esophageal mucosa due to stagnation. here again the obstruction may be prolonged, or it may be quite intermittent, due to a valve-like action of the swollen mucosal surfaces or folds intermittently coming in contact. cancerous stenosis is accompanied by infiltration of the periesophageal tissue, and usually by projecting bleeding fungations. cancer may, however, develop on a cicatrix, favored no doubt by chronic inflammation in tissue of low resistance. compression stenosis of the esophagus is characterized by the sudden transition of the lumen to a linear or crescentic outline, while the covering mucosa is normal unless esophagitis be present. the compressive mass can be detected by the sensation transmitted to the touch by the esophagoscope. _treatment_.--blind bouginage should be discarded as an obsolete and very dangerous procedure. if the stenosis be so great as to interfere with the ingestion of the required amount of liquids, gastrostomy should be done at once and esophagoscopic treatment postponed until water hunger has been relieved. gastrostomy aids in the treatment by putting the esophagus at rest, and by affording the means of maintaining a high degree of nutrition unhampered by the variability or efficiency of the swallowing function. careful diet and gentle treatment will, however, usually avoid gastrostomy. the diet in the gastrostomy-fed patients should be as varied as in oral alimentation; even solids of the consistency of mashed potatoes, if previously forced through a wire gauze strainer, may be forced through the tube with a glass injector. liquids and readily liquefiable foods are to be given the non-gastrostomized patient, solids being added when demonstrated that no stagnation above the stricture occurs. thorough mastication and the slow partaking of small quantities at a time are imperative. should food accumulation occur, the esophagus should be emptied by regurgitation, following which a glassful of warm sodium bicarbonate solution is to be taken, and this also regurgitated if it does not go through promptly. the esophagus is thus lavaged and emptied. in all these cases, whether being fed through the mouth or the gastrostomic tube, it is very important to remember that milk and eggs are not a complete dietary. a pediatrist should be consulted. prof. graham has saved the lives of many children by solving the nutritive problems in the cases at the bronchoscopic clinic. fruit and vegetable juices are necessary. vegetable soups and mashed fruits should be strained through a wire gauze coffee strainer. if the saliva is spat out by the child because it will not go through the stricture the child should be taught to spit the saliva into the funnel of the abdominal tube. this method of improving nutrition was discovered by miss groves at the bronchoscopic clinic. _esophagoscopic bouginage_ with the author's silk-woven steel-shank endoscopic bougies (fig. 40) has proven the safest and most successful method of treatment. the strictured lumen is to be centered in the esophagoscopic field, and three successively increasing sizes of bougies are used under direct vision. larger and larger bougies are used at the successive treatments which are given at intervals of from four to seven days. no anesthesia, general or local, is used for esophagoscopic bouginage. the tightness of the grasping of the bougie by the stricture on withdrawal, determines the limitation of sizes to be used. when the upper stricture is dilated, lower ones in the series are taken seriatim. if concentric, two or more closely situated strictures may be simultaneously dilated. for the use of bougies of the larger sizes, the special esophagoscopes with both the light-carrier canal and the drainage canal outside the lumen of the tube are needed. functional cure is obtained with a relatively small lumen at the point of stenosis. a lumen of 7 mm. will allow the passage of any well masticated food. it is unwise and unsafe to attempt to restore the lumen to its normal anatomic size. in cicatricial stricture cases it is advisable to examine the esophagus at monthly periods for a time after a functional cure has been obtained, in order that tendency to recurrence may be early detected. _divulsion_ of an upper stricture may be deemed advisable in order to reach others lower down, especially in cases of multiple eccentric strictures (fig. 97). this procedure is best done with the author's esophagoscopic divulser, accurately placed by means of the esophagoscope; but divulsion requires the utmost care, and a gentle hand. even then it is not so safe as esophagoscopic bouginage. _internal esophagotomy_ by the string-cutting instruments and esophagotome are relatively dangerous methods, and perhaps yield in the end no quicker results than the slower and safe bouginage per tubam. _electrolysis_ has been used with varying results in the treatment of cicatricial stenosis. _thermic bouginage_ with electrically heated bougies has been found useful in some cases by dean and imperatori. [258] _string-swallowing_, with the passage of olives threaded over the string has yielded good results in the hands of some operators. the string may be used to pull up dilators in increasing sizes, introduced through a gastrostomic fistula. the string stretched across the stomach from the cardia to the pylorus, is fished out with the author's pillar retractor, or is found with the retrograde esophagoscope (fig. 43). the string is attached to a dilator (fig. 35), and a fresh string is pulled in to replace the one pulled out. this is the safest of the blind methods. it is rarely possible to get a child under two years of age to swallow and tolerate a string. it is better after each treatment to draw the upper end of the string through the nose, as it is not so likely to be chewed off and is less annoying. with the esophagoscope, the string is not necessary, because the lumen of the stricture can be exposed to view by the esophagoscope. _retrograde esophagoscopy_ through a gastrostomy wound offers some advantages over peroral treatment; but unless the gastrostomy is high, the procedure is undoubtedly more difficult. the approach to the lowest stricture from below is usually funnel shaped and free from dilatation and redundancy. it must be remembered the stricture seen from below may not be the same one seen from above. roentgenray examination with barium mixture or esophagoscopes simultaneously in situ above and below are useful in the study of such cases. _impermeable strictures_ of the cervical esophagus are amenable to external esophagotomy, with plastic reformation of the esophagus. those in the middle third have not been successfully treated by surgical methods, though various ingenious operations for the formation of an extrathoracic esophagus have been suggested as means of securing relief. impermeable strictures of the lower third can with reasonable safety be treated by the brenneman method, which consists in passing the esophagoscope down to the stricture while the surgeon, inserting his finger up into the esophagus from the stomach, can feel the end of the esophagoscope. an incision through the tissue barrier is then made from below, passing the knife along the finger as a guide. a soft rubber stomach-tube is pulled up from below and left in situ, being replaced at intervals by a fresh one, pulled up from the stomach, until epithelialization of the new lumen is complete. catheters are used in children. in replacing the catheter or stomach tube the fresh one is attached to the old one by stitching in a loop of braided silk. frequent esophagoscopic bouginage will be required to maintain the more or less fistulous lumen until it is epithelialized, and in occasional cases, for a long time thereafter. in cases of absolute atresia the saliva does not reach the stomach. no one realizes the quantity of normal salivary drainage, nor its importance in nutritive processes. oral insalivation is of little consequence compared to esophagogastric drainage. gastrostomized children with absolute atresia of the esophagus do not thrive unless they regurgitate the salivary accumulations into the funnel of the gastrostomic feeding tube. this has been abundantly proven by observations at the bronchoscopic clinic. my attention was first called to this clinical fact by miss frances groves who has charge of these cases. _intubation of the esophagus_ with soft rubber tubes has occasionally proven useful. [260] chapter xxxiii--diseases of the esophagus (_continued_) diverticulum of the esophagus diverticula may, and usually do, consist in a pouching by herniation, of the whole thickness of the esophageal wall; or they may be herniations of the mucosa between the muscular layers. they are classified according to their etiology, as traction and pulsion diverticula. [fig. 99.--traction diverticulum of the esophagus rendered visible in the roentgenogram by a swallowed opaque mixture. case of h. w. dachtler, am. journ. roentgenology.] _traction diverticulum of the esophagus_ (fig. 99) is a rare condition, usually occurring in the thorax, and as a rule constituting a one-sided enlargement of the gullet rather than a true pouch formation. it is supposed to be formed by the pulling during cough, respiration, and swallowing, on localized adhesions of the esophagus to periesophageal structures, such as inflammatory peribronchial glands. _diagnosis_ is often incidental to examination of the gastrointestinal tract for other conditions, because traction diverticula usually cause no symptoms. unless a very large esophagoscope be used, a traction diverticulum may easily be overlooked in the mucosal folds. careful lateral search, however, will reveal the dilatation, and the localized periesophageal fixation may be demonstrated. the subdiverticular esophagus is readily followed, its lumen opening during inspiration unless very close to the diaphragm, which is very rare. perhaps most cases will be discovered by the roentgenologist. it has been said that traction diverticula are more readily demonstrated in the roentgenologic examination, if the patient be placed with pelvis elevated. _pulsion diverticulum of the esophagus_ is an acquired hernia of the mucosa between the circular and oblique fibers of the inferior constrictor muscle of the pharynx. a congenital anatomic basic factor in etiology probably exists. the pouching develops in the middle part of the posterior wall, between the orbicular and oblique fibers of the cricopharyngeus muscle, at which point there is a gap, leaving the mucosa supported only by a not very resistant fascia (fig. 100). when small, the sac is in the midline, but with increase in size, it presents either to the right or the left side, commonly the latter. the sac may be very small, or it may be sufficiently large to hold a pint or more, and to cause the neck to bulge when filled. when large, the pouch extends into the mediastinum. it will be seen that anatomically the pulsion diverticulum has its origin in the pharynx; the symptoms, however, are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch; therefore, it is properly classified as an esophageal disease. [fig. 100.--schema illustrative of the etiology of pressure diverticula. o, oblique fibers of the cricopharyngeus attached to the thyroid cartilage, t. the fundiform fibers, f, encircle the mouth of the esophagus. between the two sets of fibers is a gap in the support of the esophageal wall, through which the wall herniates owing to the pressure of food propelled by the oblique fibers, o, advance of the bolus being resisted by spasmodic contraction of the orbicular fibers, f.] _etiology_.--pressure diverticula occur after middle life, and more often in men than in women. the hasty swallowing of unmasticated food, too large a bolus, defective or artificial teeth, flaccidity of tissues, and spasm of the cricopharyngeus muscle, are etiologic factors. cicatricial stenosis below the level of the inferior constrictor is a contributory cause in some cases. _prognosis_.--after the pouch is formed, it steadily increases in size, since the swallowed food first fills and distends the sac before the overflow passes down the esophagus. when a pendulous sac becomes filled with food, it presses on the subdiverticular esophagus, and produces compression stenosis; so that there exists a "vicious circle." the enlargement of the sac produces increasing stenosis with consequent further distension of the pouch. this explains the clinically observed fact, that unless treated, pulsion diverticula increase progressively in size, and consequently in distressing symptoms. the sac becomes so large in some cases as to contribute to the occurrence of cerebral apoplexy by interference with venous return. practically all cases can be cured by radical operation. the operative mortality varies with the age, state of nutrition, and general health of the patient. in general it may be said to have a mortality of at least 10 per cent, largely due to the fact that most cases are poor surgical subjects. recurrences after radical operation are due to a persistence of the original causes, i.e., bolting of food; stenosis, spasmodic or organic, of the esophageal lumen; and weakness in the support of the esophageal wall, which, unsupported, has little strength of its own. _symptoms_.--dysphagia, regurgitation, a gurgling sound and subjective bubbling sensation on swallowing, sour odor to the breath, and cough, are the chief symptoms. with larger pouches, emaciation, pressure sensation in the neck and upper mediastinum, and the presence of a mass in the neck when the sac is filled, are present. tracheal compression by the filled pouch may produce dyspnea. the sac may be emptied by pressure on the neck, this means of relief being often discovered by the patient. the sac sometimes spontaneously empties itself by contraction of its enveloping muscular layer, and one of the most annoying symptoms is the paroxysm of coughing, waking the patient, when during the relaxation of sleep the sac empties itself into the pharynx and some of its contents are aspirated into the larynx. there are no pathognomonic symptoms. those recited are common to other forms of esophageal stenosis, and are urgent indications for diagnostic esophagoscopy. _diagnosis_.--roentgenray study with barium mixtures, is the first step in the diagnosis (fig. 101). this is to be followed by diagnostic esophagoscopy. malignant, spasmodic, cicatricial, and compression stenosis are to be excluded by esophagoscopic appearances. aneurysm is to be eliminated by the usual means. the boyce sign is almost invariably present, and is diagnostic. it is elicited by telling the patient to swallow, which action imprisons air in the sac. the imprisoned air is forced out by finger-pressure on the neck, over the sac. the exit of the air bubble produces a gurgling sound audible at the open mouth of the patient. _esophagoscopic appearances in pulsion diverticulum_.--the esophagoscope will without difficulty enter the mouth of the sac which is really the whole bottom of the pharynx, and will be arrested by the blind end of the pouch, the depth of which may be from 4 to 10 cm. in some cases the bottom of the pouch is in the mediastinum. the walls are often pasty, and may be eroded, or ulcerated, and they may show vessels or cicatrices. on withdrawing the tube and searching the anterior wall, the subdiverticular slit-like opening of the esophagus will be found, though perhaps not always easily. the esophageal speculum will be found particularly useful in exposing the subdiverticular orifice, and through this a small esophagoscope may be passed into the esophagus, thus completing the diagnosis. care must be exercised not to perforate the bottom of the diverticular pouch by pressure with the esophagoscope or esophageal speculum. the walls of the sac are surprisingly thin. [fig. 101.--pulsion diverticulum filled with bismuth mixture in a man of fifty years.] _treatment of pulsion diverticulum_.--if the pouch is small, the subdiverticular esophageal orifice may be dilated with esophagoscopic bougies, thus overcoming the etiologic factor of spastic or organic stenosis. the redundancy remains, however, though the symptoms may be relieved. cutting the common wall between the esophagus and the sac by means of scissors passed through the endoscopic tube, has been successfully done by mosher. various methods of external operation have been devised, among which are: (1) freeing the sac through an external cervical incision and suturing its fundus upward against the pharynx, which has proved successful in some cases. (2) inversion of the sac into the pharynx and suture of the mouth of the pouch. in a case so treated the pouch was blown out again during a fit of sneezing eight months after operation. (3) plication of the walls of the sac by catgut sutures, as in the matas obliterative operation for aneurysm. (4) freeing and removing the sac, with suture of the esophageal wound. (5) removal of the sac by a two-stage operation, in which method the initial step is the deliverance of the sac into the cervical wound, where it remains surrounded by gauze packing until adhesions have walled off the mediastinum. the work is completed by cutting off the sac and either suturing the esophageal wound or touching it with the cautery, and allowing it to heal by granulation. external exposure and amputation of the sac has been more frequently done than any other operation. unless the pouch is large, it is extremely difficult to find after the surgeon has exposed the esophagus, for the reasons that at operation it is empty and that when the adhesions about it are removed the walls of the sac contract. after removal, the sac is disappointingly small as compared with its previous size in the roentgenogram, which shows it distended with opaque material. it has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation. the time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the gaub-jackson operation. intratracheally insufflated ether is the anesthesia of choice. after the surgeon has exposed the esophagus by dissection, the endoscopist introduces the esophagoscope into the sac, and delivers it into the wound, while the surgeon frees it from adhesions. the esophagoscope is now withdrawn from the pouch and entered into the esophagus proper, below the diverticulum, while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope. the presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen (fig. 102). [fig. 102.--schematic representation of esophagoscopic aid in the excision of a diverticulum in the gaub-jackson operation. at a the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope. then the esophagoscopist causes the pouch to protrude as shown by the dotted line at b. after the surgeon has dissected the sac entirely loose from its surroundings, traction is made upon the sac as shown at h and the esophagoscope is inserted down the lumen of the esophagus as shown at c. the esophagoscope now occupies the lumen which the patient will need for swallowing. it only remains for the surgeon to remove the redundancy, without risk of removing any of the normal wall. the esophagoscope here shown is of the form squarely cut off at the end. the standard form of instrument with slanted end will serve as well.] _after-care_.--feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation. gastrostomy for feeding as a preliminary to the esophageal operation has been suggested, and is certainly ideal from the viewpoint of nutrition and esophageal rest. the decision of its performance may perhaps be best made by the patient himself. should leakage through the neck occur, the fistula should be flushed by the intake of sterile water by mouth. oral sepsis should, of course, be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with dakin's solution, one part, to ten parts of peppermint water. a postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus. [268] chapter xxxiv--diseases of the esophagus (_continued_) paralysis of the esophagus the passage of liquids and solids through the esophagus is a purely muscular act, controlled, after the propulsive usually voluntary start given to the bolus by the inferior constrictor, by a reflex arc having connection with the central nervous system through the vagus nerve. gravity plays little or no part in the act of deglutition, and alone will not carry food or drink to the stomach. paralysis of the esophagus may be said to be motor or sensory. it is rarely if ever unassociated with like lesions of contiguous organs. _motor paralysis of the esophagus_ is first manifested by inability to swallow. this is associated with the accumulation of secretion in the pyriform sinuses (the author's sign of esophageal stenosis) which overflows into the larynx and incites violent coughing. motor paralysis may affect the constrictors or the esophageal muscular fibers or both. _sensory paralysis of the esophagus_ by breaking the continuity of the reflex arc, may so impair the peristaltic movements as to produce aphagia. the same filling of the pyriform sinuses will be noted, but as the larynx is usually anesthetic also, it may be that no cough is produced when secretions overflow into it. _etiology_.--1. toxic paralysis as in diphtheria. 2. functional paralysis as in hysteria. 3. peripheral paralysis from neuritis. 4. central paralysis, usually of bulbar origin. embolism or thrombosis of the posterior cerebral artery is a reported cause in two cases. lues is always to be excluded as the fundamental factor in the groups 3 and 4. esophageal paralysis is not uncommon in myasthenia gravis. _esophagoscopic findings_ are those of absence of the normal resistance at the cricopharyngeus, flaccidity and lack of sensation of the esophageal walls, and perhaps adherence of particles of food to the folds. the hiatal contraction is usually that normally encountered, for this is accomplished by the diaphragmatic musculature. in paralysis of sensation, the reflexes of coughing, vomiturition and vomiting are obtunded. _diagnosis_.--hysteria must not be decided upon as the cause of dysphagia, until after esophagoscopy has eliminated paralysis. dysphagia after recent diphtheria should suggest paralysis of the esophagus. the larynx, lips, tongue, and pharynx also, are usually paralyzed in esophageal paralysis of bulbar origin. the absence of the cricopharyngeal resistance to the esophagoscope passed without anesthesia, general or local, is diagnostic. _treatment_.--the internist and neurologist should govern the basic treatment. nutrition can be maintained by feeding with the stomach-tube, which meets no resistance to its passage. should this be contraindicated by ulceration of the esophagus, gastrostomy should be done. lues of the esophagus _esophageal syphilis_ is a rather rare affection, and may show itself as a mucous plaque, a gumma, an ulceration, or a cicatrix. cicatricial stenosis developing late in life without history of the swallowing of escharotics or ulcerative lesions is strongly suggestive of syphilis, though the late manifestation of a congenital stenosis is a possibility. _esophagoscopic appearances_ of lues are not always characteristic. as in any ulcerative lesion, the inflammatory changes of mixed infections mask the basic nature. the mucous plaque has the same appearance as one situated on the velum, and gummata resemble those seen in the mucosa elsewhere. there is nothing characteristic in luetic cicatrices. _the diagnosis_ of luetic lesions of the esophagus, therefore, depends upon the history, presence of luetic lesions elsewhere, the serologic reaction, therapeutic test, examination of tissue, and the demonstration of the treponema pallidum. the therapeutic test by prolonged saturation of the system with mercury is imperative in all suspected cases and no other negative result should be deemed sufficient. _the treatment_ of luetic esophagitis is systemic, not local. luetic cicatrices contract strongly, and are very resistant to treatment, so that esophagoscopic bouginage should be begun as early as possible after the healing of a luetic ulceration, in order to prevent stenosis. a silk-woven endoscopic bougie placed in position by ocular guidance, and left _in situ_ for from half to one hour daily, may prevent severe contraction, if used early in the stage of cicatrization. prolonged treatment is required for the cure of established luetic cicatricial stenosis. if gastrostomy has been done retrograde bouginage (fig. 35) may be used. tuberculosis of the esophagus _esophageal tuberculosis_ is not commonly met, but is probably not infrequently associated with the dysphagia of tuberculous laryngitis. it may rarely occur as a primary infection, but usually the esophagus is involved in an extension from a tuberculous process in the larynx, mediastinal lymphatics, pleura, bronchi, or lungs. primary lesions appear as superficial erosions or ulcerations, with a surrounding yellowish granular zone, or the granules may alone be present. the mucosa in tuberculous lesions is usually pallid, the absence of vascularity being marked. invasion from the periesophageal organs produces more or less localized compression and fixation of the esophagus. the character of open ulceration is modified by the mixed infections. healed tuberculous lesions, sometimes resulting from the evacuation of tuberculous mediastinal lymph nodes into the esophagus may be encountered. the local fixation and cicatricial contraction may be the site of a traction diverticulum. tuberculous esophago-bronchial fistulae are occasionally seen. _diagnosis_, to be certain, requires the demonstration of the tubercule bacilli and the characteristic cell accumulation of the tubercle in a specimen of tissue removed from the lesion. actinomycosis must be excluded, and the possibility of mixed luetic and tuberculous lesions is to be kept in mind. post-tuberculous cicatrices have no recognizable characteristics. _treatment_.--the maintenance of nutrition to the highest degree, and the institution of a strict antituberculous regime are demanded. local applications are of no avail. gastrostomy for feeding should be done if dysphagia be severe, and has the advantage of putting the esophagus at rest. the passage of a stomach-tube for feeding purposes may be done, but it is often painful, and is dangerous in the presence of ulceration. pain is not marked if the lesion be limited to the esophagus, though if it is present orthoform, anesthesin, or apothesin, in powder form, swallowed dry, may prove helpful. varix and angioma of the esophagus these lesions are sometimes the cause of esophageal hemorrhage, the regurgitated blood being bright red, and alkaline in reaction, in contradistinction to the acid "coffee ground" blood of gastric origin. esophageal varices may coexist with the common dilatation of the venous system in which the veins of the rectum, scrotum, and legs are most conspicuously affected. cirrhosis and cancer of the liver may, by interference with the portal circulation, produce dilatation of the veins in the lower third of the esophagus. angioma of the esophagus is amenable to radium treatment. actinomycosis of the esophagus _esophageal actinomycosis_ has been autoptically discovered. its diagnosis, and differentiation from tuberculosis, would probably rest upon the microscopic study of tissue removed esophagoscopically, though as yet no such case has been reported. angioneurotic edema _angioneurotic edema_ involving the esophagus, may produce intermittent and transient dysphagia. the lesions are rarely limited to the esophagus alone; they may occur in any portion of the gastrointestinal, genitourinary, or respiratory tracts, and concomitant cutaneous manifestations usually render the diagnosis clear. the treatment is general. deviation of the esophagus _deviation of the esophagus_ may be marked in the presence of a deformed vertebral column, though dysphagia is a very uncommon symptom. the lack of esophageal symptoms in deviation of spinal production is probably explained by the longitudinal shortening of the spine which accompanies the deflection. compression stenosis of the esophagus is commonly associated with deviations produced by a thoracic mass. [plate iv a, gastroscopic view of a gastrojejunostomy opening drawn patulous by the tube mouth. (gastrojejunostomy done by dr. george l. hays.) b, carcinoma of the lesser curvature. (patient afterward surgically explored and diagnosis verified by dr. john j. buchanan.) c, healed perforated ulcer. (patient referred by dr. john w. boyce.) drawn from a case of postdiphtheric subglottic stenosis cured by the author's method of direct galvanocauterization of the hypertrophies. a, immediately after removal of the intubation tube; hypertrophies like turbinals are seen projecting into the subglottic lumen. b, five minutes later; the masses have now closed the lumen almost completely. the patient became so cyanotic that a bronchoscope was at once introduced to prevent asphyxia. c, the left mass has been cauterized by a vertical application of the incandescent knife. d, completely and permanently cured after repeated cauterizations. direct view; recumbent patient. photoprocess reproductions of the author's oil-color drawings from life] [273] chapter xxxv--gastroscopy the stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope. the adult size esophagoscope being 53 cm. long will reach the stomach of the average individual. longer gastroscopes are used, when necessary, to explore a ptosed stomach. various lens-system gastroscopes have been devised, which afford an excellent view of the walls of the air-inflated stomach. the optical system, however, interferes with the insertion of instruments, so that the open-tube gastroscope is required for the removal of gastric foreign bodies, the palpation of, or sponging secretions from, gastric lesions. the open-tube gastroscope may be closed with a window plug (fig. 6) having a rubber diaphragm with a central perforation for forceps, when it is desired to inflate the stomach. _technic_.--relaxation by general anesthesia permits lateral displacement of the dome of the diaphragm along with the esophagus, and thus makes possible a wider range of motion of the distal end of the gastroscope. all of the recent gastroscopies in the bronchoscopic clinic, however, have been performed without anesthesia. the method of introduction of the gastroscope through the esophagus is precisely the same as the introduction of the esophagoscope (q.v.). it should be emphasized that with the lens-system gastroscopes, the tube should be introduced into the stomach under direct ocular guidance, without a mandrin, and the optical apparatus should be inserted through the tube only after the stomach has been entered. blind insertion of a rigid metallic tube into the esophagus is an extremely dangerous procedure. the descriptions and illustrations of the stomach in anatomical works must be disregarded as cadaveric. in the living body, the empty stomach is usually found, on endoscopic inspection, to be a collapsed tube of such shape as to fit whatever space is available at the particular moment, with folds and rugae running in all directions, the impression given as to form being strikingly like searching among a mass of earth worms or boiled spaghetti. the color is pink, under proper illumination, if no food is present. poor illumination may make the color appear deep crimson. if food is present, or has just been regurgitated, the color is bright red. to appreciate the appearance of gastritis, the eye must have been educated to the endoscopic appearances under a degree of illumination always the same. the left two-thirds of the stomach is most easily examined. the stomach wall can be pushed by the tube into almost any position, and with the aid of gentle external abdominal manipulation to draw over the pylorus it is possible to examine directly almost all of the gastric walls except the pyloric antrum, which is reachable in relatively few cases. a lateral motion of from 10 to 17 cm. can be imparted to the gastroscope, provided the diaphragmatic musculature is relaxed by deep anesthesia. the stomach is explored by progressive traverse. that is, after exploring down to the greater curvature, the tube-mouth is moved laterally about 2 centimeters, and the withdrawing travel explores a new field. then a lateral movement affords a fresh field during the next insertion. this is repeated until the entire explorable area has been covered. ballooning the stomach with air or oxygen is sometimes helpful, but the distension fixes the stomach, lessens the mobility of the arch of the diaphragm, and thus lessens the lateral range of gastroscopic vision. furthermore, ballooning pushes the gastric walls far away from the reach of the tube-mouth. a window plug (fig. 6) is inserted into the ocular end of the gastroscope for the ballooning procedure. [275] like many other valuable diagnostic means, gastroscopy is very valuable in its positive findings. negative results are entitled to little weight except as to the explorable area. the gastroscopist working in conjunction with the abdominal surgeon should be able to render him invaluable assistance in his work on the stomach. the surgeon with his gloved hand in the abdomen, by manipulating suspected areas of the stomach in front of the tube-mouth can receive immediately a report of its interior appearance, whether cancerous, ulcerated, hemorrhagic, etc. _lens-system ballooning gastroscopy_ may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained. care must be exercised not to exert an injurious degree of air-pressure. the distended portion of the stomach assumes a funnel-like form ending at the apex in a depression with radiating folds, that leads the observer to think he is looking at the pylorus. the foreshortening produced by the lens system also contributes to this illusion. the best lens-system gastroscope is that of henry janeway, which combines the open-tube and the lens system. _gastroscopy for foreign bodies_.--the great majority of foreign bodies that reach the stomach unassisted are passed per rectum, provided the natural protective means are not impaired by the administration of cathartics, changes in diet, etcetera. this, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. if an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate. certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles. these should be removed by gastroscopy when such decision is made. it is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus, whence they are easily removed by esophagoscopy. the double-planed fluoroscope of manges is helpful in the removal of gastric foreign bodies, but there is great danger of injury to the stomach walls, and even the peritoneum, unless forceps are used with the utmost caution. [277] chapter xxxvi--acute stenosis of the larynx _etiology_.--causes of a relatively sudden narrowing of the lumen of the larynx and subjacent trachea are included in the following list. two or more may be combined. 1. foreign body. 2. accumulation of secretions or exudate in the lumen. 3. distension of the tissues by air, inflammatory products, serum, pus, etc. 4. displacement of relatively normal tissues, as in abductor paralysis, congenital laryngeal stridor, etcetera. 5. neoplasms. 6. granulomata. _edema of the larynx_ may be at the glottic level, or in the supraglottic or subglottic regions. the loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone. in children the subglottic area is very vascular, and swelling quickly results from trauma or inflammation, so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords. dyspnea, and croupy, barking, cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis. edema may accompany inflammation of either the superficial or deep structures of the larynx. the laryngeal lesion may be primary, or may complicate general diseases; among the latter, typhoid fever deserves especial mention. _acute laryngeal stenosis_ complicating typhoid fever is frequently overlooked and often fatal, for the asthenic patient makes no fight for air, and hoarseness, if present, is very slight. the laryngeal lesion may be due to cordal immobility from either paralysis or inflammatory arytenoid fixation, in the absence of edema. perichondritis and chondritis of the laryngeal cartilages often follow typhoid ulceration of the larynx, chronic stenosis resulting. _laryngeal stenosis in the newborn_ may be due to various anomalies of the larynx or trachea, or to traumatism of these structures during delivery. the normal glottis in the newborn is relatively narrow, so that even slight encroachment on its lumen produces a serious degree of dyspnea. the characteristic signs are inspiratory indrawing of the supraclavicular fossae, the suprasternal notch, the epigastrium, and the lower sternum and ribs. cyanosis is seen at first, later giving place to pallid asphyxia when cardiac failure occurs. little air is heard to enter the lungs, during respiratory efforts and the infant, becoming exhausted by the great muscular exertion, soon ceases to breathe. paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur. _acute laryngeal stenosis in infants, from laryngeal perichondritis_, may be a delayed result of traumatism to the laryngeal cartilages during delivery. the symptoms usually develop within four weeks after birth. lues and tuberculosis are possible factors to be eliminated by the usual methods. _surgical treatment of acute laryngeal stenosis_.--multiple puncture of acute inflammatory edema, while readily performed with the laryngeal knife used through the direct laryngoscope, is an uncertain measure of relief. tracheotomy, if done low in the neck, will completely relieve the dyspnea. by its therapeutic effect of rest, it favors the rapid subsidence of the inflammation in the larynx and is the treatment to be preferred. intubation is treacherous and unreliable except in diphtheritic cases; but in the diphtheritic cases it is ideal, if constant skilled watching can be had. [279] chapter xxxvii--tracheotomy _indications_.--tracheotomy is indicated in dyspnea of laryngotracheal origin. the cardinal signs of this form of dyspnea are: 1. indrawing at the suprasternal notch. 2. indrawing around the clavicles. 3. indrawing of the intercostal spaces. 4. restlessness. 5. choking and waking as soon as the aid of the voluntary respiratory muscles ceases in falling to sleep. 6. cyanosis is a dangerously late symptom. as a therapeutic measure in diseases of the larynx its place has been thoroughly established. marked improvement of the laryngeal lesions has been observed to follow tracheotomy in advanced laryngeal tuberculosis, and in cancer of the larynx. it has proven, in some cases, a useful adjunct in the treatment of luetic laryngitis, though it cannot be regarded as indicated, in the absence of dyspnea. perichondritis and other inflammations are benefited by tracheotomy. a marked therapeutic effect on multiple laryngotracheal papillomata in children has been noted by the author in hundreds of cases. _tracheotomy for foreign body_ is no longer indicated either for the removal of the intruder, or for the insertion of the bronchoscope. tracheotomy may be urgently indicated for foreign body dyspnea, but not for foreign body removal. _subcutaneous rupture of the trachea_ from external trauma may produce dyspnea and generalized emphysema, both of which will be relieved by tracheotomy. [280] _acromegalic stenosis of the larynx_ is a rare but urgent indication for tracheotomy. _contraindications_.--there are no contraindications to tracheotomy for dyspnea. _the instruments_ required for an orderly tracheotomy are: headlight scalpels 2 retractors trousseau dilator 6 hemostats scissors (dissecting) tracheal cannulae (six sizes) curved needles needle holder hypodermic syringe for local anesthesia no. 1 plain catgut ligatures linen tape gauze sponges these are sterilized and kept in a sterile copper box ready for instant use. beside the patient's bed following the tracheotomy the following sterile materials are placed: sterile gloves 1 hemostat sterile new gauze trousseau dilator scissors duplicate tracheotomy tube silver probe basin of bichloride of mercury solution, 1 : 10,000 tracheotomy is one of the oldest operations known to surgery, yet strange to say, it is probably more often improperly performed today, and more often followed by needless mortality, than any other operation. the two chief preventable sequelae are death from improper routine surgical care and wrongly fitted tube, and stenosis from too high an operation. the classical descriptions of crico-thyroidotomy and high and low tracheotomy have been handed down to generations of medical students without revision. every medical graduate has been taught that there are two kinds of tracheotomy, high and low, the low operation being very difficult, the high operation very easy. when he is suddenly called upon to do an emergency tracheotomy, this erroneous teaching is about all that remains in the dim recesses of his memory; consequently he makes sure of doing the operation high enough, and goes in through the larynx, usually dividing the cricoid cartilage, the only complete ring in the trachea. as originally made the distinction between high and low as applied to tracheotomy referred to operations above and below the isthmus of the thyroid gland, in a day when primitive surgery attached too much importance to operations upon the thyroid gland. the isthmus is entitled to absolutely no consideration whatever in deciding the location at which to incise so vital a structure as the trachea. students are taught different short skin incisions for these two operations, and it is no wonder that they, as did their predecessors, find tracheotomy a difficult, bloody, and often futile operation. the trachea is searched for at the bottom of a short, deep wound filled with blood, the source of which is difficult to find and impossible to control. _tracheotomic cannulae_ should be made of sterling silver. german silver plated with pure silver is good enough for temporary use, but the plating soon wears off under the galvanic action set up between the two metals. aluminum becomes roughened by boiling and contact with secretions, and causes the formation of granulations which in time lead to stenosis. hard rubber tubes cannot be boiled, the walls are so thick as to leave too little lumen, and the rubber is irritating to the tissues. all tracheotomy tubes should be fitted with pilots. many of the tubes furnished to patients have no pilots to facilitate the introduction, and the tubes are inserted with somewhat the effect of a cheese tester, and with great pain and suffering on the part of the patient. most of the the tubes in the shops are too short to allow for the swelling of the tissues of the neck following the operation. they may reach the trachea at the time of the operation, but as soon as the reactionary swelling occurs, the end of the tube is pulled out (fig. 103) of the tracheal incision; the air hissing along the tube is considered by the attendant to indicate that the tube is still in place, and the increasing dyspnea and accelerated respiratory rate are attributed to supposed pneumonia or edema of the lungs, under which erroneous diagnosis the patient is buried. in all cases in which it is reported that in spite of tracheotomy the dyspnea was only temporarily relieved, the fault is the lack of a "plumber." that is, an attendant who will make sure that there is at all times a clear airway all the way down to the lungs. with a bronchoscope and aspirator he will see that the airway is clear. to begin with, a proper sized cannula must be selected. the series of different sized, full curved tubes, one of which is illustrated in fig. 104, will under all conditions reach the trachea. if the tube seems to be too long in any given case, it will usually be found that the tracheotomy has been done too high, and a lower one should be done at once. if the operation has not been done too high, and the cannula is too long, a pad of gauze under the shield will take up the surplus length. in cases of tracheal compression from new growth, thymus or other such cases, in which the ordinary tube will not pass the obstruction, the author's long cane-shaped cannula (see fig. 104) can be inserted past the obstruction, and if necessary into either bronchus. the fenestrum placed in the cannula in many of the older tubes, with the supposed function of allowing partial breathing through the larynx, is a most pernicious thing. a properly fitted tube should not take up more than half of the cross section of the trachea, and should allow the passage of sufficient air for free laryngeal breathing when it is completely corked. the fenestrum is, moreover, rarely so situated that air can pass through it; the fenestral edges act as a constant irritant to the wound, producing bleeding and granulation tissue. [fig. 103.--schema showing thick pad of gauze dressing, filling the space, a, and used to hold out the author's full-curved cannula when too long, prior to reactionary swelling, and after subsidence of the latter. at the right is shown the manner in which the ordinary cannula of the shops permits a patient to asphyxiate, though some air is heard passing through the tracheal opening, h, after the cannula has been partially withdrawn by swelling of the tissues, t.] [fig. 104.--the author's tracheotomic cannulae. a, shows cane-shaped cannula for use in intrathoracic compressive or other stenoses. b, shows full curved cannula for regular use. pilots are made to fit the outer cannula; the inner cannula not being inserted until after withdrawal of the pilot.] _anesthesia_.--no dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. when this action is stopped by beginning unconsciousness, respiration ceases. if the trachea is not immediately opened, artificial respiration instituted, and oxygen insufflated, the patient dies on the table. skin infiltration along the line of incision with a very weak cocaine solution (1/10 of 1 per cent), apothesine (2 per cent), novocaine, schleich's fluid or other local anesthetic, suffices to render the operation painless. the deeper structures have little sensation and do not require infiltration. it has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula. it would seem, however, that this introduces the risk of aspiration pneumonia and pulmonary abscess, by permitting the aspiration and clotting of blood in small bronchi, followed by subsequent breaking down of the clots. as the author has so often said, "the cough reflex is the watch dog of the lungs," and if not drugged asleep by local or general anesthesia can safely be relied upon to prevent all possibility of the blood or the pus which nearly always is present in acute or chronic conditions calling for tracheotomy, being aspirated into the deeper air-passages. cocaine in any form, by any method, and in any dosage, is dangerous in very young children. _technic_.--the patient should be placed in the recumbent position, with the extended head held in the midline by an assistant. the shoulders, not the neck, should be slightly raised with a sand bag. the head should be somewhat lower than the feet, to lessen the danger of aspiration of blood. a midline incision dividing the skin and fascia is made from the thyroid notch to just above the suprasternal notch. the cricoid is now located, and the deeper dissection is continued from below this point. the ribbon muscles are separated with dissecting scissors or knife, and held apart with retractors. if the isthmus of the thyroid gland is in the way, it may be retracted upward; if large, however, it should be divided and ligated, for it is apt to slip over the tracheal incision afterward, and render difficult the quick finding of the incision during after-care. this covering of the tracheal incision by the slipping back of the drawn-aside thyroidal isthmus is one of the most frequent avoidable causes of mortality, because it deflects the cannula off into the tissues when it is replaced after cleaning during the early postoperative period. the corrugated surface of the trachea can be felt, and its exact location can be determined by the index finger. if the tracheotomy is proceeding in an orderly manner, all bleeding points should be caught and tied with plain catgut (no. 1) before the trachea is opened. because of distension of vessels during cough, all but the tiniest vessels should be ligated. side-cut veins are particularly treacherous. they should be freed of tissue, cut across and the divided ends ligated. the _incision in the trachea_ should be as low as possible, and should never be made through the first ring. the incision should be through the third, fourth and fifth rings. only in cases of laryngoptosis will it be necessary to incise the trachea higher than this. the incision must be made in the midline, and in the long axis of the trachea, and care must be exercised that the point of the knife does not perforate the posterior tracheal wall. stab incisions are always to be avoided. if the incision in the trachea is found to be of insufficient length, the original incision must be found and elongated. a second incision must not be made, for the portion of cartilage between the two incisions will die and will almost certainly make a site of future tracheal stenosis. the cricoid should never be cut, for stenosis is almost sure to follow the wearing of a cannula in this position. a trousseau dilator should now be inserted in the tracheal incision, its blades gently separated. with the tracheal lumen thus opened, a cannula of proper size is introduced with absolute certainty of its having entered the trachea. a quadruple-folded square of gauze in the form of a pad about four inches square is moistened with mercuric chloride solution (1:10,000) and is slit from the lower border to its midpoint. this pad is slipped from above downward under the tape holder of the cannula, the slit permitting the tubal part of the cannula to reach the central part of the pad (fig. 108), and completely covers the wound. no attempt should be made to suture the skin wound, for this tends to form a pocket in which lodge the bronchial secretions that escape alongside the tube, resulting in infection of the wound. furthermore it renders the daily changing of the tube much more difficult. in fact it prevents the attendant from being certain that the tube is actually placed in the trachea. suturing of the skin to the trachea should never be done, for the sutures soon tear out and often set up a perichondritis of the tracheal cartilages, with resulting difficult decannulation. [fig. 105.--schema of practical gross anatomy to be memorized for emergency tracheotomy. the middle line is the safety line, the higher the wider. below, the safety line narrows to the vanishing point vp. the upper limit of the safety line is the thyroid notch until the trachea is bared, when the limit falls below the first tracheal ring. in practice the two-dark danger lines are pushed back with the left thumb and middle finger as shown in fig. 106, thus throwing the safety line into prominence. this is generally known as jackson's tracheotomic triangle.] [fig. 106.--schema showing the author's method of rapid tracheotomy. first stage. the hands are drawn ungloved for the sake of clearness. the upper hand is the left, of which the middle finger (m) and the thumb are used to repress the sterno-cleido-mastoid muscles, the finger and thumb being close to the trachea in order to press backward out of the way the carotid arteries and the jugular vein. this throws the trachea forward into prominence, and one deep slashing cut will incise all of the soft tissues down to the trachea.] _emergency tracheotomy_.--stabbing of the cricothyroid membrane, or an attempted stabbing of the trachea, so long taught as an emergency tracheotomy, is a mistake. the author's "two stage, finger guided" method is safer, quicker, more efficient, and not likely to be followed by stenosis. to execute this promptly, the operator is required to forget his textbook anatomy and memorize the schema (fig. 105). the larynx and trachea are steadied by the thumb and middle finger of the left hand, which at the same time push back the important nerves and vessels which parallel the trachea, and render the central safety line more prominent (fig. 106). a long incision is now made from the thyroid notch almost to the suprasternal notch, and deep enough to reach the trachea. this completes the first stage. [fig. 107.--illustrating the author's method of quick tracheotomy. second stage. the fingers are drawn ungloved for the sake of clearness. in operating the whole wound is full of blood, and the rings of the trachea are felt with the left index which is then moved slightly to the patient's left, while the knife is slid down along the left index to exactly the middle line when the trachea is incised.] second stage. the entire wound is full of blood and the trachea cannot be seen, but its corrugations can be very readily felt by the tip of the free left index finger. the left index finger is now moved a little to the patient's left in order that the knife shall come precisely in the midline of the trachea, and three rings of the trachea are divided from above downward (fig. 107). the trousseau dilator should now be inserted, the head of the table should be lowered, and the patient should be turned on the side to allow the blood to run away from the wound. if respiration has ceased, a cannula is slipped in, and artificial respiration is begun. oxygen insufflation will aid in the restoration of respiration, and a pearl of amyl nitrite should be crushed in gauze and blown in with the oxygen. in all such cases, excessive pressure of oxygen should be avoided because of the danger of producing ischemia of the lungs. hope of restoring respiration should not be abandoned for half an hour at least. one of the author's assistants, dr. phillip stout, saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing. the _after-care_ of the tracheotomic wound is of the utmost importance. a special day and night nurse are required. the inner tube of the cannula must be removed and cleaned as soon as it contains secretion. secretion coughed out must be wiped away quickly, but gently, before it is again aspirated. the gauze dressing covering the wound must be changed as soon as soiled with secretions from the wound and the air-passages. each fresh pad should be moistened with very weak bichloride of mercury solution (1:10,000). the outer tube must be changed every twenty-four hours, and oftener if the bronchial secretion is abundant. student-physicians who have been taught my methods and who have seen the cases in care of our nurses have often expressed amazement at the neglect unknowingly inflicted on such cases elsewhere, in the course of ordinary routine surgery. it is not unusual for a patient to be sent to the bronchoscopic clinic who has worn his cannula without a single changing for one or two years. in some cases the tube had broken and a portion had been aspirated into the trachea. [fig. 108.--method of dressing a tracheotomic wound. a broad quadruple, in-folded pad of gauze is cut to its centre so that it can be slipped astride of the tube of the cannula back of the shield. no strings, ravellings or strips of gauze are permissible because of the risk of their getting down into the trachea.] if the respiratory rate increases, instead of attributing it to pulmonary complications, the entire cannula should be removed, the wound dilated with the trousseau forceps, the interior of the trachea inspected, and all secretions cleaned away. then the tracheal mucosa below the wound should be gently touched with a sterile bent probe, to induce cough to rid the lower air passages of accumulated secretions. in many cases it is a life-saving procedure to insert a sterile long malleable aspirating tube to remove secretions from the lower air-passages. when all is clear, a fresh sterile cannula which has been carefully inspected to see that its lumen has been thoroughly cleaned, is inserted, and its tapes tied. good "plumbing," that is, the maintenance at all times of a clear, clean passage in all the "pipes," natural and artificial, is the reason why the mortality in the bronchoscopic clinic has been less than half of one per cent, while in ordinary routine surgical care in all hospitals collectively it ranges from 10 to 20 per cent. _bronchial aspiration_.--as mentioned above, bronchial aspiration is often necessary. when the patient is unable to get up secretions, he will, as demonstrated by the author many years ago, "drown in his own secretions." in some cases bronchoscopic aspiration is required (peroral endoscopy, p. 483). occasionally, very thick secretions will require removal with forceps. pus may become very thick and gummy from the administration of morphin. opiates do not lessen pus formation, but they do lessen the normal secretions that ordinarily increase the quantity and fluidity of the pus. when to this is added the dessicating effect of the air inhaled through the cannula, unmoistened by the upper air-passages, the secretions may be so thick as to form crusts and plugs that are equivalent to foreign bodies and require removal with forceps. diphtheritic membrane in the trachea may require removal with bronchoscope and forceps. thinner secretions may be removed by sponge-pumping. in most cases, however, secretions can be brought up through an aspirating tube, connected to a bronchoscopic aspirating syringe (fig. 11), an ordinary aspirating bottle, or preferably, a mechanical aspirator such as that shown in fig. 12. in this, combined with bronchoscopic oxygen insuflation (q.v.), we have a life-saving measure of the highest efficiency in cases of poisoning by chlorine and other irritant and asphyxiating gases. an aspirating tube for insertion into the deeper air passages should be of copper, so that it can be bent to the proper curve to reach into the various parts of the tracheobronchial tree, and it should have a removable copper-wire core to prevent kinking, and collapse of the lumen. the distal end should be thickened, and also perforated at the sides, to prevent drawing-in of the mucosa and trauma thereto. a rubber tube may be used, but is not so satisfactory. the one shown in fig. 10 i had made by mr. pilling, and it has proved very satisfactory. _decannulation_.--when the tracheal incision is placed below the first ring, no difficulty in decannulation should result from the operation per se. when by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained sufficient size to allow free breathing, a smaller-sized tracheotomic tube should be substituted to allow free passage of air around the cannula in the trachea. in doing this, the amount of secretion and the handicap of impaired glottic mobility in the expulsion of thick secretions must be borne in mind. babies labor under a special handicap in their inefficient bechic expulsion and especially in their small cannulae which are so readily occluded. if breathing is not free and quiet with the smaller tube; the larger one must be replaced. if, however, there is no trouble with secretions, and the breathing is free and quiet, the inner cannula should be removed, and the external orifice of the outer cannula firmly closed with a rubber cork. if the laryngeal condition has been acute, decannulation can usually be safely done after the patient has been able to sleep quietly for three nights with a corked cannula. if free breathing cannot be obtained when the cannula is corked, the larynx is stenosed, and special work will be required to remove the tube. children sometimes become panic stricken when the cannula is completely corked at once and they are forced to breathe through the larynx instead of the easier shortcut through the neck. in such a case, the first step is partially to cork the cannula with a half or two-thirds plug made from a pure rubber cord fashioned in the desired shape by grinding with an emery wheel (fig. 112). thus the patient is gradually taught to use the natural air-way, still feeling that he has an "anchor to windward" in the opening in the cannula. when some swelling of the laryngeal structures still exists, this gradual corking has a therapeutic effect in lessening the stenosis by exercising the muscles of abduction of the cords and mobilizing the cricoarytenoid articulation during the inspiratory effort. the forced respiration keeps the larynx freed from secretions, which are more or less purulent and hence irritating. after removing the cannula, in order that healing may proceed from the bottom upward, the wound should be dressed in the following manner: a single thickness of gauze should be placed over the wound and the front of the neck, and a gauze wedge firmly inserted over this to the depths of the tracheotomic wound, all of this dressing being held in place by a bandage. if the skin-wound heals before the fibrous union of the tracheal cartilages is complete, exuberant granulations are apt to form and occlude the trachea, perhaps necessitating a new tracheotomy for dyspnea. it is so important to fix indelibly in the mind the cardinal points concerning tracheotomy that i have appended to this chapter the teaching notes that i have been for years giving my classes of students and practitioners, hundreds of whom have thanked me for giving them the clear-cut conception of tracheotomy that enabled them, when their turn came to do an emergency tracheotomy, to save human life. resume of tracheotomy _instruments_. headlight sandbag scalpel hemostats small retractors tenaculum tracheotomic cannulae (proper kind) long. half area cross-section trachea. proper curve: radius too short will press ant. tracheal wall; too long, post. wall. sterling silver tracheobronchial aspirator. probe. tapes for cannulae trousseau dilator sponges infiltration syringe and solution oxygen tank. _indications_: laryngeal dyspnea. (indrawing guttural and clavicular fossae and at epigastrium. pallor. restlessness. drowning in his own secretions.) do it early. don't wait for cyanosis. [294] never use general anesthesia on dyspneic patient. forget about "high" and "low" distinctions until trachea is exposed. memorize jackson's tracheotomic triangle. patient recumbent, sand bag under shoulders or neck. nose to zenith. infiltration, _intra_dermatic. incise from adam's apple to guttural fossa. hemostasis. keep in middle line. feel for trachea. expose isthmus of thyroid gland. draw it upward or downward or cut it. ligature, torsion, etc. before incising trachea. hold trachea with tenaculum. incise trachea below first ring. avoid cutting cricoid or first ring. cut 3 rings vertically. don't hack. don't cut posterior wall which almost touches the anterior wall during cough. spread carefully, with trousseau dilator. insert cannula; _see_ it enter tracheal lumen; remove pilot; tie tapes. don't suture wound. dress with large squares. don't give morphine. decannulation by corking partially, after changing to smaller cannula. do not remove cannula permanently until patient sleeps without indrawing with corked cannula. resume of emergency tracheotomy the following notes should be memorized. 1. essentials: knife and pair of hands (but full equipment better). [295] 2. don't do a laryngotomy, or stabbing. 3. "two stage, finger guided" operation better. 4. sand bag or substitute. 5. press back danger lines with left thumb and middle finger, making safety line and trachea prominent. 6. memorize jackson's tracheotomic triangle. 7. incise exactly in middle line from adam's apple to sternum. 8. feel for tracheal corrugations with left index in pool of blood, following trachea with finger downward from superficial adam's apple. 9. pass knife along index and incise trachea (not too deeply, may cut posterior wall). 10. don't mind bleeding; but keep middle line and keep head straight; keep head low; don't bother about thyroid gland. 11. don't expect hiss when trachea is cut if patient has stopped breathing. 12. start artificial respiration. 13. amyl nitrite. oxygen. 14. practice palpation of the neck until the tracheal landmarks are familiar. 15. practice above technic, up to point of incision, at every opportunity. 16. _jackson's tracheotomic triangle_: a triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy. apex at suprasternal notch. sides anterior edge sternomastoids. base horizontal line lower edge cricoid. resume of after-care of a tracheotomic case 1. always bear in mind that tracheotomy is not an ultimate object. the ultimate object is to pipe air down into the lungs. tracheotomy is only a means to that end. 2. sterile tray beside bed should contain duplicate (exact) tracheotomy tube, trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. sterile gloves ready. 3. special nursing necessary for safety. 4. laxative. 5. sponge away secretions before they are drawn in. 6. cover wound with wide large gauze square slit so it fits around cannula under the tape holder. pull off ravelings. keep wet with 1 : 10,000 bichloride solution. 7. change dressing every hour or oftener. 8. abundance of fresh air, temperature preferably about 70 degrees. 9. _nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling._ 10. outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. a pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage. 11. a sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. an aspirating tube should be used, when necessary. 12. a patient with a properly fitted cannula free of secretions breathes noiselessly. any sound demands immediate attention. 13. if the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications. 14. be sure that: (a) the cannula is clear and clean. (b) the cannula is long enough to reach well down into the trachea. a cannula that was long enough when the operation was done may be too short after the cervical tissues swell. (c) the distal end of the cannula actually is deeply in the trachea. the only way to be sure is, when inserting the cannula, to spread the wound and the tracheal incision with a trousseau dilator, then _see_ the interior of the tracheal lumen and _see_ the cannula enter therein. 15. if after attending to the above mentioned details there are still signs of obstructive dyspnea, a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi. 16. if all the "pipes," natural and instrumental, are clear there can be no such thing as obstructive dyspnea. 17. pneumonia and pulmonary edema may exist before tracheotomy, but they are rare sequelae. 18. decannulation, in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least 3 nights with his cannula tightly corked. a properly fitted cannula (i.e. one not larger than half the area of cross section of the trachea) permits the by-passage of plenty of air. a partial cork should be worn for a few days first for testing and "weaning" a child away from the easier breathing through the neck. in cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation. 19. a tracheotomic case may be aphonic, hence unable to call for help. 20. the foregoing rules apply to the post-operative periods. after the wound has healed and a fistula is established, the patient, if not a child, may learn to care for his own cannula. [298] 21. do not give cough-sedatives or narcotics. the cough reflex is the watch dog of the lungs. notes on nursing tracheotomized patients bedside tray should contain: duplicate cannula scalpel trousseau dilator hemostat dressing forceps sterile vaseline scissors tape probe gauze sponges gauze squares probe-pointed curved bistoury. 1. room should be abundantly ventilated, as free from dust and lint as possible, and the air should be moistened by steam in winter. 2. keep mouth clean. tooth brush. rinse alcohol 1:10. 3. sponge away secretion after the cough before drawn in. 4. remove inner cannula (not outer) as often as needed. not less often than every hour. replace immediately. never boil a cannula until you have thoroughly cleaned it. 5. obstruction of cannula calling for cleaning indicated by: blue or ashy color. indrawing at clavicles, sternal notch, epigastrium. noisy breathing. (learn sound.) 6. surgeon (in our cases) will change outer cannula once daily or oftener. 7. duplicate cannulae. 8. be careful in cleaning cannulae not to damage. 9. watch for loose parts on cannula. 10. change dressing (in our cases) as often as soiled. not less often than every hour. large squares. never narrow strips. 11. watch color of lips and ears and face. [299] 12. report at once if food or water leaks through wound. (coughing and choking). 13. never leave a tracheotomized patient unwatched during the first days or weeks, according to case. 14. remember trousseau dilator or hemostat will spread the tracheal wound or fistula when cannula is out. 15. remember life depends on a clear cannula if the patient gets no air through the mouth. 16. remember it takes very little to clog the small cannula of a child. 17. remember a tracheotomized patient cannot call for help. 18. decannulation. testing by corking partially. watch corks not too small, or broken. attach them by braided silk thread. pure rubber cord ground down makes best cork. [300] chapter xxxviii--chronic stenosis of the larynx and trachea the various forms of laryngeal stenosis for which tracheotomy or intubation has been performed, and the difficulties encountered in restoring the natural breathing, may be classified into the following types: 1. panic 2. spasmodic 3. paralytic 4. ankylotic (arytenoid) 5. neoplastic 6. hyperplastic 7. cicatricial (a) loss of cartilage (b) loss of muscular tissue (c) fibrous _panic_.--nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made. crying and possibly glottic spasm increase the difficulties. _spasmodic stenosis_ may be associated with panic, or may be excited by subglottic inflammation. prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. the treatment for spasmodic stenosis and panic is similar. the use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. very rarely a tracheotomy may be required; if so, it should be done low. the wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation. corking the cannula with a slotted cork (fig. 111) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed. [plate v--photoprocess reproductions of the author's oil-color drawings from life--laryngeal and tracheal stenoses: 1, indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (see fig. 5.) 2, indirect view, sitting position; posttyphoid cicatricial stenosis. mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. cured by laryngostomy. (see fig. 6.) 3, indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. cured by laryngostomy; failure to form adventitious band (fig. 7) because of lack of arytenoid activity. 4, indirect view, recumbent position; posttyphoid cicatricial stenosis. cured of stenosis by endoscopic evisceration with sliding punch forceps. anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in fig. 15. ultimate result shown in fig. 8. 5, same patient as fig. 1; sketch made two years after decannulation and plastic. 6, same patient as fig. 2; sketch made four years after decannulation and plastic. 7, same patient as fig. 3; sketch made three years after decannulation and plastic. 8, same patient as fig. 4; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form adventitious cords. 9, direct view, recumbent patient; web postdiphtheric (?) or congenital (?). "rough voice" since birth, but larynx never examined until stenosed after diphtheria. web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). cure by laryngostomy. this view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations. 10, direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. cured by galvanocauterization. 11, direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. forceps excision; extubation one month later; still well after four years. 12, bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. 13, direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. cured by thymopexy. 14, indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. 15, direct view; posttyphoid stenosis after cure by laryngostomy. dotted line shows place of excision for clearing out the anterior commissure to restore the voice. 16, endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. tracheotomy originally done for influenzal tracheitis. cured by tracheostomy.] _paralysis_.--bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. in cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. the operation of _ventriculocordectomy_ consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. in some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. an interval of two months between operations is advisable to avoid adhesions. in almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration. the ultimate vocal results are good. evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. only too often, however, the condition is complicated by the results of a faultily high tracheotomy. a rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. in recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy. _ankylosis_.--fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. this, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula. _neoplasms_.--decannulation in neoplastic cases depends upon the nature of the growth, and its curability. cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. the stenosis produced by benign tumors is usually relieved by their removal. _papillomata_.--decannulation after tracheotomy done for papillomata should be deferred at least 6 months after the discontinuance of recurrence. not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. it is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. this method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis. _compression stenosis of the trachea_.--decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. glandular disease may be of the hodgkins' type. thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents. surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. the possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases. _hyperplastic and cicatricial chronic stenoses_ preventing decannulation may be classified etiologically as follows: 1. tuberculosis 2. lues 3. scleroma 4. acute infectious diseases (a) diphtheria (b) typhoid fever (c) scarlet fever (d) measles (e) pertussis 5. decubitus (a) cannular (b) tubal 6. trauma (a) tracheotomic (b) intubational (c) operative (d) suicidal and homicidal (e) accidental (by foreign bodies, external violence, bullets, etc.) most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues. [304] _tuberculosis_.--in the non-cicatricial forms, galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway. should the pulmonary and laryngeal tuberculosis be fortunately cured, leaving, however, a cicatricial stenosis of the larynx, decannulation may be accomplished by laryngostomy. _lues_.--active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis. prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful, but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices. _scleroma_ is rarely encountered in america. radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan. radium may be tried, and its application is readily made through the direct laryngoscope. _diphtheria_.--chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic, since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy. prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia. _the supraglottic type_ consists in an edematous thickening around the base of the epiglottis, sometimes involving also the glossoepiglottic folds and the ventricular bands. an improperly shaped or fitted tube is the usual cause of this condition, and a change to a correct form of intubation tube may be all that is required. excessive polypoid tissue hypertrophy should be excised. the less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. the former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. _subglottic hypertrophic stenosis_ consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition. preliminary tracheotomy is required in those cases in which it has not already been done, and in the cases in which a high tracheotomy has been done, a low tracheotomy must be the first step in the cure. cicatricial types of postdiphtheritic stenosis may be seen as webs, annular cicatrices of funnel shape, or masses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen. (see color plates.) as a rule, when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered. if a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube. _typhoid fever_.--ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection, though thrombosis of a small vessel, with subsequent necrosis is also seen. if the ulceration reaches the cartilage, cicatricial stenosis is almost certain to follow. _trauma_.--the chief traumatic factors in chronic laryngeal stenosis are: (a) prolonged presence of a foreign body in the larynx (b) unskilled attempts at intubation and the wearing of poorly fitting intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting cannula; (e) war injuries; (f) attempted suicide; (g) attempted homicide; (h) neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea. _treatment of cicatricial stenosis_.--a careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case. granulations should be removed. intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken. a certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests, supplemented by biopsy if necessary. vigorous antiluetic treatment, especially with protiodide of mercury, must precede operation in all luetic cases. necrotic cartilage is best treated by laryngostomy. intubational dilatation will succeed in some cases. [fig. 109.--schema showing the author's method of laryngostomy. the hollow upward metallic branch (n) of the cannula (c) holds the rubber tube (r) back firmly against the spur usually found on the back wall of the trachea. moreover, the air passing up through the rubber tube (r) permits the patient to talk in a loud whisper, the external orifice of the cannula being occluded most of the time with the cork (k). the rubber tubing, when large sizes are reached may extend down to the lower end of the cannula, the part c coming out through a large hole cut in the tubing at the proper distance from the lower end.] _laryngoscopic bouginage_ once weekly with the laryngeal bougies (fig. 42) will cure most cases of laryngeal stenosis. for the trachea, round, silk-woven, or metallic bougies (fig. 40) are better. [307] _laryngostomy_ consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (fig. 109). over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread. progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. painstaking after-care is essential to success. when dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall. _intubational treatment of chronic laryngeal stenosis_ may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. the tube is a silver-plated brass one of large size (fig. 110). a post which screws into the anterior surface of the tube prevents its expulsion. over the post is slipped a block which serves to keep open the tracheal fistula. detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. before undertaking any of the foregoing procedures, a careful study of the complete descriptions in peroral endoscopy is necessary, and a practical course of training is advisable. [fig. 110.--the author's retaining intubation tube for treatment of chronic laryngeal stenosis. the tube (a) is introduced through the mouth, then the post (b) is screwed in through the tracheal wound. then the block (c) is slid into the wound, the square hole in the block guarding the post against all possibility of unscrewing. if the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula. the shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.] [309] chapter xxxix--decannulation after cure of laryngeal stenosis in order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. this is best done by inserting a rubber cork in the inner cannula. at first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis, new corks with smaller grooves being substituted as laryngeal breathing becomes easier. corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis. the added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures. by no other method can panic and spasmodic stenosis be so efficiently cured. [fig. 111.--illustration of corks used to occlude the cannula in training patients to breathe through the mouth again, before decannulation. the corks allow air leakage, the amount of which is regulated by the use of different shapes. a smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated. a central hole is sometimes used instead of a slot. a, one-third cork; b, half cork; c, three-quarter cork; d, whole cork.] following the subsidence of an acute laryngeal stenosis, it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for 3 days and nights. this rule does not apply to chronic laryngeal stenosis, for while the lumen under ordinary conditions might be ample, a slight degree of inflammation might render it dangerously small. in these cases, many weeks are sometimes required to determine when decannulation is safe. a test period of a few months is advisable in most cases of chronic laryngeal stenosis. recurrent contractions after closure of the wound are best treated by endoscopic bouginage. the corks are best made of pure rubber cord, cut and ground to shape, and grooved, if desired, on a small emery wheel (fig. 112). the ordinary rubber corks and those made of cork-bark should not be used because of their friability, and the possible aspiration of a fragment into the bronchus, where rubber particles form very irritant foreign bodies. [fig. 112.--this illustration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel. after grinding the taper, if a partial cork is desired, a groove is ground on the angle of the wheel. if a half-cork is desired half of the cork is ground away on the side of the wheel. reliable corks made in this way are now obtainable from messers charles j. pilling and son.] bibliography the following list of publications of the author may be useful for reference: 1. peroral endoscopy and laryngeal surgery, textbook, 1914. (contains full bibliography to date of publication.) 2. acromegaly of the larynx. journ. amer. med. asso., nov. 30, 1918, vol. lxxi, pp. 1787-1789. 3. a fence staple in the lung. a new method of bronchoscopic removal. journ. amer. med. asso., vol. lxiv, june 5, 1917, pp. 1906-7. 4. amalgam tooth-filling aspirated into lung during extraction. dental cosmos, vol. lix, may, 1917, pp. 500-502. 5. amalgam filling removed from lung after a seven months' sojourn: case report. dental cosmos, april, 1920. 6. a mechanical spoon for esophagoscopic use. the laryngoscope, january, 1918, pp. 47-48. 7. an anterior commissure laryngoscope. the laryngoscope, vol. xxv, aug., 1915, p. 589. 8. ancient foreign body cases. editorial. the laryngoscope, vol. xxvii, july, 1917, pp. 583-584. 9. an esophagoscopic forceps. the laryngoscope, jan., 1918, p. 49. 10. a new diagnostic sign of foreign body in trachea or bronchi, the "asthmatoid wheeze." amer. journ. med. sciences, vol. clvi, no. 5, nov., 1918, p. 625. 11. a new method of working out difficult mechanical problems of bronchoscopic foreign-body extraction. the laryngoscope, vol. xxvii, oct., 1917, p. 725. 12. arachidic bronchitis. journ. amer. med. asso., aug. 30, 1919, vol. lxxiii, pp. 672-677. 13. band of a gold crown in the bronchus: report of a case. dental cosmos. vol. lx, oct., 1918, p. 905. 14. bronchiectasis and bronchiectatic symptoms due to foreign bodies. penn. med. journ., vol. xix, aug., 1916, pp. 807-814. 15. bronchoscopic and esophagoscopic postulates. annals of otology, rhinology and laryngology, june, 1916, pp. 414-416. 16. bronchoscopic removal of a collar button after twenty-six years sojourn in the lung. annals of otology, rhinology and laryngology, june, 1913. 17. bronchoscopy. keen's surgery, 1921, vol. viii. 18. caisson bronchoscopy in lung-abscess due to foreign body. surg., gyn. and obstet., oct., 1917, pp. 424-428. 19. cancer of the larynx. is it preceded by a recognizable precancerous condition? proceedings amer. laryngol. soc., 1922. 20. din. editorial. the laryngoscope, vol. xxvi, dec., 1916, pp. 1385-1387. 23. endoscopie perorale et chirurgie laryngienne. arch. de laryngol., t. xxxvii, no. 3, 1914, pp. 649-680. 24. endoscopy and the war. editorial. the laryngoscope, vol. xxvi, june, 1916, p. 992. 25. endothelioma of the right bronchus removed by peroral bronchoscopy. amer. journ. of med. sci., no. 3, vol. clii, march, 1917, p. 371. 26. esophageal stenosis following the swallowing of caustic alkalies, journ. amer. med. asso., july 2, 1921, vol. lxxvii, pp. 22-23. 27. esophagoscopic radium screens. the laryngoscope, feb., 1914. 28. foreign bodies in the insane. editorial. the laryngoscope, vol. xxvii, june, 1917, pp. 513-515. 29. foreign bodies in the larynx, trachea, bronchi and esophagus etiologically considered. trans. sec. laryn., otol. and rhin., amer. med. asso., 1917, pp. 36-56. 30. gold three-tooth molar bridge removal from the right bronchus: case report. dental cosmos, oct., 1919. 31. high tracheotomy and other errors the chief causes of chronic laryngeal stenosis. surg., gyn. and obstet., may, 1921, pp. 392-398. 32. inducing a child to open its mouth. editorial. the laryngoscope, vol. xxvi, nov., 1917, p. 795. 33. intestinal foreign bodies. editorial. the laryngoscope, vol. xxvi, may, 1916, p. 929. 34. laryngoscopic, esophagoscopic and bronchoscopic clinic. international clinics, vol. iv, 1918. j. b. lippincott co. 35. local application of radium supplemented by roentgen therapy (discussion). amer. journ. of roentgenology. 36. localization of the lobes of the lungs by means of transparent outline films. amer. journ. roent., vol. v, oct., 1918, p. 456. also proc. amer. laryn., rhin. and otol. soc., 1918. 37. mechanical problems of bronchoscopic and esophagoscopic foreign body extraction, journ. am. med. assn., jan. 27, 1917. 38. observation on the pathology of foreign bodies in the air and food passages based on the analysis of 628 cases. mutter lecture, 1917, surg. gyn. and obstet., mar., 1919, pp. 201-261. 39. orthopedic treatment by corking. journ. of laryn. and otol., london, vol. xxxii, feb., 1917. 40. peroral endoscopy. journ. of laryn. and otol., edinburgh, nov., 1921. 41. peroral endoscopy and laryngeal surgery. the laryngoscope, feb., 1919. 42. postulates on the cough reflex in some of its medical and surgical phases. therapeutic gazette, sept. 15, 1920. 43. prognosis of foreign body in the lung. journ., amer. med. asso., oct. 8, 1921, vol. lxxvii, pp. 1178-1181. 44. pulsion diverticulum of the esophagus. surg., gyn. and obstet., vol. xxi, july, 1915, pp. 52-55. 45. radium. editorial. the laryngoscope, vol. xxvi, aug., 1916, pp. 1111-1113. 46. reaction after bronchoscopy. penn. med. journ., april, 1919. vol. xxii p. 434. 47. root-canal broach removed from the lung by bronchoscopy. the dental cosmos, vol. lvii, march, 1915, p. 247. 48. safety pins in stomach, peroral gastroscopic removal without anesthesia. journ. amer. med. asso., feb. 26, 1921, vol. lxxvi, pp. 577-579. 49. symptomatology and diagnosis of foreign bodies in the air and food passages. am. journ. med. sci., may, 1921, vol. clxi, no. 5, p. 625. 50. the bronchial tree, its study by insufllation of opaque substances in the living. amer. journ. roentgenology, vol. 5, oct., 1918, p. 454. also proc. amer. laryn., rhinol. and otol. soc., 1918. 51. thymic death. editorial. the laryngoscope, vol. xxvi, may, 1916, p. 929. 52. tracheobronchitis due to nitric acid fumes. new york med. journ., nov. 4, 1916, pp. 898-899. 53. treatment of laryngeal stenosis by corking the tracheotomic cannula, the laryngoscope, jan., 1919. 54. ventriculocordectomy. proceedings amer. laryngol. soc., 1921. 55. new mechanical problems in the bronchoscopic extraction of foreign bodies from the lungs and esophagus. annals of surgery, jan., 1922. 56. the diaphragmatic pinchcock in so-called cardiospasm. laryngoscope, jan., 1922. transcriber's note: a few typographical errors have been corrected; they are listed at the end of the text. page numbers enclosed by curly braces (e.g., {125}) are included in the text to enable the reader to use the "table of the chapters" [table of contents] which is located at the end of the book. the _compleat surgeon_: or, the whole art of _surgery_ explain'd in a most familiar method. containing an exact account of its principles and several parts, _viz._ of the _bones_, _muscles_, _tumours_, _ulcers_, and _wounds_ simple and complicated, or those by _gun-shot_; as also of _venereal diseases_, the _scurvy_, _fractures_, _luxations_, and all sorts of chirurgical operations; together with their proper bandages and dressings. to which is added, a _chirurgical dispensatory_; shewing the manner how to prepare all such medicines as are most necessary for a surgeon, and particularly the _mercurial panacæa_. * * * * * written in _french_ by _m. le clerc_, physician in ordinary, and privy-counsellor to the _french_ king; and faithfully translated into _english_. * * * * * london, printed for _m. gillyflower_, in _westminster-hall_; _t. goodwin_, and _m. wotton_, in _fleet-street_; _j. walthoe_, in the _middle-temple_ cloysters; and _r. parker_, under the _royal-exchange_, in _cornhill_, 1696. * * * * * the preface. _so great a number of treatises of surgery, as well ancient as modern, have been already publish'd, that a plenary satisfaction seems to have been long since given on this subject, even to the judgment of the most curious inquirers: but if it be consider'd that a young surgeon ought always to have in view the first principles of this noble art explain'd after a familiar and intelligible manner, it will be soon acknowledg'd that there is good reason to set about_ _the work anew: for besides that the writings of the ancients being so voluminous, are not portable, they are also very intricate and confus'd; nay the whole art has been so far improv'd and brought to perfection by able masters in the present age, that they are now almost become unprofitable._ _some modern authors have set forth certain small tracts, which only explain a few chirurgical operations, and on that account deserve only the name of fragments. indeed the works of some others seem to be sufficiently compleat, but are printed in so large volumes, and contain so many discourses altogether foreign from the principal subject, that they have almost the same inconveniences with those of the ancients. therefore the reader is here presented with a small treatise of surgery, yet very plain and perspicuous, in a portable volume; being free from a multiplicity of impertinent words, and containing every thing of moment that has been producd by the most approv'd authors both ancient and modern._ _an introduction is made into the matter by small colloquies or dialogues, to the end that the young student may be at first lead as it were by the hand; but as soon as he has attain'd to a considerable progress in these studies, this innocent and puerile manner of speaking is abandon'd, to conduct him in good earnest to the most sublime heights of so admirable an art; to which purpose, after having penetrated into its first rudiments and grounds, he is well instructed in anatomy, and furnish'd with a general _idea_ of wounds and tumours, which are afterward treated of in particular: he is also taught a good method of curing wounds made by gun-shot, the scurvy, and all sorts of venereal diseases: from thence he is introduced into the practice of all manner of chirurgical operations in fractures and luxations; together with the use of their respective dressings and bandages._ _at the end of the work is added a _compleat chirurgical dispensatory_, shewing the method of preparing such medicinal compositions as are chiefly us'd in the art of surgery; so that upon the whole matter, it may be justly affirm'd, that this little manual has all the advantages of the ancient and modern writings on the same subject, and is altogether free from their superfluities and defects._ * * * * * {1} the _compleat surgeon:_ or, the whole art of surgery explain'd, _&c._ * * * * * chap. i. _of the qualifications of a surgeon, and of the art of surgery._ _who is a surgeon?_ a person skill'd in curing diseases incident to humane bodies by a methodical application of the hand. _what are the qualifications of a good surgeon in general?_ {2} they are three in number: _viz._ skill in the theory, experience in the practical part, and a gentle application of the hand. _why ought a surgeon to be skilful?_ because without a discerning faculty he can have no certainty in what he doth. _why must he be experienc'd?_ because knowledge alone doth not endue him with a dexterity of hand requisite in such a person, which cannot be acquir'd but by experience, and repeated manual operations. _why must he be tender-handed?_ to the end that by fit applications he may asswage those pains which he is oblig'd to cause his patients to endure. _what is chirurgery or surgery?_ it is an art which shews how to cure the diseases of humane bodies by a methodical manual application. the term being derived from the _greek_ word [greek: cheir], signifying a hand and [greek: ergon], a _work_ or _operation_. _after how many manners are chirurgical operations usually perform'd?_ four several ways. _which be they?_ i. _synthesis_, whereby the divided parts are re-united; as in wounds. ii. _diæresis_, that divides and separates those parts, which, by their union, hinder the cure of diseases, such is the continuity of abscesses or impostumes which must be open'd to let out the purulent matter. iii. _exæresis_, which draws out of the body whatsoever is noxious or hurtful, as bullets, arrows, _&c._ iv. _prosthesis_ adds some instrument or body to supply {3} the defect of those that are wanting; such are artificial legs and arms, when the natural ones are lost. it also furnishes us with certain instruments to help and strengthen weak parts, such as _pessaries_, which retain the _matrix_ in its proper place when it is fallen, crutches to assist feeble persons in going, _&c._ _what ought to be chiefly observed before the undertaking an operation?_ four things; _viz._ 1. what the operation to be perform'd is? 2. why it is perform'd? 3. whether it be necessary or possible? and 4. the manner of performing it. _how may we discern these?_ the operation to be perform'd may be known by its definition; that is to say, by explaining what it is in it self: we may discover whether it ought to be done, by examining whether the distemper cannot be cur'd otherwise: we may also judge whether it be possible or necessary, by a competent knowledge of the nature of the disease, the strength of the patient, and the part affected: lastly, the manner of performing it may be found out, by being well vers'd in the practice of surgery. _what are the fundamental principles of surgery?_ they are three in number: _viz._ 1. the knowledge of man's body. 2. that of the diseases which require a manual operation. 3. that of proper remedies and helps upon every occasion. _how may one attain to the knowledge of humane bodies?_ {4} by the study of anatomy. _how may one learn to know the distempers relating to surgery, and the remedies appropriated for them?_ two several ways; _viz._ 1. by the reading of good books, and instructions receiv'd from able masters of that art. 2. by practice and the observation of what is perform'd by others upon the bodies of their patients. _what are the diseases in general that belong to surgery?_ they are tumours, impostumes, wounds, ulcers, fractures, dislocations, and generally all sorts of distempers whereto manual operations may be applyed. _what are the instruments in general which are commonly used in surgery for the curing of diseases?_ they are five; _viz._ the hand, bandages, medicines, the incision-knife, and fire. _what is the general practice which ought to be observ'd in the application of these different helps?_ _hippocrates_ teacheth us, in saying, that when medicines are not sufficient, recourse may be had to the incision-knife, and afterward to fire; intimating that we must proceed by degrees. _are there any distempers that may be cured by the surgeon's hand alone?_ yes, as when a simple and small dislocation is only to be reduced. * * * * * {5} chap. ii. _of chirurgical instruments, portable and not portable._ _what do you call portable and not portable instruments?_ portable instruments are those which the surgeon carries in his lancet-case with his plaister-box; and not portable are those that he doth not carry about him, but is oblig'd to keep at home; the former being appointed for the ready help which he daily administers to his patients, and the others for greater operations. _what are the instruments which a surgeon ought to have in his plaister-box?_ these instruments are a good pair of _sizzers_, a _razor_, an _incision-knife_ streight and crooked, a _spatula_, a greater _lancet_ to open impostumes, and lesser for letting blood. they likewise carry separately in very neat lancet-cases, a hollow _probe_ made of silver or fine steel; as also many other probes, streight, crooked, folding, and of different thickness; a _pipe_ of silver or fine steel, to convey the cauterizing _button_ to a remote part, without running the hazard of burning those that are near it; another _pipe_ or _tube_ serving instead of a case for _needles_, which have eyes at one end for sowing; a _carlet_, or thick triangular needle; a small _file_; a steel instrument to cleanse the teeth; a {6} _fleam_; a pair of crooked _forceps_ to draw a tooth; a _pelican_; a _crow's bill_; several sorts of _raspatories_; a _hook_ to hold up the skin in cutting, _&c._ _what are the instruments which a surgeon ought to keep in his repository to perform the greater operations?_ some of them are peculiar to certain operations, and others are common to all. the instruments appropriated to particular operations, are the _trepan_ for opening the bones in the head, or elsewhere: the _catheters_ or probes for men and women afflicted with the stone, or difficulty of making water. _extractors_, to lay hold on the stone in _lithotomy_, and to gather together the gravel; large crooked _incision-knives_, and a _saw_, to make amputations of the arms or legs; great _needles_ with three edges, to be used in making _setons_; small _needles_ to couch cataracts; other _needles_; thin _plates_ and _buckles_ to close a hair-lip, _&c._ _may not the salvatory be reckon'd among the portable instruments?_ yes, because the balsams, ointments, and plaisters contain'd therein, are means whereof the surgeon makes use to restore health. * * * * * {7} chap. iii. _of anatomy in general; and in particular of all the parts whereof the humane body is compos'd._ _what is anatomy?_ it is the _analysis_ or exact division of all the parts of a body, to discover their nature and original. _what is requisite to be observ'd by a surgeon before he goes about to dissect a body?_ two things; _viz._ the external structure of the body, and the proportion or correspondence between the outward parts, and those that are within. _why so?_ because without this exterior and general knowledge, the surgeon wou'd be often mistaken in the judgment he is to pass concerning a dislocation or wound, inasmuch as it is by the deformity which he perceives in the member, that he knows the dislocation, as it is also by the means of the correspondence which the outward parts have with the inward, that he is enabled to draw any certain consequences relating to a wound, which penetrates into the body. _what is a part?_ it is that whereof the whole body is compos'd, and which partakes of a common life or sensation with it. {8} _how many sorts of parts are there in a humane body?_ we may well reckon up fifteen distinct parts, which are the bone, the cartilage, the ligament, the tendon, the membrane, the fibre, the nerve, the vein, the artery, the flesh, the fat, the skin, the scarf-skin, the hair, and the nails. _what is a bone?_ it is the hardest and driest part of the whole body, and that which constitutes its principal support. _what is a cartilage or gristle?_ it is a yielding and supple part, which partakes of the nature of a bone, and is always fasten'd to its extremities, to mollifie and facilitate its motion. _what is a ligament?_ it is a membranous contexture usually sticking to the bones to contain them; as also sometimes to other parts, to suspend, and retain them in their proper place. _what is a tendon?_ it is the tail or extremity of the muscles, made by the re-union of all the fibres of their body, which serves to corroborate it in its action, and to give motion to the part. _what is a membrane?_ it is a nervous part, the use whereof is to adorn and secure the cavities of the body on the inside, and to wrap up or cover the parts. _what is a fibre?_ they are fleshy lines of which the body of a muscle is compos'd. _what is a nerve?_ it is a long, white, and thin body, consisting {9} of many fibres, enclos'd within a double tunick, and design'd to carry the animal spirits into all the parts, to give them sense and motion. _what is an artery?_ it is a canal compos'd of four coats, that carreyth with a kind of beating or pulse even to the very extremity of the parts, the blood full of spirits, which proceeds from the heart, to distribute to them at the same time both life and nourishment. _what is a vein?_ it is a canal made likewise of four tunicles, which receives the arterial blood, to carry it back to the heart. _what is flesh?_ it is a part which is form'd of blood thicken'd by the natural heat; and that constitutes the body of a muscle. _what is fat?_ it is a soft body made of the unctuous and sulphurous part of the blood. _what is the _derma_ or skin?_ it is a net compos'd of fibres, veins, arteries, lymphatick vessels and nerves, which covers the whole body to defend it from the injuries of the air, and to serve as a universal emunctory: it is very thin in the face, sticking close to the flesh, and is pierc'd with an infinite number of imperceptible pores, affording a passage to insensible transpiration. _what is the _epiderma_, or scarf-skin?_ it is a small fine skin, transparent and insensible, having also innumerable pores for the discharging of sweat, and other humours by {10} imperceptible transpiration: it is extended over the whole inner skin, to dull its too exquisite sense, by covering the extremities of the nerves which are there terminated. it also renders the same skin even and smooth, and so contributes very much to beauty. _what is the hair?_ the hairs are certain hollow filaments planted in the glandules of the skin, from whence their nourishment is deriv'd. they constitute the ornament of some parts, cover those which modesty requires to be conceal'd, and defend others from the injury of the weather. _what is a nail?_ the nails are a continuity of the skin harden'd at the end of the fingers, to strengthen and render them fit for work. * * * * * chap. iv. _of the general division of a humane body._ _how is the humane body divided before it is dissected, in order to anatomical demonstration?_ some anatomists distinguish it into _similar_ and _dissimilar_ parts, appropriating the former denomination to all the simple parts of the body taken separately, as a bone, a vein, a nerve, _&c._ but they attribute the name of dissimilar to all those members that are compos'd of many similar or simple parts together; such are the arms, {11} legs, eyes, _&c._ wherein are contain'd all at once, bones, veins, nerves, and other parts. others divide it into _containing_ and _contained_ parts, the former enclosing the others, as the skull includes the brain, and the breast the lungs; whereas the contained parts are shut up within others; as the entrails within the belly, the brain within the skull, _&c._ others again divide the whole body into _spermatick_ and _sanguineous_ parts; the former being those which are made at the time of formation; and the latter all those that are grown afterward by the nourishment of the blood. _are there not also other methods of dividing the humane body?_ yes: many persons consider it as a contexture of bones, flesh, vessels and entrails, which they explain in four several treatises, whereof the first is call'd _osteology_, for the bones; the second _myology_, for the muscles; the third _angiology_, for the veins, arteries and nerves, which are the vessels; and the fourth _splanchnology_, for the entrails. but lastly, the most clear and perspicuous of all the divisions of the body of man, is that which compares it to a tree, whereof the trunk is the body, and the branches are the arms and legs. the body is divided into three _venters_, or great cavities, _viz._ the upper, the middle, and the lower, which are the head, the breast, and the lower belly. the arms are distributed into the arms properly so called, the elbow and hands; and the legs in like manner into thighs, shanks, {12} and feet: the hands being also subdivided into the _carpus_ or wrist, _metacarpium_ or back of the hand, and the fingers; as the feet into the _tarsus_, _metatarsus_, and toes. this vision is at present follow'd in the anatomical schools. * * * * * chap. v. _of the skeleton._ _why is anatomy usually begun with the demonstration of the skeleton, or contexture of bones?_ because the bones serve for the foundation connexion, and support of all other parts of the body. _what is the skeleton?_ it is a gathering together, or conjunction of all the bones of the body almost in their natural situation. _from whence are the principal differences of the bones derived?_ they are taken from their substance, figure, articulation, and use. _how is all this to be understood?_ first then, with respect to their substance, there are some bones harder than others; as those of the legs compared with those of the back-bone. again, in regard of their figure, some are long, as those of the arm; and others short, as those of the _metacarpium_. some are also broad, as those of the skull and {13} _omoplatæ_ or shoulder-blades; and others narrow, as the ribbs. but with respect to their articulation, some are joined by thick heads, which are received into large cavities, as the huckle-bones with those of the hips; and others are united by the means of a simple line, as the chin-bones. lastly, with relation to their use; some serve to support and carry the whole body, as the leg-bones, and others are appointed to grind the meat, as the teeth; or else to form some cavity, as the skull-bone, and those of the ribs. _what are the parts to be distinguished in the bones?_ they are the body, the ends, the heads, the neck, the _apophyses_, the _epiphyses_, the _condyli_ or productions, the cavities, the _supercilia_ or lips, and the ridges. the body is the greatest part, and the middle of the bone; the ends are the two extremities; the heads are the great protuberances at the extremities; the neck is that part which lies immediately under the head; the _apophyses_ or processes are certain bunches or knobs at the ends of the bones, which constitute a part of them; the _epiphyses_ are bones added to the extremities of other bones; the _condyli_ or productions are the small elevations or extuberances of the bones; the cavities are certain holes or hollow places; the _supercilia_ or lips are the extremities of the sides of a cavity, which is at the end of a bone; the ridges are the prominent and saliant parts in the length of the body of the bone. {14} _how are the bones join'd together?_ two several ways, _viz._ by _articulation_ and _symphysis_. _how many sorts of articulations are there in the bones?_ there are generally two kinds, _viz._ _diarthrosis_ and _synarthrosis_. _what is diarthrosis?_ _diarthrosis_ is a kind of articulation which serves for sensible motions. _how many kinds of diarthroses, or great motions are there?_ there are three, _viz._ _enarthrosis_, _arthrodia_, and _ginglymus_. _enarthrosis_ is a kind of articulation which unites two bones with a great head on one side, and a large cavity on the other; as the head of the thigh-bone in the cavity of the _ischion_ or huckle-bone. _arthrodia_ is a sort of articulation, by the means whereof two bones are join'd together with a flat head receiv'd into a cavity of a small depth. such is the head of the shoulder-bone with the cavity of the _omoplata_ or shoulder-blade; and that of the twelfth _vertebra_ of the back with the first of the loins. _ginglymus_ is a kind of articulation which unites two bones, each whereof hath at their ends a head and a cavity, whereby they both receive and are received at the same time, such is the articulation in the bones of the elbow and the _vertebræ_. _what is _synarthrosis_?_ _synarthrosis_ being opposite to _diarthrosis_, is a {15} close or compacted articulation, destitute of any sensible motion. _how many sorts of _synarthroses_, or close articulations are there?_ there are three. _viz._ _sutura_, _harmonia_, and _gomphosis_. a _suture_ is that which joins together two bones by a kind of seam or stitch, or by a connexion of their extremities dispos'd in form of a saw, the teeth whereof are reciprocally let one into another: such are the sutures of the skull-bones. _harmonia_ is the uniting of two bones by a simple line; as the bone of the cheek with that of the jaw. _gomphosis_ is a kind of close articulation, which unites two bones after the manner of nails or wooden pins fixt in the holes made to receive them: such is that of the teeth in their sockets. _what is _symphysis_?_ _symphysis_ is the uniting of two bones by the interposition of a _medium_, which ties them very streight together, being also threefold: such is the connexion of the knee-pan or whirl-bone of the knee, and the _omoplata_ or shoulder-blade. _are not these three kinds of articulations or _symphyses_ distinguish'd one from another?_ yes; for tho' they are all made by the means of a third body intervening, which joins them together; nevertheless every one of these various bodies gives a different denomination to its respective articulation: thus the articulation which is caus'd by a glutinous and {16} cartilaginous substance, is properly call'd _synchondrosis_; as that of the nose, chin, _os pubis_, _&c._ but an articulation which is made by a ligament is termed _synncurosis_, as that of the knee-pan. lastly, that which is wrought by the means of flesh, bears the name of _syssarcosis_; as the jaw-bones, the _os hyoides_, and the _omoplata_ or shoulder-blade. _have the bones any sense of feeling or motion?_ they have neither; for their sense of pain proceeds from nothing else but their _periostium_, or the membrane with which they are cover'd, and their motion is perform'd only by the muscles that draw them. _doth the marrow afford any nutriment to the bones?_ no, all the bones are nourish'd by the blood, as the other parts; but the marrow is to the bones what the fat is to the flesh; that is to say, it is a kind of oil or unctuous substance, which moistens, and renders them less brittle. _are all the bones of the same colour?_ no, they follow the temperament and constitution of the persons. _how many in number are the bones of the humane skeleton?_ there are two hundred and fifty usually reckon'd, _viz._ 61 in the head, 67 in the trunk or chest, 62 in the arms and hands, and 60 in the legs and feet; but the true number cannot be exactly determin'd, by reason that some persons have more, and others fewer; for some have more _ossa sesamoidea_, teeth and {17} breast-bones than others: again, some have many indentings in the _lambdoidal_ suture, and others have none at all. _can you rehearse the number of the bones of the head?_ there are fifteen in the skull, and forty six in the face. the fifteen of the skull are the _coronal_ for the fore-part of the head; the _occipital_ for the hinder-part; the two _parietals_ for the upper-part and each side; the two _temporals_ for the temples; the _os sphenoides_ or _cuneiforme_, which closeth the _basis_ or bottom of the skull; the _os ethmoides_, or _cribriforme_, situated at the root of the nose; and the four little bones of the ear on each side, _viz._ the _incus_ or anvil; the _stapes_ or stirrup; the _malleolus_ or hammer; and the _orbiculare_ or orbicular bone. of the forty six of the face, twenty seven are counted in the upper-jaw, _viz._ the two _zygomatick_, or the two bones of the cheek-knots; the two _lachrymal_ in the great corners of the eyes toward the nose; the two _maxillar_, that receive the upper-teeth, and which form part of the palate of the mouth, and the orbits of the eyes; the two bones of the nose; the two palate-bones which are at its end, and behind the nostrils; the last being single is the _vomer_, which makes the division of the lower part of the nostrils; and there are generally sixteen upper-teeth. the lower-jaw contains nineteen bones, _viz._ sixteen teeth; two bones that receive them; and the _os hyoides_, which is single, and fix'd at the root of the tongue. {18} _how are the teeth usually divided with respect to their qualities?_ into _incisive_ or cutters, _canine_ or dog-teeth, and _molar_ or grinders: there are eight incisive, and four canine, which have only one single root; as also twenty molar, every one whereof hath one, two, or three roots. _can you recite the number of the bones of the trunk or chest?_ there are generally thirty and three in the _spine_ or chine-bone of the back, _viz._ seven _vertebra's_ in the neck, twelve in the back, five in the legs, five, six, and sometimes seven in the _os sacrum_, three or four in the _coccyx_, and two cartilages at its end. there are twenty nine in the breast, _viz._ twenty four ribs, two clavicles or channel-bones and commonly three bones in the _sternum_. the hip-bones are likewise divided into three, _viz._ _ilion_, _ischion_ and _os pubis_. _do you know the number of the bones of the arms?_ there are thirty and one bones in each arm, that is to say, the _omoplata_ or shoulder-blade; the _humerus_ or shoulder-bone; the two bones of the elbow call'd _ulna_, and _radius_; eight little bones in the _carpus_ or wrist; five in the _metacarpium_ or back of the hand; and fourteen in the fingers, three to every one except the thumb, which hath only two. _can you give us a list of the bones of the leg in their order?_ there are thirty bones in each leg, _viz._ the _femur_ or great thigh-bone, the knee-pan or {19} whirl-bone on the top of the knee; the _tibia_, _greater focile_, or shin-bone; and the _perone_ or _fibula_, or _lesser focile_, which are the two associated bones of the leg; seven little bones in the _tarsus_; five in the _metatarsus_; and fourteen in the toes; that is to say, three to every one, except the great toe, which hath only two. thus the number of bones of the humane _skeleton_ amounts to two hundred and fifty, without reckoning the _sesamoides_, the indentings of the skull, and some others which are not always to be found. * * * * * chap. vi. _of myology, or the anatomy of the muscles of a humane body._ _what is a muscle?_ it is the principal organ or instrument of motion; or it is a portion of flesh, wherein there are veins, arteries, nerves, and fibres, and which is cover'd with a membrane. _how many parts are there in a muscle?_ three, _viz._ the head, the belly, and the tail: the head is that part thro' which the nerve enters; the belly is the body or middle of the muscle; and the tail is the extremity, where all the fibres of the muscle are terminated to make the tendon or string which is fasten'd to the part whereto it gives motion. {20} _have all the muscles their fibres streight from the head to the tail?_ no, some have them streight, others transverse, and others oblique or circular, according to the several motions to which they are appropriated. _how many sorts of muscles are there with respecting to their action?_ there are two different kinds, _viz._ the _antagonists_ and the _congenerate_; the former are those that produce opposite motions; as a _flexor_ and an _extensor_, a _depressor_ and a _levator_. the congenerate are those that contribute to one and the same action; as when there are two flexors or two extensors, and then one supplies the defect of the other; whereas when one of the antagonist muscles is cut, the other becomes useless, and void of action. _how is the action of a muscle perform'd?_ it is done by contraction and extension; the former causeth the antagonist to swell, and the other compels it to stretch forth in length. _what is _aponeurosis_?_ it is the continuity of the fibres of a tendon which makes a connexion that serves to strengthen the muscle in its motion. * * * * * {21} chap vii. _of the myology, or anatomy of the muscles of the head._ _how many muscles are there appointed to move the head, and which be they?_ the head is mov'd by the means of fourteen muscles, seven on each side; of these, two serve to depress it, eight to lift it up, and four to turn it round about. the two depressors are call'd _sternoclinomastoidei_; they take their rise in the _sternum_, at the clavicles, and proceed obliquely to join the _apophysis mastoides_. of the four elevators on each side the first is the _splenius_, which begins at the five _vertebræ_ of the back and the three lower ones of the neck, and ascending obliquely, cleaves to the hinder part of the head. the second, named _complexus_ or _trigeminus_, having its beginning as the _splenius_, sticks in like manner to the hinder part of the head, and they form together a figure resembling that of s. _andrew_'s cross. the third is the _rectus major_, which proceeding from the second _vertebra_ of the neck, shoots forward to join the hinder part of the head. the fourth is the _rectus minor_, which begins at the first _vertebra_ of the neck, and ends likewise in the hinder part of the head. the two muscles on each side, which move the head circularly, are the _obliquus major_ and {22} _minor_; the _greater oblique_ taking its rise from the second _vertebra_ of the neck, goes to meet the first; but the _lesser oblique_ hath its origine in the hinder part of the head, and proceeds to join the other obliquely in the first _vertebra_. _how many muscles are there in the lower-jaw, and which be they?_ the lower-jaw hath twelve muscles which cause it to move; that is to say, six on each side, whereof four serve to close and two to open it. the first of the openers is the _latus_, which beginning at the top of the _sternum_, clavicle, and _acromion_, cleaves on the outside to the bottom of the lower-jaw-bone. the second of the openers is the _digastricus_, which takes its rise in a fissure lying between the occipital bone and the _apophysis mastoides_, from whence it passeth to the bottom of the chin on the inside. the first of the shutters is the _crotaphites_ or temporal muscle, which hath its origine at the bottom, and on the side of the _os coronale_, the _os parietale_, and the _os petrosum_, from whence it is extended till it cleaves to the _apophysis coronoides_ of the lower-jaw, after having passed above the _apophysis_ of the _zygoma_: its fibres are spread from the circumference to the center, and it is covered again with the _pericranium_, which renders its wounds very dangerous; so that the least incisions as can be, ought to be made therein. the second is the _pterygoideus_ or _aliformis externus_, whose rise is in the _apophysis pterygoides_, from whence it sets forward till it stick between the _condylus_ and the coronal of the lower-jaw. the third is the _masseter_, which hath two {23} sources or beginnings, and as many insertions; the first source thereof is at the cheek-knot or ball of the cheek, and the second at the lower part of the _zygoma_. the first insertion is at the outer corner of the jaw, and the second in the middle part, by that means forming the figure of the letter x. the fourth is the _pterygoideus_ or _aliformis internus_, which hath its beginning in the _apophysis pterygoides_, and is terminated in the inner corner of the jaw; so that mastication or chewing is perform'd by the means of these four muscles. _how many muscles are there in the face, and which be they?_ there are two for the forehead, call'd _frontal_, whose origine is in the upper part of the head, from whence they descend by streight fibres, until they are fasten'd in the skin of the forehead near the eye-brows, where they are re-united: their action or office is to draw the skin of the forehead upward, whereto they stick very close. there are also two others call'd _occipital_, which have their beginning in the same place with the preceeding, but they descend backward, and cleave to the skin of the hinder part of the head, which they draw upward. there are two muscles to each eye-lid, one whereof is termed the _attollens_ or _elevator_ and the other the _depressor_. the elevator takes its rise in the bottom of the orbit of the eye, and is fastned by a large _aponeurosis_ to the edge of the upper eye-lid. the shutter or depressor, call'd also the _orbicular_, hath its origine in the great _canthus_, or corner of the eye, passeth over the {24} eye-lid upward, and is join'd to the lesser corner of the same eye, being extended along its whole compass. the eyes have each six muscles, _viz._ four _recti_ and two _obliqui_; the _recti_ or streight muscles are the _elevator_, the _depressor_, the _adductor_, and the _abductor_. the first of these call'd _elevator_, or _superbus_, draws the eye upward, as it is pull'd downward by the _depressor_ or _humilis_; the _adductor_ or _bibitorius_ draws it toward the nose, and the _abductor_ or _indignarorius_ toward the shoulder: all these small muscles have their originals and insertions in the bottom of the orbit through which the optick nerve passeth, and are terminated in the corneous tunicle, by a very large _tendon_. the first of the oblique ones is term'd the _obliquus major_, and the other _obliquus minor_, because they draw the eye obliquely. these muscles cause children to squint when they do not act together. the _obliquus minor_ is fasten'd at the outward part of the orbit near the great corner, and draws the eye obliquely toward the nose: but the _obliquus major_ is fixt in the inner part of the orbit, and ascends along the bone to the upper part of the great corner, where its tendon passeth thro' a small cartilage nam'd _trochlea_, and is inserted in the little corner with the lesser _obliquus minor_, to draw the eye obliquely toward the lesser corner. the ear, altho' not usually endu'd with any sensible motion, nevertheless hath four muscles, _viz._ one above, and three behind; the first being situated over the temporal, and fasten'd to the ear to draw it upward: the three others have {25} their beginning in the _mammillary apophysis_, and are terminated in the root of the ear, to draw it backward. there are also three muscles in the inner part of the ear, whereof the external belonging to the _malleus_ or hammer lies under the exterior part of the bony passage which reacheth from the ear to the palate of the mouth, being fixt in a very oblique sinuosity which is made immediately above the bone that bears the furrow, into which is let the skin of the _tympanum_ or drum. the internal muscle lies hid in a bony semi-canal, in the _os petrosum_; one part of which semi-canal is without the drum, and clos'd on the top with a passage that leads from the ear into the palate. but the other part within the drum advanceth to the _fenestra ovalis_, and is inserted in the hinder part of the handle of the _malleus_. the muscle of the _stapes_ or stirrup is also hid in a bony tube, almost at the bottom of the drum, and fixt in the head of the _stapes_. the nose hath seven muscles, that is to say, one common and six proper; the common constitutes part of the orbicular muscle of the lips, and draws the nose downward with the lip. of the six proper muscles of the nose, four serve to dilate it, being situated on the outside, and two to contract it, which are placed in the inside. the two first dilatators of a pyramidal figure, take their rise in the suture of the forehead, and are fasten'd by a large filament to the _alæ_ of the nose. the two other dilatators resembling a myrtle-leaf have their source in {26} the bone of the nose, and are inserted in the middle of the _ala_. the two restrictors are membranous, beginning in the internal part of the bone of the nose and adhering to the inner _ala_ of the nostril. the lips have thirteen muscles, _viz._ eight proper, and five common: of the proper there are four for the upper-lip, and as many for the lower: with two common for each, and the odd one. the first of the proper of the upper-lip bears the name of the _incisivus_, its origine being in the jaw, in the place of the incisive teeth and its insertion is in the upper-lip. the second is the _triangulis_, antagonist to the former; its rise is on the outside, at the bottom of the lower-jaw; and it is implanted in the upper-lip, near the corner of the mouth. the third being the _quadratus_, springs from the bottom of the chin before, and cleaves to the edge of the lower-lip. the fourth is the _caninus_, antagonist to the _quadratus_, beginning in the upper-jaw-bone and being terminated in the lower-lip near the corner of the mouth. the first of the common is the _zygomaticus_, the origine whereof is in the _zygoma_ and its insertion in the corner of the mouth, to draw it toward the ears; so that it is the muscle which acts when we laugh. the second of the common is the _buccinator_ or trumpeter, which is swell'd when one sounds a trumpet. it hath its rise at the root of the molar teeth of both the jaws, and is extended quite round about the lips. {27} the odd muscle, or the thirteenth in number, is the _orbicular_, which makes a _sphincter_ round about the lips to close or shut them up. the _uvula_ or palate of the mouth hath four muscles, whereof the two first are the _peristaphylini externi_, taking their rise from the upper-jaw, above the left molar tooth, and being ty'd to the palate by a thin _tendon_. the two others are the _peristaphylini interni_, which have their beginning in the _apophysis pterygoides_ on the inside, and likewise stick to the palate. the tongue, altho' all over musculous and fibrous, yet doth not cease to have its peculiar muscles, which are eight in number. the first of these is call'd _genioglossus_, taking its rise in the lower part of the chin, from whence it is extended till it cleave to the root of the tongue before, to cause it to go out of the mouth. the second is term'd _styloglossus_, its rise being in the _apophysis styloides_, from whence it passeth to the side above the tongue, to lift it up. the third bearing the name of _basiglossus_, commenceth in the _basis_ or root of the _os hyoides_, and thence insinuates it self into the root of the tongue, to draw it back to the bottom of the mouth. the fourth is the _ceratoglossus_, deriving its original from the horn of the _os hyoides_, and cleaving to the side of the tongue to draw it on one side: the action of these muscles of both sides together, causeth an orbicular motion in the tongue. to these some add a fifth {28} pair of muscles, call'd _myloglossus_, which serves to draw it obliquely upward. _what is the action of the _os hyoides_ in the throat, and how many muscles hath it?_ the use of the _os hyoides_ is to consolidate the root of the tongue; and it hath five muscles on each side, which keep it as it were hung up. the first of these, call'd the _geniohyoideus_ hath its beginning in the chin on the inside, and adheres to the top of the _os hyoides_, which it draws upward. the second is the _mylohyoideus_, whose origine is in the inner side of the jaw, from whence it cleaves side-ways to the root of the _os hyoides_, which it draws upward, and to one side. the third is the _stylohyoideus_, which after it hath taken its rise in the _apophysis styloides_, is fasten'd to the horn of the _os hyoides_, to draw it toward the side. the fourth is the _coracohyoideus_, which springing up from the _apophysis coracoides_ of the _omoplata_, cleaves to the root and side of the _os hyoides_, to draw it downward and to the side. the fifth is the _sternomohyoideus_, that hath its beginning in the bone of the _sternum_ on the inside and is inserted in the root of the _os hyoides_, which it draws downward. _how many muscles hath the _larynx_?_ there are fourteen, _viz._ four common, and ten proper. the first pair of the common is the _sternothyroideus_ or _bronchycus_, which proceeding from the inside, and the top of the _sternum_, ascends along the cartilages of the wind-pipe, and is terminated in the bottom of the {29} _scutiformis_ or buckler-like cartilage, which it draws downward. the second is the _hyothyroideus_, which ariseth from the root of the _os hyoides_, and is inserted in that of the _scutiforme_. this muscle serves to lift up the _larynx_, as also to dilate the bottom of the _scutiformis_, and to close its top. the first pair of the proper is the _cricothyroideus anticus_, which deriving its original from the hinder and upper part of the _cricoides_, or ring-like cartilage, is fixt in the upper and lateral part of the _scutiformis_, to close or shut it up. the second is the _thyroides_. the third is the _cricoarytenoideus lateralis_, which proceeds from the side of the _cricoides_ within, and is fasten'd to the bottom and side of the _arytenoides_, which it removes to dilate the mouth of the _larynx_. the fourth is the _thyroarytenoideus_, which arising from the fore-part on the inside of the _scutiformis_, is terminated on the side of the _arytenoides_, to close the orifice of the _larynx_. the fifth is the _arytenoideus_, which having its source in that place where the _cricoides_ is united to the _arytenoides_ is inserted in its upper and lateral part, to close the _larynx_. _how many muscles hath the _pharynx_?_ it hath seven, the first whereof is the _oesophagieus_, which takes its rise from the side of the _scutiformis_ or buckler-like cartilage, and passing behind the _oesophagus_ or gullet, is fasten'd to the other side of the cartilage. it thrusts the meat down by locking up the _pharynx_ as a _sphincter_. the second named _stylopharingæus_, springs from within the acute _apophysis_ of the _os sphenoides_, or _cuneiforme_, and is inserted obliquely {30} in the side of the _pharynx_, which it dilates by drawing it upward. the third, call'd _sphenopharyngæus_, proceeds from the _apophysis styliformis_, and is terminated in the side of the _pharynx_, which it dilates by drawing its sides. the fourth pair is the _cephalopharyngæus_ which ariseth from the articulation of the head with the first _vertebra_, and closeth the _larynx_. _how many muscles are there in the neck, and which be they?_ there are four muscles in the neck on each side, _viz._ two flexors, and two extensors. the _flexors_ are the _scalenus_ and the _rectus_ or _longus_; and the extenders are the _spinatus_ and the _transversalis_. the _scalenus_ or _triangularis_ hath two remote sources, _viz._ one in the first rib, and the other in the clavicle, and is fasten'd to the third and fourth _vertebra_ of the neck. the _rectus_ or _longus_ begins in the side of the four upper _vertebra's_ of the back, and is join'd to the upper _vertebra's_ of the neck, and the hinder part of the head. the _spinatus_ hath its origine in the fourth and fifth upper _vertebra's_ of the back, and is fasten'd to all the six lower _vertebra's_ of the neck. the _transversalis_ springs forth out of the upper _vertebra's_ of the back, and cleaves to the extremity of the four _vertebra's_ of the neck. * * * * * {31} chap. viii. _of the myology or anatomy of the muscles of the chest; or of the breast belly, and back._ _how many muscles are there in the breast, and which be they?_ the breast hath fifty seven muscles, that is to say, thirty that serve to dilate it, twenty six whose office is to contract it, and the _diaphragm_ or midriff, which partakes of both actions. the thirty which dilate the breast are equally plac'd to the number of fifteen, _viz._ the _subclavius_, the _serratus major anticus_, the two _serrati postici_, and the eleven external _intercostals_. the twenty six which contract the breast are likewise equally rank'd to the number of thirteen on each side, _viz._ the _triangularis_, the _sacrolumbus_, and eleven internal _intercostals_. the _subclavian_ takes up the whole space between the clavicle and the first rib: its original being in the internal and lower part of the _clavicula_, and its insertion in the upper part of the first rib. the _serratus major_ is a large muscle having seven or eight indentings or jaggs. it takes its rise in the interior basis of the _omoplata_ or shoulder-blade, and its jaggings are inserted in {32} the five lower true ribs, as also in the two upper spurious ribs. the _serratus posticus superior_, begins with a large _aponeurosis_ in the _apophyses_ of the three lower _vertebræ_ of the neck, and of the first of those of the back; then passing under the _rhomboid_, it is join'd obliquely by four indentings to the four upper ribs. the _serratus posticus inferior_, commences in like manner with a large _aponeurosis_ in the _apophyses_ of the three lower _vertebra's_ of the back, and of the first of those of the loins, and is afterwards fasten'd by four digitations to the four lower ribs. the eleven _external intercostal_ muscles are situated in the spaces between the twelve ribs passing obliquely and on the outside from the back part to the fore part. they take their rise below the upper rib, and have their insertion above the lower rib. the _triangularis_ is the first of those that contract the breast, and possesseth the inward part of the _sternum_: its original is in its lower part, and its insertion in the top of the cartilages of the two upper ribs. the _sacrolumbus_ hath its source in the hinder part of the _os sacrum_, as also in the _vertebra's_ of the loins, and ascending from thence, insinuates it self into the hinder part of the ribs, to every one of which it imparts two _tendons_, one whereof sticks on the outside, and the other on the inside. this muscle is fleshy within, and fibrous without. the eleven _internal intercostals_, contrary to the external, derive their original from the {33} top of every lower rib, and ascend obliquely from the back-part to the fore-part, till they are join'd to the lower lip of every upper rib: thus these internal muscles, with the external, form, by the opposition of their fibres, a figure resembling a _burgundian_ cross. the diaphragm or midriff is esteem'd as the fifty seventh muscle of the breast, and serves as well for its dilatation as contraction. it separates the _thorax_ or chest from the lower belly, and is tied circularly to all the extremities of the bastard ribs, immediately under the _xiphoides_, or sword-like cartilage. modern anatomists have discover'd that the diaphragm is compos'd of two muscles, _viz._ one upper, and the other lower; so that the upper cleaves to the extremities of the spurious ribs, and is terminated in a flat _tendon_ in the middle, which hath been always taken for its nervous part. the lower begins with two productions, the longest whereof being on the right side, ariseth from the three upper _vertebra's_ of the loins, and the other on the left from the two _vertebra's_ of the back, till it is lost in the _aponeurosis_ of the upper muscle. _how many muscles are there in the back and the loins, and which be they?_ there are three in each side, _viz._ one for flection, and the other for extension. the _triangularis_ is the _flexor_, taking its rise in the hinder part of the rib of the _os ilion_, and the inner part of the _os sacrum_, in passing from whence it is joined to the last of the {34} bastard ribs, and to the transverse productions of the _vertebra's_ of the loins. the _extensors_ are the _sacer_, and the _semi-spinatus_, which make the waste streight, and are so interwoven along the back-bone, that one would imagine that there were as many pairs of muscles as _vertebra's_, affording _tendons_ to all. the _sacer_ springs from behind the _os sacrum_, as also from the hinder and upper extremity of the _os ilium_, and is inserted in the spines of the _vertebra's_ of the loins and back. the _semi-spinatus_ hath its source in the spines of the _os sacrum_, and is join'd to all the transverse productions of the _vertebra's_ from the back to the neck, being exactly situated between the _sacer_ and the _sacrolumbus_. * * * * * chap. ix. _of the myology, or anatomy of the muscles of the lower belly._ _how many muscles are there in the lower belly, and which be they?_ there are generally ten, five on each side, that is to say, two _obliqui_, one ascending, and the other descending; one _transversus_, one _rectus_, and two pyramidal, of which last, nevertheless, there is sometimes only one, and sometimes none at all. {35} the _obliquus descendens_, which is the first, hath its original by digitation in the sixth and seventh of the true ribs, in all the spurious ribs, and in the transverse _apophyses_ of the _vertebra's_ of the loins, and comes near to the _serratus major anticus_ of the breast; from whence it proceeds to the external rib of the _os ilion_, and is terminated by a large _aponeurosis_ in the _linea alba_ or _white line_, which separates the muscles that are on each side of the _abdomen_ or lower belly. the _obliquus ascendens_ ariseth from its source in the upper part of the _os pubis_, and in the ridge of the hip-bone, till it cleaves to the _apophyses_ of the _vertebra's_ of the loins in the extremities of all the ribs, and in the _xiphoides_ or sword-like cartilage, and is terminated in the white line by a large _aponeurosis_. the _rectus_ being situated between the _aponeuroses_ of the _obliquus_, takes its rise in the cartilages of the ribs, in the _xiphoides_ and the _sternum_, and enters into the _os pubis_, having many nervous parts to corroborate it in its length. the _transversus_ having its beginning in the transverse _apophyses_ of the _vertebra's_ of the loins, is fasten'd to the internal rib of the _os ilium_, and within the cartilages of the lower ribs, and is terminated by a large _aponeurosis_ in the _linea alba_, passing over the _rectus_, and sticking to the _peritonæum_. the oblique muscles, and the transverse, have holes toward the groin, to give passage to the spermatick vessels of men, and to a round {36} ligament of the _matrix_ in women; so that ruptures or burstenness happen through these parts in both sexes, although the holes of these three muscles are not situated one over-against another. the pyramidal, so named by reason of its figure, is situated in the lower _tendon_ of the _rectus_, its origine being in the upper and external part of the _os pubis_; but it is terminated in the white line, three fingers breadth above the _pubes_, and sometimes even in the navel itself. these muscles are not found in all bodies for there are sometimes two, sometimes only one, and sometimes none. the use of the muscles of the lower belly is to compress all the contain'd parts, in order to assist them in expelling the excrements. _how many muscles are there in the testicles?_ they have each of them one, call'd _cremaster_; this muscle takes its rise from the ligaments of the _os pubis_, and by the dilatation of its tendon covers the testicle, which it draws upward. _how many muscles hath the _penis_?_ it hath two pair, _viz._ the _erectores_ or _directores_, and the _dilatantes_: the _erectores_ arise from the internal part of the _os ischion_, under the beginning of the _corpora cavernosa_, where they are inserted, and retake their fibres in their membranes. the _dilatantes_ or _acceleratores_ have their source in the _sphincter_ of the _anus_ and slipping from thence obliquely under the _ureter_, are join'd to the membrane of the nervous bodies. _how many muscles are there in the _clitoris_?_ {37} it hath two erectors which spring forth from the protuberance of the _os ischion_, and are inserted in the nervous bodies of the _clitoris_. there are also two others suppos'd to be its elevators, which proceed from the _sphincter_ of the _anus_, and are terminated in the _clitoris_. _how many muscles are there in the _anus_?_ there are three, _viz._ the _sphincter_, and two _levatores_. the _sphincter_ is two fingers broad, to open and close the _rectum_. this muscle being double, is fasten'd in the fore-part to the _penis_ in men, and to the neck of the _matrix_ in women, as also behind to the _coccyx_, and laterally to the ligaments of the _os sacrum_, and the hips. the two _levatores_ arise from the inner and lateral part of the _os ischion_, and are fasten'd to the _sphincter_ of the _anus_, to lift it up after the expulsion of the excrements. the _bladder_ hath also a _sphincter_ muscle to open and shut its orifice. * * * * * chap. x. _of the muscles of the _omoplatæ_, or shoulder-blades, arms, and hands._ _how many ways doth the _omoplata_ or shoulder-blade move, and what are its muscles?_ the _omoplata_ moves upward, downward, forward, and backward, by the means of four proper muscles, which are the _trapezius_, the {38} _rhomboides_, the proper _levator_, and the lesser _pectoral_, or _serratus minor anticus_. the _trapezius_ or _cucullaris_ hath its beginning in the back part of the _occiput_, or hinder part of the head, in the spines of the six lower _vertebra's_ of the neck, and of the nine upper of the back, in passing from whence it is implanted in the spine of the _omoplata_ or shoulder-blade, and the external part of the _clavicula_, as far as the _acromion_. this muscle produceth many motions by reason of its different fibres, drawing the shoulder-blade obliquely upward, downward, and forward. the _rhomboides_ is situated over the _trapezius_, its rise being in the _apophyses_ of the three lower _vertebra's_ of the neck, and of the three upper of the back, but it is afterward join'd to the whole _basis_ or root of the _omoplata_, which it draws backward. the proper _levator_ commenceth in the _transverse apophyses_ of the four first _vertebra's_ of the neck, by different progressions, but is afterward re-united, and inserted in the upper corner of the _omoplata_, which it draws upward. the _lesser pectoral_, or _serratus minor anticus_, is situated under the great _pectoral_, its rise being by digitation or indenting in the second, third, and fourth of the upper ribs, and its insertion in the _apophysis coracoides_ of the shoulder-blade, which it draws forward. _how many motions are there in the _humerus_, or arm; which be they, and what are its muscles?_ {39} the arm performs all sorts of motions by the help of nine muscles: for it is lifted up by the _deltoides_ and the _infra-spinatus_; it is depress'd by the _largissimus_, and the _rotundus major_; it is drawn forward by the _pectoralis major_, and the _coracoideus_; it is drawn backward by the _infra-spinatus_, and the _rotundus minor_. it is drawn near the ribs by the _subscapularis_, and its circular motion is performed when all these muscles act together successively. the _deltoides_ or _triangular_ hath its beginning in the whole spine of the _omoplata_, the _acromion_, and half the _clavicula_, and by its point cleaves with a strong _tendon_ to the middle of the arm. the _infra-spinatus_ takes its rise in the cavity that lies above the spine of the _omoplata_, which it fills, passing over the _acromion_, until it is join'd to the neck of the shoulder-bone, which it surrounds with a large _tendon_. the _largissimus_, otherwise call'd _ani-scalptor_, covers almost the whole back, proceeding from a large and nervous stock, in the third and fourth lower _vertebra_ of the back, the five _vertebra's_ of the loins, the spine of the _os sacrum_, the hinder part of the lip of the hip-bone, and the external part of the lower bastard-ribs, in passing from whence it insinuates it self into the lower corner of the _omoplata_, as also into the upper and inner part of the _humerus_. the _rotundus major_, or _teres major_, having its origin in the external cavity of the lower corner of the _omoplata_, is confounded with the _largissimus_, and adheres with it by the same {40} _tendon_ to the upper and inner part of the _humerus_, a little below the head. the greater _pectoral_ hath its source in half the _clavicula_, on the side of the _sternum_; covers the fore-part of the breast, and is fasten'd by a short, broad, and nervous _tendon_, to the top of the shoulder-bone, on the inside, between the _biceps_ and the _deltoides_. the _coracoideus_ or _coracobrachyæus_, beginning in the _apophysis coracoides_ of the _omoplata_ or shoulder-blade, adheres to the middle of the arm on the inside, which with the _pectoral_ it draws forward. the _infra-spinatus_ fills the cavity which lies below the spine of the _omoplata_, its origine being in the lower rib of the _omoplata_, from whence it passeth between the spine and the _rotundus minor_, to cleave to the neck of the shoulder-bone, which it embraceth, and draws backward. the _rotundus minor_, or _teres minor_, proceeds from the lower rib of the _omoplata_, and adheres to the neck of the shoulder-bone with the _infra-spinatus_ to draw it in like manner backward. the _sub-scapularis_ or _immersus_ is situated entirely under the _omaplata_, proceeding from the internal lip of the _basis_ or root of the same _omoplata_, and being terminated in the neck of the arm-bone, which it causeth to lie close to the ribs. _how many motions are there in the_ cubitus _or elbow, and what are its muscles?_ the _cubitus_ or _ulna_ is endu'd with two sorts of motions, _viz._ that of flection and that of {41} extension, the former being perform'd by the help of two muscles, that is to say, the _biceps_, and the _brachiæus internus_; and the later by eight others, which are the _longus_, the _brevis_, the _brachiæus externus_, and the _anconeus_. the _biceps_ is a muscle with two heads, one whereof proceeds from the _apophysis coracoides_, and the other from the cartilaginous edge of the _glenoid_ cavity of the _omoplata_ or shoulder-blade: these two heads descend along the fore-part of the arm, and are united in one and the same body, from whence springs forth a ligament, which is inserted in a tuberosity situated in the upper and fore-part of the _radius_. the _brachiæus internus_ is a small fleshy muscle, lying hid under the _biceps_, which takes its rise in the upper and fore-part of the _humerus_, and is implanted in the upper and inner-part of the _radius_, to bend the elbow with the _biceps_. the first of the four extenders is the _longus_ having two sources, _viz._ one situated in the lower rib of the _omoplata_, near its neck, and the other descending to the hinder-part of the arm, till it is tyed to the _olecranum_ or _ancon_, by a strong _aponeurosis_, which is common thereto, with the _brevis_, and the _brachiæus externus_. the _brevis_ or short muscle of the elbow arising from the hinder and upper-part of the _humerus_, is fasten'd to the _olecranum_ with the _longus_. the _brachiæus externus_ is a fleshy muscle which proceeds from the hinder part of the {42} _humerus_, and adheres to the _olecranum_ with the _brevis_ and the _longus_. the _anconeus_ or _cubitalis_ being situated behind the fold of the _cubitus_, is the least muscle of all; it springs from the extremity of the arm-bone, at the end of the _brevis_ and the _longus_, and in descending is inserted between the _radius_ and the _cubitus_ or _ulna_, three or four fingers breadth below the _olecranum_. _how many muscles hath the _radius_, and which are its motions?_ the _radius_ is endu'd with a twofold motion by the means of four muscles: of these the _rotundus_ and _quadratus_ cause that of _pronation_, as the _longus_ and the _brevis_ that of _supination_. the _pronator superior rotundus_, or round muscle of the _radius_, commenceth from the inner _apophysis_ of the shoulder-bone, in a very fleshy stock, and is terminated obliquely by a membranous _tendon_ in the middle and exterior part of the _radius_. the _pronator inferior quadratus_, springing forth from the bottom and inside of the _cubitus_, is fixt in the lower and outward part of the _radius_ by a tail as large as its head. this muscle lying hid under the others near the wrist, is that which jointly with the _rotundus_, turns the arm with the palm of the hand downward, which is the motion of _pronation_. the _longus_ is the first of the _supinators_, whose origine is three or four fingers breadth above the external _apophysis_ of the arm-bone; from whence it passeth along the _radius_, and cleaves to the inner-part of its lower _apophysis_. {43} the _brevis_, or the second of the _spinators_ arising from the lower part of the _inferior condylus_, and the external of the _humerus_, is twisted round about the _radius_, going forward from the hinder-part till it is united to its upper and forepart. this muscle, with the _longus_, serves to turn the arm and the palm of the hand upward, and produceth the motion of _supination_. _how many sorts of motions belong to the wrist, and what are its muscles_? two several motions are perform'd by the wrist, _viz._ one of flection, and the other of extension, three muscles being appropriated to the former, and as many to the later: but it ought to be observed, that a strong ligament, call'd the _annular_, appears here, which, surrounding all the _tendons_ of the muscles as it were a bracelet, holds them together, and elsewhere serves to unite the two bones of the elbow. the three flexors or bending muscles of the wrist are the _cubitæus internus_, the _radiæus internus_, and the _palmaris_. the _cubitæus internus_ derives its original from the part of the arm-bone, passeth under the annular ligament, and is ty'd by a thick _tendon_ to the small bone of the wrist, which is plac'd above the others. the _radiæus internus_ proceeds from the same place with the _cubitæus_, and is fasten'd to the first wrist-bone which supports the thumb. it lies along the _radius_, and passeth under the _annular_ ligament. the _palmaris_ is reckon'd among the flexors of the wrist, although situated in the palm of the hand. it ariseth from the inner process or knob {44} of the arm-bone, and is united by a large _tendon_ to the first _phalanges_ of the fingers, slipping under the transverse or _annular_ ligament and sticking under the skin of the palm of the hand. the three extending muscles of the wrist are the _cubitæus externus_, and the _radiæus externus_ or the _longus_, and the _brevis_. the _cubitæus externus_ taking its rise from the hinder-part of the elbow, passeth under the _annular_ ligament, and adheres to the upper and outward-part of the bone of the _metacarpus_ that stayeth the little finger. the _radiæus externus_, or the _longus_, having its origine in the edge of the lower part of the arm-bone, slides from thence along the _radius_ on the outside, extends it self under the _annular_ ligament, and cleaves to the wrist-bone, which stayeth the fore-finger. the _brevis_ or _short_ muscle of the wrist springs from the lower part of the same edge; afterwards it runs along the _radius_, passeth under the _annular_ ligament, and is terminated in the bone of the _carpus_ or wrist, which stayeth the middle finger. but we must take notice, that besides these six muscles, there is also _caro quædam quadrata_, or a square piece of flesh under the _palmaris_, which seems to arise from the _thenar_, and sticks to the eighth wrist-bone. it is supposed that this musculous piece of flesh serves with the _hypothenar_ of the little finger, to make that which is call'd _diogenes's cup_. _how many motions are there in the fingers, and what are their muscles_? {45} the fingers are bent, extended, and turn'd from one side to the other by the means of twenty-three muscles, whereof ten are proper, and thirteen common: the former are those that serve all the fingers in general, and the other those that are particularly serviceable to some of them: the common are the _sublimis_, the _profundus_, the common _extensor_, the four _lumbricales_, and the six _interossei_. the _sublimis_ or _perforatus_, arising from the internal part of the lower process of the _humerus_ or shoulder-bone is divided into four _tendons_, which run below the _annular_ ligament of the wrist, and are inserted in the second _phalanx_ of the bones of the four fingers, after having stuck in passing to those of the first _phalanx_, to help to bend it. it is also observed that every one of these _tendons_ hath a small cleft in its length, to let in the _tendons_ of the _profundus_. the _profundus_ or _perforans_ lies under the _sublimis_, deriving its original from the top of the _cubitus_ and _radius_. it creeps along these two bones, and is divided into four _tendons_, which pass under the _annular_ ligament, and slip into the fissures of the _tendons_ of the _sublimis_, to adhere to the third _phalanx_ of the fingers, which they bend with the _sublimis_: so that these two muscles make together the bending of the fingers. the _extensor magnus_ is that which extends the four fingers. it springs from the external and lower process of the arm-bone, and is divided into four flat _tendons_, which pass under the _annular_ ligament, and cleave {46} to the second and third _phalanx_ of the fingers. the four _lumbricales_ or _vermiculares_ are in the palm of the hand, to draw the fingers to the thumb: they proceed from the _tendons_ of the _profundus_, and the _annular_ ligament, extend themselves along the sides of the fingers and are inserted in their second articulation, to cause the drawing toward the thumb. the three _interossei interni_, and the three _externi_, are situated between the four bones of the _metacarpium_, as well on the inside of the hand as without: they have their beginning in the intervals or spaces between the bones of the _metacarpium_, are united with the _lumbrical_, and fixt in the last articulation of the bones of the fingers, to produce the motion of drawing back or removing from the thumb. the thumb is mov'd by five particular muscles; one whereof serves to bend it, two to extend it, one to remove it from the fingers, and another to draw it to them. the _flexor_ of the thumb takes its rise from the upper and inner part of the _radius_, passes under the _annular_ ligament, as also under the _thenar_, and adheres to the first and second bones of the same thumb to bend it. the two _extensors_ of the thumb are the _longior_ and the _brevior_: the former proceeding from the upper and outward part of the _cubitus_, ascends above the _radius_, and is ty'd with a forked _tendon_ to the second bone of the thumb. the _brevior_ hath the same origin with the _longior_, keeps the same track, passes under the _annular_ ligament, and is terminated in the third thumb-bone. {47} the _thenar_ removes the thumb from the fingers, and forms that part which is call'd the _mount of venus_: it hath its source in the first bone of the _carpus_ or wrist, and the _annular_ ligament, and is inserted in its second bone. the _antithenar_ draws the thumb to the other fingers, having its origine in the bone of the _metacarpus_, that stayeth the middle finger, and its insertion is in the first bone of the thumb. the muscle which serves to extend the fore-finger, is call'd _indicator_: it proceeds from the middle and outer part of the _cubitus_, and is fixt by a double _tendon_ in the second articulation of the fore-finger, as also in the _tendon_ of the great _extensor_ of the fingers. that which draws the fore-finger to the thumb is term'd _adductor_: it commenceth in the fore-part of the first thumb-bone, and is terminated in the bones of the fore-finger. that which removes the fore-finger from the thumb is known by the name of _abductor_, which arising out of the external and middle part of the bone of the elbow, and passing under the _annular_ ligament, cleaves to the lateral and outward part of the bones of the fore-finger. the little-finger hath two proper muscles, _viz._ an _extensor_ and an _abductor_. the _extensor_ springs from the lower part of the _condylus_ of the arm-bone, and is fasten'd by a double _tendon_ in the second articulation of the little-finger, and in the _tendon_ of the _extensor_ of all the others. {48} the _abductor_, call'd also _hypothenar_, hath its beginning in the small bone of the wrist, which is situated over the others, and is terminated in the first bone of the little-finger on the outside. * * * * * chap. xi. _of the muscles of the thighs, legs, and feet._ _what are the motions of the thighs?_ the thigh performs five kinds of motions; for it is bent, extended, drawn within side and without, and turn'd round: all these motions are produc'd by the means of fourteen muscles, _viz._ three _flexors_, three _extensors_, three _adductors_, three _abductors_, and two _obturators_ for the circular motion. the _flexors_ of the thigh are the _psoas_, _iliacus_, and _pectineus_. the _psoas_ or _lumbaris_ is situated inwardly in the _abdomen_, on the side of the _vertebra's_. it proceeds from the transverse _apophyses_ of the two lower _vertebra's_ of the back, and of the upper of the loins, and lying on the inner face of the _os ilion_, sticks to the lesser _trochanter_ or _rotator_. the _iliacus internus_ hath its origine in all the lips of the inner cavity of the _os ilion_, and being joyn'd by a _tendon_ to the _lumbaris_, is inserted with it in the lesser _trochanter_. {49} the _pectineus_ takes its rise from the fore-part of the _os pubis_, and is united before to the thigh-bone a little below the lesser _trochanter_. the _extensors_ of the thigh are the _glutæus major_, _medius_, and _minimus_. the _glutæus major_ springs forth out of the lateral part of the _os sacrum_, as also the hinder and outer part of the _os ilion_ and _coccyx_, and enters into the thigh-bone, four fingers breadth below the great _trochanter_ or _rotator_, being the thickest of all the muscles of the body. the _glutæus medius_, deducing its original from the hinder and outward part of the _os ilion_, is inserted three fingers breadth below the great _trochanter_. the _glutæus minimus_ ariseth from the bottom of the cavity of the _os ilion_, and is fasten'd to a small hole near the great _trochanter_. the _adductors_ of the thigh are the _triceps superior, medius_, and _inferior_. the _triceps superior_ hath its beginning in the top of the _os pubis_, and is terminated in the top of a line, which is on the inside of the thigh. the _triceps medius_ proceeding from the middle of the _os pubis_, is inserted in the thigh-bone a little lower than the _triceps superior_. the _triceps inferior_ hath its source in the bottom of the _os pubis_, and is implanted in the thigh-bone, a little lower than the _triceps medius_. some anatomists make only one muscle of these three, attributing thereto three originals and three insertions. these muscles serve to draw the thighs one against another. the _abductors_ of the thigh are the _iliacus externus_, or _pyriformis_, the _quadratus_, and the _gemelli_. {50} the _pyriformis_ arising from the upper and lateral part of the _os sacrum_, and the the _os ilion_ cleaves to the neck of the great _trochanter_. the _quadratus_ or square muscle of the thigh takes its origine from the external prominence of the _os ischion_, and adheres to the outward part of the great _trochanter_. the _gemelli_ or twin muscles arise from two small knobs in the hinder-part of the _ischion_ and insinuate themselves into a small cavity in the neck of the great _trochanter_. the circular motion of the thigh is performed by the means of two muscles, named the _obturatores externi_ and _interni_. the _obturator internus_ springs from the inner circumference of the oval hole of the _ischion_ and its _tendons_ passing between the two _gemelli_ are inserted in a small cavity at the root of the great _trochanter_ or _rotator_. the _obturator externus_ ariseth from the outward circumference of the same hole of one _ischion_, and is terminated in the side of the other near the great _trochanter_. _what are the motions of the leg, and what are its muscles?_ the leg is mov'd four several ways, that is to say, it is bent, extended, and drawn inward and outward, by the means of eleven muscles _viz._ three _flexors_, four _extensors_, two _adductors_ and two _abductors_. the three _flexors_ of the leg are the _biceps_, the _semi-nervosus_, and the _semi-membranosus_. the _biceps_ hath two heads, the longer whereof cometh out of the bottom of the prominence {51} of the _ischion_, and the other from the middle and exterior part of the _femur_, and is terminated in the outward and upper part of the _epiphysis_ of the _perone_ or _fibula_. the _semi-nervosus_ hath its origine in the knob of the _ischion_, and is join'd backward to the top of the _epiphysis_ of the _tibia_. these three muscles are plac'd in the back-part of the thigh below the buttocks. the four _extensors_ of the leg are the _rectus_, the _vastus internus_, the _vastus externus_, and the _crureus_. the _rectus_ or streight muscle of the leg takes its rise from the fore-part and the bottom of the _ilion_, and descends in a right line: it covers with its _tendon_, which is common to the three following, the whole knee-pan, and adheres to the top of the _tibia_, on the fore-part. the _vastus internus_, being situated on the inside of the thigh, hath its beginning in the top of the thigh inwardly, and a little below the lesser _trochanter_ or _rotator_: afterward it is ty'd to the _tibia_ by a large _tendon_, common thereto with the preceeding. the _vastus externus_ is plac'd on the outside of the thigh, springing from the top and the fore-part of the _femur_, being united by the same _tendon_ with the two preceeding. the _crureus_ proceeds from the top, and the fore-part of the thigh-bone, between the two _trochanters_; then covering the whole bone, it is also fasten'd to the leg-bone with the three preceeding muscles, after having cover'd the knee-pan with their common {52} _tendon_, which serves likewise as a ligament to the knee. the two _adductors_ of the leg are the _sartorius_ and the _gracilis_. the _sartorius_ or the _longissimus_ draws the leg inward, deriving its original from the upper _spine_ of the _ischion_; from whence it descends obliquely thro' the inside of the thigh, and cleaves to the top on the inside of the _tibia_. the _gracilis_ hath its origine in the fore-part at the bottom of the _os pubis_, and its insertion in the top of the _tibia_ on the inside. the two _abductors_ of the leg are the _fascia lata_, and the _poplitæus_. the _fascia lata_, or the _membranosus_, is as it were a kind of large band, which covers all the muscles of the thigh. it proceeds from the outward lip of the _os ilion_, is ty'd by a large membrane to the top of the _perone_ or _fibula_ and sometimes descends to the end of the foot. the _poplitæus_, or _sub-poplitæus_, arises from the lower and external _condylus_ of the thigh-bone, passeth obliquely from the outside to the inside, till it is lost in the upper and inner part of the leg-bone under the ham. _what are the motions of the foot, and what are its muscles?_ the foot performs two motions by the help of nine muscles, as being bent by two, and extended by seven. the two _flexors_ are the _crureus anticus_, and the _peronæus anticus_. the _crureus_ or _tibiæus anticus_, is plac'd along the _tibia_, and takes its rise from its upper and fore-part: afterward it is bound by two {53} _tendons_ to the first _os cuneiforme_, or wedge-like bone, and to that of the _metatarsus_ or instep, which stayeth the great toe, after having pass'd under the annular ligament. the _peronæus anticus_ springs from the middle and outward-part of the _perone_ or _fibula_, and insinuating it self thro' the cleft which is under the external _malleolus_ before, sticks to the bone of the _metatarsus_ that supports the little toe. the seven _extensors_ of the foot are the two _gemelli_, or the _soleus_, the _plantaris_, the _crureus posticus_, and the two _peronæi postici_. the _gemelli_ are the _interior_ and the _exterior_; the former having its source in the inner _condylus_, and the other in the outward and lower of the thigh-bone; from whence they extend themselves till they are fasten'd to the _talus_ or ankle-bone by a _tendon_ common to them, with the two following. the _soleus_ ariseth from the top on the back-part of the leg-bone and _perone_, and confounding its _tendon_ with that of the _gemelli_, sticks close to the _talus_. the _plantaris_, which lies hid between the _gemelli_ and the _soleus_, hath its origine from the _exterior condylus_ of the thigh-bone; then uniting its _tendon_ with the preceeding, it adheres to them; and this common _tendon_ is call'd _chorda achillis_. the _crureus_ or _tibiæus posticus_, springs from the back-part of the leg-bone, from whence extending it self downward, it passeth thro' the fissure in the _internal malleolus_, and cleaves to the inner-part of the _os scaphoides_. {54} the _peronæi_, or _fibulæi postici_, are otherwise call'd the _longus_ and the _brevis_, whereof one proceeds from the upper and almost fore-part of the _perone_, terminating in the upper-part of the bone, that supports the great toe in the _metatarsus_, and the other from the lower part of the _perone_, adhering in like manner to the bone with which the little toe is sustain'd. _with what motions are the toes endu'd, how many muscles have they, and which be they?_ the toes are bent and extended, as also drawn inward and outward, by the means of twenty two muscles, of which sixteen are common, and six proper. the former are two _flexors_, two _extensors_, four _lumbricales_, and eight _interossei_. the first _flexor_ is nam'd _sublimis_, and the other _profundus_. the _sublimis_ or _perforatus_ derives its original from the lower and inner-part of the _talus_ and is fixt in its proper place by four cleft _tendons_, which are inserted in the upper-part of the bones of the first _phalanx_ of the four toes. it is situated under the sole of the feet. the _profundus_ or _perforans_ hath its beginning in the top and back-part of the leg-bone and _perone_, slips under the _malleolus internus_ thro' the _sinus calcaris_, and makes four _tendons_ which pass thro' the fissures of the _tendon_ of the _sublimis_, and cleaves to the bones of the last _phalanx_ of the toes, to bow them. the first _extensor_ is call'd the _common_, and the other the _pediæus._ the _common extensor_, or the _longus_, takes its rise from the top and fore-part of the _tibia_ in the place of its joyning with the _perone_ or {55} _fibula_, and divides it self into four _tendons_, which after having pass'd under the annular ligament, are inserted in the articulations of every toe. the _pediæus_ or the _brevis_, being plac'd over the foot, proceeds from the annular ligament, and the lower-part of the _perone_, and sends forth four _tendons_, which are fixt to the first articulation of the four toes on the outside, thus this muscle, together with the _longus_, causeth their extension. the four _lumbrical_ muscles of the toes arise from the _tendons_ of the _profundus_, and a mass of flesh at the sole of the feet. they are joyn'd by their _tendons_ with those of the _interossei interni_, and adhere inwardly to the side of the first bones of the four toes, to incline them toward the great toe. the _abductors_, or those muscles that remove the toes from the great toe, are the eight _interossei_, whereof four are call'd _externi_, and as many _interni_. the former take their rise in the spaces between the bones of the _metatarsus_, and are terminated outwardly in the side of the first bones of the toes. the internal lie in the bottom of the foot, and take up the spaces between the five bones of the _metatarsus_. they arise from the bones of the _tarsus_, and the intervals between those of the _metatarsus_, and are implanted with the four _lumbricales_ inwardly, in the upper-part of the bones of the first _phalanx_ of the four toes. of the six proper muscles of the toes, there are four appointed for the great toe, which cause it to perform the motions of flexion, {56} extension, and drawing forward or backward. the two others are the _adductor_ of the second toe to the great toe, and the _abductor_ of the little toe, call'd _hypothenar_. the proper _flexor_ of the great toe, arises from the top of the _perone_ or _fibula_, on the back part, passeth thro' the ancle-bone on the inside to the sole of the foot, and is fasten'd to the bone of the last _phalanx_. the proper _extensor_ of the great toe springs from the middle of the fore-part of the _perone_, passeth over the foot, and hath its insertion in the upper-part of the bone of the great toe. the proper _adductor_ of the great toe, or the _thenar_, taking its rise inwardly on the side of the _talus_, the _ossa schaphoidea_ and _innominata_, extends it self over the outward-part of the bone of the _metatarsus_, which stayeth the great toe, and adheres to the top of the second bone of the great toe, which it draws inward. the proper _abductor_ of the great toe, or the _antithenar_, draws it toward the other toes. it derives its origine from the bone of the _metatarsus_, which supports the little toe, slides obliquely over the other bones, and cleaves to the first bone of the great toe on the inside. the _adductor_ appropriated to the second toe hath its source in the first bone of the great toe, on the inside, and sticks close to the bones of the second toe, which it draws to the great toe. {57} the _abductor_ of the little toe, or the _hypothenar_, proceeds from the outward part of the bone of the _metatarsus_, that stayeth the little toe, and is inserted in the top of the little toe, on the outside, to remove it from the others. _a list of all the muscles in the humane body._ the fore-head hath two muscles 2 the hinder-part of the head 2 the eye-lids 4 the eyes 12 the nose 7 the ears on the outside 8 the ears on the inside 6 the lips 13 the tongue 8 the _uvula_, or palate of the mouth 4 the _larynx_ 13 the _pharynx_ 7 the _os hyoides_ 10 the lower jaw 12 the head 14 the neck 8 the _omoplatæ_ or shoulder-blades 8 the arms 18 the elbows 12 the _radii_ 8 the wrists 12 the fingers 48 the breast, or the parts of respiration 57 the loins 6 the _abdomen_ or lower belly 10 the testicles 2 the bladder 1 {58} the _penis_ 4 the _clitoris_ 4 the _anus_ 3 the thighs 30 the legs 22 the feet 18 the toes 44 total 425 * * * * * chap. xii. _of the anatomy of the nerves, arteries, and veins in general._ _what is the structure of the nerves?_ the nerves are round white bodies enclos'd in a double membrane, communicated to them from the two _meninges_ of the brain: their office is to convey the animal spirits into all the parts. _where is the root and first beginning of all the nerves?_ all the nerves take their original from the _medulla oblongata_, and that of the spine. _how is the distribution of them made thro' the whole body?_ it is directly perform'd by conjugations or pairs, whereof one goes to the right-hand, and the other to the left: there are nine pairs of them that proceed from the _medulla oblongata_ and enter into the skull; and a tenth that comes from the marrow which lies between the occipital and the first _vertebra_ of the neck. it {59} passeth thro' the hole of the _dura mater_, thro' which the vertebral artery enters, to distribute its branches into several parts. _to what use are the nine pairs of nerves appropriated, which proceed from the root of the brain?_ they are chiefly design'd for the senses, and also for the motion of their organs, of which the ancients discover'd only seven. the first pair of nerves is call'd the _olfactory_, and serves for the smelling. the second pair is the _optici_ or _visorii nervi_, and bestows upon the eyes the faculty of seeing. the third is term'd _motorii oculorum_, being serviceable for the motion of the eyes. the fourth pair is nam'd _oculorum pathetici_, which shews the passion of the mind in the eyes, whereto it imparts a string as well as to the lips. the fifth is call'd the _gustative_, and appropriated to the taste, because it sends twigs more especially to the tongue, as also to the fore-head, temples, face, nostrils, teeth, and privy-parts. the sixth is likewise for the taste, and goes to the palate. the seventh is the _auditive_ nerve, that enters into the _os petrosum_, where it divides it self into many branches, which when gone forth, are distributed to the muscles of the tongue, lips, mouth, face, fore-head, eye-lids, &c. the eighth is the _os vagum_, or wandering pair, which is united to the intercostal nerve, as also to the recurrent, diaphragmatick, mesenterick, &c. {60} the ninth pair, after having form'd a trunk with the eighth, disperseth its twigs several ways, whereof one is join'd with the twig to the tenth, to be distributed together into the muscle _sternohyoideus_, and into the tongue. the _intercostal_ and _spinal_ are not pairs of nerves, but only branches or twigs of other pairs. _what is the distribution and use of the thirty pairs of nerves that proceed from the spinal marrow?_ there are seven that go forth from the several _vertebra's_ of the neck, twelve from those of the back, five from the loins, and six from the _os sacrum_, according to the following progression. the first of the seven pairs of nerves of the neck proceeds from between the occipital bone and the first _vertebra_, nam'd _atlas_, its fibres being lost in the muscles of the hinder-part of the head and neck. the second pair springs from between the first and second _vertebra_ of the neck; the fibres whereof are lost in the muscles of the head, and in the skin of the face. the third pair issueth from between the second and third _vertebra_ of the neck; and its fibres are lost in the flexor muscles and extensors of the neck. the fourth, fifth, sixth, and seventh pairs proceed from between the _vertebra's_, as before, but their fibres are lost in the neck of the _omoplata_, in the arm, and in the _diaphragme_ or midriff. here it ought to be observ'd by the way that the arms receive branches not only from the {61} four last pairs of the nerves of the neck, but also from the two first pairs of the back, which are extended even to the end of the fingers: whence it happens that in the palsie of the arms, remedies are usually apply'd to the _vertebra's_ of the neck; and that in phlebotomy or letting blood, care must be taken to avoid pricking the nerve, which accompanies the basilick vein in the elbow. the twelve pairs of nerves that have their beginning from between the _vertebra's_ of the back, are each of them divided into two branches, as the others; and their branches are distributed in like manner to the muscles of the breast, and to those of the back and _abdomen_. the five pairs which take their rise from between the _vertebra's_ of the loins, have thicker branches than the others, and the distribution of them is made to the muscles of the loins, _hypogastrium_, and thighs. of the six pairs of nerves that proceed from the _os sacrum_, the four upper with the three lower of the loins, send forth fibres of nerves to the thigh, leg, and foot; and the two last pairs impart nerves to the _anus_, bladder, and privy parts. _what is the structure of the arteries?_ the arteries are long and round canals, consisting of four sorts of tunicks or membranes, which have their rise from the left ventricle of the heart, from whence they receive the blood, and convey it to all the parts of the body for their nourishment. _what is the construction of these four tunicks or membranes of the arteries?_ {62} the first being thin and nervous in its outward superficies, is in the inside a _plexus_ or interlacement of small veins and arteries, and fibres of nerves, which enter into the other following tunicks, to nourish them. the second sticking close to the former, is altogether full of whitish glandules, that serve to separate the serous particles of the blood. the third is intirely musculous, and interwoven with annular fibres. the fourth is very thin, and hath its fibres all streight. _whence proceeds the pulse or beating of the arteries?_ it is deriv'd from the heart, and exactly answers to its motion of _diastole_ and _systole_. _by what name is the first trunk of the arteries call'd, and what is the effect of the distribution made thence to the whole body?_ the first trunk of the arteries is nam'd _aorta_, or the _thick artery_, which proceeds immediately from the left ventricle of the heart, whereto it communicates before its departure from the _pericardium_, one or two small branches call'd the _coronary_: afterward it is divided into two branches, whereof one goes upward, and is term'd the _ascending artery_; and the other downward, under the denomination of the _descending artery_. the _ascending artery_ ariseth upward along the _aspera arteria_ or wind-pipe, to the clavicles, and is there divided into two branches, call'd the _subclavian arteries_, one whereof goes forward to the right side, and the other to the left; and they both send forth on each side {63} divers branches, which take their names from the several parts, whereto they are distributed; such are the _carotides_ or _soporales interni & externi_, which pass to the head; the _mediastina_; the _intercostal_; the _axillar_, and others. the _descending artery_, before its departure from the breast, affords certain branches to the _pericardium_, diaphragm, and lower ribs; afterward it penetrates the diaphragm, and constitutes seven double branches. the first is of those that are call'd _coeliack_, and which go to the liver and spleen. the second branch contains the _upper mesenterick_. the third the _emulgent_, which pass to the reins. the fourth the _spermatick_, which are extended to the genitals. the fifth the _lower mesenterick_. the sixth the _lumbar_. and the seventh the _muscular_. but assoon as the great trunk is come downward to the _os sacrum_, it divides it self into two thick arteries nam'd the _iliack_, which are distributed on both sides, each of them making two internal and external branches, which likewise impart sprigs or lesser arteries, to the bladder, _anus_, _matrix_, and other adjacent parts: then the master-branch forms the _crural_ arteries on the inside of the thighs, which are communicated by multiplying their number even to the ends of the toes, in passing over the external ancle-bones of the feet. _what is the structure of the veins?_ the veins are long and round canals made of four kinds of tunicks or membranes, whose office it is to receive the blood that remains after the nourishment is taken, and to carry it back to the heart to be reviv'd. {64} _what is the form of the four tunicks that make the canals of the veins?_ the first is a contexture of nervous and streight fibres. the second is a _plexus_ of small vessels that carry the nourishment. the third is all over beset with glandules thro' which are filtrated the serous particles of the blood contain'd in the vessels of the second tunicle. the fourth is a series of annular and musculous or fleshy fibres. _which are the most numerous, the arteries or the veins?_ the number of the veins exceeds that of the arteries; and there are scarce any arteries without veins accompanying them. _where is the beginning and original of all the veins?_ all the veins have their root in the liver, and two of the three great trunks that proceed from thence, are call'd _vena portæ_, and _vena cava_; and the third is twofold, _viz._ the _ascending_ and the _descending_. the _vena portæ_ is distributed to all the parts contain'd in the lower belly, and terminated in the fundament; where it makes the internal hæmorrhoidal veins. the _vena cava_ is immediately divided into two thick branches, one whereof ariseth upward to the right ventricle of the heart, and forms the _ascending vena cava_; as the other goes downward to the feet, and constitutes the _descending_. _what is the distribution of the ascending _vena cava_?_ it perforates the diaphragm, goes to the heart, and ascends from thence to the clavicles, {65} after having communicated to the midriff in passing, a small branch call'd the _phrenicus_; as also one or two to the heart, nam'd the _coronary_; and some others to the upper ribs, besides the single branch, term'd _azygos_, only on the right side. but the trunk of the _ascending vena cava_, being once come up to the clavicles, is divided into two branches, well known by the name of the _subclavian_, one whereof shoots forth toward the right side, and the other toward the left; and they both make various ramifications like to those of the thick ascending artery, by producing the _cervicalis_ or _soporalis_, and the internal and external _jugulars_ that go to the head; as also the _axillars_, which pass to the arms and shoulders, forming the _cephalick_, the _median_, and the _basilick_ on the inside of the elbow. the _descending vena cava_ in like manner accompanieth the ramifications of the _aorta_, or thick descending artery, to the fourth _vertebra_ of the loins, where it sends forth two branches, nam'd the _iliack_, one whereof goes to the right side, and the other to the left, both inwardly and outwardly; imparting divers twigs or lesser branches to all the parts contain'd in the _abdomen_ or lower belly, even as far as the fundament, where it makes the external _hæmorrhoidal_ veins. afterward the outward branch of the _iliack_ descends in the thigh, to form the _crural_, and others, as far as the _saphæna_, together with those that are situated at the end of the feet. * * * * * {66} chap xii. _of the anatomy of the _abdomen_, or lower belly_. _what is the clearest division of the human body into various parts, and that which is most followed in the anatomical schools?_ it is that which constitutes three _venters_, that is to say, the upper, the middle, and the lower, which are the head, the _thorax_ or breast and the _abdomen_ or lower belly, together with the extremities, which are the arms and legs. _what is the lower belly?_ it is a cavity of the body that contains the nourishing parts, as the reins, the bladder, and all those that are appropriated to generation in both sexes. _what is to be consider'd outwardly in the lower belly?_ its different regions, and the several parts therein contain'd. _what are these regions?_ they are the _epigastrick_, the _umbilical_, and the _hypogastrick_. _what is their extent?_ it is from the _xyphoides_ or sword-like cartilage to the _os pubis_, the division whereof into three equal parts, constitutes the three different regions; the _epigastrium_ being the first upward, the _umbilicus_ the second, and the _hypogastrium_ the third. {67} _what are the parts contain'd in the _epigastrium_, and what place do they possess therein?_ the parts contain'd in the _epigastrium_ are the liver, the spleen, the stomach, and the _pancreas_ or sweet-bread, which lies underneath: the stomach takes up the middle before, the liver being plac'd on the right side, and the spleen on the left; so that these two sides of the epigastrick region, are call'd the right and left _hypochondria_. _what parts are there contain'd in the umbilical region, and what is their situation?_ they are the most part of the thin intestines or small guts, _viz._ the _duodenum_, the _jejunum_, and the _ileon_, which have their residence in the middle, where they are encircled with a portion of the two great guts, _cæcum_ and _colon_, that take possession of the sides, otherwise call'd the flanks. the reins or kidneys are also in this place, above, and somewhat backward. _what parts are there contain'd in the _hypogastrium_, and of what place are they possest?_ the greater part of the thick-guts, _coecum_, and _colon_, are enclos'd therein, with the entire _rectum_; there is also a portion of the _ileon_, which hides it self in the sides of the _ilia_, or hip-bones: in the middle under the _os pubis_, the bladder is situated on the gut _rectum_ in men, and the _matrix_ in women lies between the _rectum_ and bladder. _after what manner is the opening of a corps or dead body perform'd at a publick dissection?_ {68} it is begun with a crucial incision in the skin from underneath the throat downward, traversing from one side to another in the umbilical region; then this skin is pull'd off at the four corners, and the _panicula adiposa_ is immediately discover'd: under this fat lies a fleshy membrane, call'd _membrana carnosa_; and after that, the common membrane of all the muscles of the lower belly. thus we have taken a view of what anatomists commonly term the _five teguments_, that is to say, the _epiderma_ or scarf-skin, the _derma_ or true skin, the _panicula adiposa_, the _panicula carnosa_ or _membranus carnosa_, and the common membrane of the muscles. the five teguments being remov'd, we meet with as many muscles on each side, _viz._ the descending oblique, the ascending oblique, the transverse, the streight, and the pyramidal, by the means whereof the belly is extended and contracted. afterwards appears a membrane nam'd _peritonæum_, which contains all the bowels, and covers the whole lower belly, being strongly fasten'd to the first and third _vertebra's_ of the back. the fat skinny net which lies immediately under the _peritonæum_, is call'd _epiploon_ and _omentum_, or the caul; it floats over the bowels, keeping them in a continual suppleness necessary for their functions, maintains the heat of the stomach, and contributes to digestion. it remains to take an account of the bowels _viz._ the stomach, mesentery, liver, spleen, kidneys, bladder, and guts, together with the parts appointed for generation, which in men {69} are the spermatick vessels, the testicles, and the _penis_; and in women, the spermatick vessels, the testicles or ovaries, the _matrix_, and its _vagina_ or neck. _what is the stomach?_ it is the receptacle of the aliments or food convey'd thither thro' the _oesophagus_ or gullet, which is a canal, or kind of streight gut that reacheth from the throat to the mouth of the stomach. the stomach it self is situated immediately under the _diaphragm_ or midriff, between the liver and the spleen, having two orifices, whereof the left is properly call'd _stomachus_, or the upper, and the right (at its other extremity) _pylorus_, or the lower orifice. its figure resembleth that of a bag-pipe, and the greater part of its body lies toward the left side. it is compos'd of three membranes, _viz._ one common, which it receives from the _peritonæum_; and two proper; the two uppermost being smooth, and the innermost altogether wrinkled. _what is the _pancreas_ or sweet-bread?_ it is a fat body, consisting of many glandules wrapt up in the same tunicle, being situated under the _pylorus_ or lower orifice of the stomach: it helps digestion, and hath divers other uses; but its principal office is to separate the serous particles of the blood, to be convey'd afterward into the gut _duodenum_, by a canal or passage, nam'd the _pancreatick_. this juice serves to cause the chyle to ferment with the choler, in order to remove the grosser particles from those that ought to enter into the lacteal vessels. _into how many sorts are the guts distinguish'd?_ {70} there are two sorts, _viz._ the thin and the thick. _how many thin or small guts are there?_ three; that is to say, the _duodenum_, the _jejunum_, and the _ileon_. _how many thick guts are there?_ three likewise; _viz._ the _coecum_, the _colon_, and the _rectum_. _why are some of them call'd thin guts, and others thick?_ because the thin are smaller, being appointed only to transport the chyle out of the stomach into the reserver; whereas the thick are more large and stronger, serving to carry forth the gross excrements out of the belly. _are the six guts of an equal length?_ no, the _duodenum_, which is the first of the thin guts, is only twelve fingers breadth long. the _jejunum_, being the second, so call'd because always empty, is five foot long: the third is nam'd _ileon_, by reason of its great turnings which oblige it to pass to the _os ilion_, where it produceth a rupture; it extends it self almost twenty foot in length. the first of the thick guts, known by the name of _coecum_, is very short, and properly only an _appendix_ or bag of a finger's length. that which follows is the _colon_, being the largest of all, and full of little cells, which are fill'd sometimes with wind and other matters that excite the pains of the colick. it encompasseth the thin guts, in passing from the top to the bottom of the belly, by the means of its great circumvolutions, and is from eight to nine foot long. the last is the _rectum_ or {71} streight gut, so nam'd, because it goes directly to the fundament: it is no longer than ones hand, but it is fleshy, and situated upon the _os sacrum_, and the _coccyx_ or rump-bone. _what is the _peristaltick_ motion of the guts?_ it is the successive motion and undulation, whereby the guts insensibly push forward from the top to the bottom, the matters contain'd in them; and that motion which on the contrary is perform'd from the bottom to the top, is term'd the _antiperistaltick_ as it happens in the _iliack_ passion, or twisting of the guts, call'd _domine miserere_, by reason of its intolerable pain. _what is the mesentery?_ it is a kind of membrane somewhat fleshy, which is join'd to the spine in the bottom and middle of the belly, and by its folding, keeps all the guts steady in their place; it is all over beset with red, white, and lymphatick vessels; that is to say, those that carry the blood, chyle, and _lympha_, which serves to cause this last to run more freely, and to ferment. three notable glandules are also observ'd therein, the greatest whereof lies in the middle, and is nam'd _asellius's pancreas_; the two other lesser are call'd _lumbar_ glandules, as being situated near the left kidney. from each of these glandules proceeds a small branch; and both are united together to make the great _lacteal_ vein, or _thoracick_ canal. this tube conveys the chyle along the _vertebra's_ of the back to the left _subclavian_ vein; from whence it passeth into the ascending _vena cava_, and descends in the right ventricle of the heart, {72} where it assumes the form of blood; from whence it passeth to the lungs thro' the _pulmonary_ artery; then it returns to the heart thro' the _pulmonary_ vein, and goes forth again thro' the left ventricle of the heart, between the _aorta_ or great artery, to be afterward distributed to all the parts of the body. this is the ordinary passage for the circulation of the chyle, and the sanguification of the heart. _what is the liver?_ the liver, being the thickest of all the bowels, is plac'd in the right _hypochondrium_, at the distance only of a fingers breadth from the diaphragm; its figure much resembling that of a thick piece of beef: it is convex on the outside, and concave within; its substance is soft and tender, its colour and consistence being like coagulated blood: it is cleft at bottom, and divided into two lobes, _viz._ one greater, and the other less: its office is to purifie the mass of blood by filtration; and it is bound by two strong ligaments, the first whereof adheres to the diaphragm, and the second to the _xiphoides_ or sword-like cartilage. two great veins take their rise from hence, _viz._ the _vena portæ_, and the _vena cava_, which form innumerable branches, as it were roots in the body of the liver. the gall-bladder is fasten'd to the hollow part thereof, and dischargeth its choler into the gut _duodenum_, thro' the vessels that bear the name of _meatus choledochi_, or _ductus biliares._ this choler is not a meer excrement, but on the contrary of singular use in causing the fermentation of the chyle, and bringing it to perfection. {73} _what is the spleen?_ the spleen is a bowel resembling a hart's tongue in shape, and situated in the left _hypochondrium_, over-against the liver: its length is about half a foot, and its breadth equal to that of three fingers; its substance being soft, as that of the liver, and its colour like dark coagulated blood: it is fasten'd to the _peritonæum_, left kidney, diaphragm, and to the caul on the inside; as also to the stomach by certain veins, call'd _vasa brevia_; nevertheless these ligatures do not hinder it from wandering here and there in the lower belly, where it often changeth its place, and causeth many dreadful symptoms by its irregular motions. its office is to subtilize the blood by cleansing and refining it. _what are the reins?_ the reins or kidneys are parts of a fleshy consistence, harder and more firm than that of the liver and spleen: they are both situated in the sides of the umbilical region, upon the muscle _psoas_, between the two tunicks of the _peritonæum_; but the right is lower than the left: their shape resembleth that of a _french_ bean, and they receive nerves from the stomach, whence vomitings are frequently occasion'd in the nephritical colicks: they are fasten'd to the midriff, loins, and _aorta_, by the _emulgent_ arteries; as also to the bladder by the _ureters_. the right kidney likewise adheres to the gut _cæcum_, and the left to the _colon_. their office is to filtrate or strain the urine in the _pelves_ or basons, which they have in the middle of their body on the inside, and {74} to cause it to run thro' the vessels call'd _ureters_ into the bladder. immediately above the reins on each side, is a flat and soft glandule, of the thickness of a nut; they are nam'd _renal glandules_, or _capsulæ atribiliariæ_, because they contain a blackish liquor, which (as they say) serves as it were leaven for the blood, to set it a fermenting. _what is the bladder?_ it is the bason or reserver of urines, of a membranous substance as the stomach, being plac'd in the middle of the hypogastrick region; so that it is guarded by the _os sacrum_ behind, and by the _os pubis_ before: two parts are to be distinguish'd therein, _viz_. its bottom and top; by its membranous bottom it is join'd to the navel, and suspended by the means of the _urachus_, and the two umbilical arteries which degenerate into ligaments in adult persons: as by its fleshy neck, longer and crooked in men, and shorter and streight in women it cleaves to the _intestinum rectum_ in the former, and to the neck of the womb in the latter. lastly, its office is to receive the urines to keep them, and to discharge them from time to time. _what are the genitals in men?_ they are the spermatick vessels, the testicles, and the _penis_. the spermatick vessels are a vein and an artery on each side; the former proceeding from the _aorta_, or thick artery of the heart; and the other from the branches of the _vena cava_ of the liver. these arteries and veins are terminated in the body of the {75} testicles, which are two in number, enclos'd within the _scrotum_. the office of the testicles is to filtrate the seed, which is brought thither from all the parts of the body, thro' the spermatick vessels, called _præparantia_, and afterwards to cause it to pass thro' others nam'd _deferentia_, to the _vesiculæ seminales_, from whence it is forc'd into the _ureter_, thro' two small and very short canals. the _penis_ or yard is a nervous and membranous part, well furnish'd with veins and arteries, containing in the middle the canal of the _ureter_: its extremity, which consists of a very delicate and spongy sort of flesh, is call'd _balanus_, or _glans_, and the nut, the skin that covers it being nam'd the _præputium_, or the fore-skin. thus by the means of this swell'd part, and stiff thro' the affluence of the spirits, the male injects his seed into the _matrix_ of the female, to propagate his kind. _what are the parts appropriated to generation in women?_ they are the spermatick vessels, the ovaries or testicles, and the _matrix_. the spermatick vessels are a vein and an artery on each side, as in men: the ovaries or testicles, situated on the side of the bottom of the _matrix_, are almost of the same bigness with those of men, but of a round and flat figure. the _vesiculæ_, or little bladders which they contain, are usually term'd _ova_ or eggs by modern anatomists; and the vessels that pass from these testicles or ovaries to the _cornua_ of the _uterus_, are call'd _deferentia_ or _ejaculatoria_. {76} the _matrix_, _uterus_ or womb, is the principal organ of generation, and the place where it is perform'd, resembling the figure of a pear with its head upward, and being situated between the gut _rectum_ and the bladder: it is of a fleshy and membranous substance, retain'd in its place by four ligaments, fasten'd to the bottom; whereof the two upper are large ones, proceeding from the loins, and the two lower round, taking their rise from the groin, where they form a kind of goose-foot, which is extended to the _os pubis_, and the flat part of the thighs; which is the cause that women are in danger of miscarrying when they fall upon their knees. the exterior neck of the womb, call'd _vagina_, is made almost in form of a throat or gullet, extending it self outwardly to the sides of the lips of the _pudendum_, and being terminated inwardly at the internal orifice of the _matrix_, the shape whereof resembleth that of the muzzle or nose of a little dog. the outward neck of the womb is fasten'd to the bladder and the _os pubis_ before, and in the hinder part to the _os sacrum_: between the lips of the _pudendum_ lie the _nymphæ_, which are plac'd at the extremity of the canal of the bladder, to convey the urines; and somewhat farther appear four caruncles, or small pieces of flesh, at the entrance of the _vagina_, which when join'd together make the thin membrane call'd _hymen_. * * * * * {77} chap. xiv. _of the anatomy of the _thorax_, breast, or middle _venter_._ _what is the breast?_ it is a cavity in which the heart and the lungs are principally enclos'd. _what is to be consider'd outwardly in the breast?_ its extent, and the situation of the parts therein contain'd. _what is its extent?_ it is extended from the _clavicles_ to the _xiphoides_, or sword-like cartilage on the fore-part, and bounded on the hinder by the twelfth _vertebra_ of the back, having all the ribs to form its circumference, and the diaphragm for its bounds at bottom, separating it from the _abdomen_ or lower belly. _what is the situation of the parts contain'd in the breast?_ the lungs take up the upper region, and fill almost the whole space, descending at the distance of two fingers breadth from the diaphragm; the heart is situated in the middle, bearing its point somewhat towards the left side, under the lobes of the lungs, which are divided by the _mediastinum_ that distinguishes them into the right and left parts. _how is the breast anatomiz'd or open'd?_ {78} after the dissection of the five teguments, and the removal of the muscles, as in the lower belly, the anatomist proceeds to lift up the _sternum_ or breast-bone, by separating it from the ribs; then it is laid upon the face, or else entirely taken away, to the end that the internal parts of the breast may be more clearly discover'd; whereupon immediately appear, the heart, the lungs, the diaphragm, and the _mediastinum_, which sticks to the _sternum_ throughout its whole length. _what is the heart?_ it is a most noble part, being the fountain of life, and the first original of the motion of all the others; on which account it is call'd _primus vivens_, & _ultimum moriens_; that is to say, the first member that begins to live, and the last that dies. _what parts are to be consider'd in the heart?_ its fleshy substance, with all its fibres turn'd round like the skrews of a vice; its _basis_, point, auricles, ventricles, large vessels, _pericardium_ and ligatures or tyes: the _basis_ is the uppermost and broadest part; the point is the lowermost and narrowest part; the two auricles or small ears being as it were little cisterns or reservers, that pour the blood by degrees into the heart, are situated on each side above the ventricles. the ventricles, which are likewise two in number, are certain cavities in its right and left sides. the large vessels are the _aorta_ or great artery, and the _vena cava_ together with the pulmonary artery and vein. the _pericardium_ is a kind of bag fill'd with water, wherein the heart is kept; which is {79} fasten'd to the _mediastinum_ by its _basis_, and to the large vessels that enter and go out of its ventricles. _what are the terms appropriated to the continual beating of the heart?_ they are _diastole_ and _systole_, from whence proceed two several motions, the first whereof is that of dilatation, and the other of contraction, communicated to all the arteries which have the same pulse. _to what use serves the water contain'd in the _pericardium_?_ it prevents the drying of the heart by its perpetual motion. _what are the lungs?_ they are an organ serving for respiration, of a soft substance, and porous as a sponge, being all over beset with arteries, veins, nerves, and lymphatick vessels, and perforated with small cartilaginous tubes, that are imparted to it from the wind-pipe, and are call'd _bronchia_. their natural colour is a pale red, and marbl'd dark brown; and their whole body is wrapt up in a fine smooth membrane, which they receive from the _pleuron_. they are suspended by the wind-pipe, by their proper artery and vein, and by the ligatures that fasten them to the _sternum_, _mediastinum_, and frequently to the _pleuron_ it self: they are also divided into the right and left parts by the _mediastinum_; having four or five lobes, whereof those on the left side cover the heart. their continual motion consists in _inspiration_, to take in the air, and _expiration_, to drive it out. the _larynx_ makes the entrance of the wind-pipe {80} into the lungs, and the _pharynx_ that of the _oesophagus_ or gullet, at the bottom of the mouth to pass into the stomach. * * * * * chap. xv. _of the anatomy of the head, or upper _venter_._ _what is the head?_ it is a bony part, that contains and encloseth the brain within its cavity. _what is most remarkable in the outward parts of the head?_ the temporal arteries, the _crotaphitæ_, or temporal muscles, and the sutures of the skull. _why are these things considerable?_ the temporal arteries are of good note, because they are expos'd on the outside, lying even with the skin. the _crotophite_ muscles are so likewise, in regard that they cannot be hurt without danger of convulsions, by reason of the _pericranium_ with which they are cover'd. and the sutures, because the _meninges_ of the brain proceed from thence to form the _pericranium._ _what is the _pericranium_?_ it is a membrane that lies under the thick hairy skin of the head, and immediately covers the skull. _what are the _meninges_?_ they are two membranes that enclose the substance or marrow of the brain. _what is a suture?_ {81} it is a kind of thick seam or stitch, that serves to unite the bones of the skull. _how many sorts of sutures are there?_ there are two sorts, _viz._ the true, and the false or bastard. _what are the true sutures?_ they are three in number, namely the _sagittal_, the _coronal_, and the _lambdoidal._ _what is the disposition or situation of the true sutures?_ the _sagittal_ is streight, beginning in the middle of the fore-head, and sometimes at the root of the nose, and being terminated behind, at the joining of the two branches of the _lambdoidal suture_. the coronal appears in form of a crown, passing to the middle of the head, and descending thro' the temples, to finish its circumference in the root of the nose. the _lambdoidal_ suture is made like an open pair of compasses, the legs whereof are extended toward the shoulders; and the button is in the top of the head backward. _what are the bastard sutures?_ they are those that are call'd _squamous_ or scaly. _what is the disposition of natural situation of these false sutures?_ they are plac'd at the two sides of the head, and make a semi-circle of the bigness of the ears, round the same ears. _what difference is there between the true and spurious sutures._ the true sutures are made in form of the teeth of a saw, which enter one into the other; and the false or bastard ones are those that resemble the scales of fishes, which {82} are join'd together by passing one over the other. _what is the use of the sutures?_ the ancients were of opinion, that they were made to hinder the fracture of one skull-bone from passing thro' the whole head; but there is more reason to believe that they have the three following uses, that is to say, 1. to promote the transpiration of the brain. 2. to give passage to the vessels that go to the _diploe_. 3. to retain the _meninges_, and to support the mass of the brain, which is cover'd by them. _what are the names of the bones that compose the skull?_ the bone of the fore-part of the head is call'd _sinciput_, or the fore-head-bone, as also the _frontal_ or _coronal_ bone. the bone of the hinder-part, enclos'd within the _lambdoidal_ suture, is term'd the _occipital._ the two bones that form the upper-part, and are distinguish'd by the sagittal suture, bear the name of _parietals_, one being on the right side, and the other on the left. and those behind the ears are call'd _temporal_, _squamosa_, or _petrosa_. these also are distinguish'd into the right and left temporals, and are join'd to the bottom of the parietal by a bastard squamous suture. _what is most remarkable in the thickness of the skull-bones?_ the _diploe_, which is nothing else but a _plexus_ or contexture of small vessels, that nourish the bones, and in the middle of their thickness make the distinction of the first and second tablature of the bones; whence it sometimes {83} happens that an exfoliative trepan, or semi-trepan, is sufficient, when the first of these two tables is only broken, the other remaining entire. _is the brain which is preserv'd in the skull all of one piece, or one equal mass?_ no, it is distinguish'd by the means of the _meninges_ into the brain it self, and the _cerebellum_ or little brain; the brain, properly so called, takes up almost the whole cavity of the skull, and the _cerebellum_ is lodg'd altogether in the hinder-part, where it constitutes only one entire body; whereas the former is divided into the right and left parts by the _meninges_, which cut it even to the bottom; whence these foldings are call'd _falx_; i. e. a _scythe_ or _sickle_. _what is chiefly remarkable in the substance of the brain?_ the ventricles or cavities which are found therein, together with the great number of veins, arteries, lymphatic vessels, and nerves, that carry sense to all the parts of the body, and spirits for their motion. _an exact historical account of all the holes of the skull, and the vessels that pass thro' them._ to attain to an exact knowledge of all the holes with which the inside of the _basis_ of the skull is perforated, they are to be consider'd either with respect to the nerves, or to the sanguinary vessels. {84} there are nine pairs of nerves that arise from the _medulla oblongata_, and go forth out of the skull through many holes hereafter nam'd. the first pair is that of the _olfactory_ nerves, appropriated to the sense of smelling, which are divided below the _os cribiforme_, or sieve-like bone, into divers threads, that passing into the nose through many holes with which this bone is pierc'd, are distributed to the inner tunick of the nose. the second pair is that of the _optick_ or visual nerves, that pass into the orbits of the eyes, thro' certain peculiar holes made in the _os sphenoides_, or wedge-like bone, immediately above the _anterior apophysis clinoides_. in the portion of the _os sphenoides_, that makes the _basis_ of the orbit, lies a fissure about seven or eight hairs breadth long, which is to be observ'd chiefly at the bottom, that is to say, below the hole, thro' which the optick nerve passeth; where it is almost round, and larger than at the top, where it is terminated in a very long and acute angle. there are many pairs of nerves that enter into the orbit thro' this fissure, _viz._ 1. the third pair, call'd the _motorii oculorum_. 2. the fourth pair, nam'd _pathetici_, by dr. _willis_. and 3. the whole sixth pair. besides these three pairs, which go entire thro' this cleft, there is also a passage for the upper branch of the foremost fibre of the fifth pair, which the same renowned physician calls the _ophthalmick_ branch. beyond the lower-part of the said fissure, toward the hinder-part of the head, is to be seen {85} in the _os sphenoides_ on each side, a hole that doth not penetrate the _basis_ of the skull, but makes a kind of _ductus_, about an hair's breadth long, which is open'd behind the orbit on the top of the space between the _apophysis pterygoides_, and the third bone of the jaw; thro' this _ductus_ runs the lower branch of the foremost fibre of the fifth pair. about the length of two hairs breadth beyond these _ductus's_, we may also discover in the _os sphenoides_, or wedge-like bone, two holes of an oblong and almost oval figure, which are plac'd in the hindermost sides of that of the _os sphenoides_, and gives passage to the hindermost fibre of the fifth pair. the hole thro' which runs the _auditory_ nerve, that makes the seventh pair, is in the middle of the hinder-part of the _os petrosum_, that looks toward the _cerebellum_: this hole being very large, is the entrance of a _ductus_ that is hollow'd in the _os petrosum_, and which sinking obliquely from the fore-part backward, for the depth of about two hairs breadth, forms as it were the bottom of a sack, the lowermost part whereof is terminated partly by the _basis_ of the _cochlea_, and partly by a portion of the mouth of the _vestibulum_. at the bottom of this _ductus_ are many holes, but the most considerable is that of the upper-part, thro' which passeth a portion of the auditory nerve. this is also the entrance of another _ductus_ made in the _os petrosum_, which is open'd between the _apophysis mastoides_ and _styloides_: these other holes afford a passage to the branches of the soft portion of the same auditory nerve. {86} below this _ductus_ there is a remarkable hole form'd by the meeting of two hollow cuts the larger whereof is in the occipital bone and the other in the lower-part of the _apophysis petrosi_: from the middle of the upper-part of this hole issueth forth a small prominence or bony point, whereto is join'd an appendix of the _dura mater_, which divides the hole into two parts; so that thro' the foremost orifice passeth the nerve of the eighth pair, and that which is call'd the _spinal_ nerve. we shall have occasion hereafter to shew the use of the hinder orifice. near the great hole of the occipital bone from whence proceeds the _medulla oblongata_, we may observe a hole almost round and oblong thro' which passeth the nerve of the ninth pair. this hole is entirely situated in the occipital bone, and making a little way in the bone passeth obliquely from the back-part forward. in the inside of the skull this hole is sometimes double, but its two entrances are re-united in the outward-part of the skull; and the two branches that form the origine of this nerve and which pass thro' these two holes, are likewise re-united at their departure, these are the passages of the nine pairs of nerves that proceed from the _medulla oblongata_, and it remains only to show that paths thro' which the intercostal nerve goes forth, as also that of the tenth pair. the intercostal runs out of the skull thro' the _ductus_ that gives entrance to the internal _carotick_ artery. as for the tenth pair, in regard that it ariseth from the marrow which is enclos'd between the occipital {87} bone and the first _vertebra_, it goes forth thro' the hole of the _dura mater_, where the vertebral artery enters. to know well the holes thro' which the vessels that belong to the inner-part of the head enter, and issue forth, it is requisite to distinguish them into those which are distributed to the _dura mater_, and those that are appointed for the brain. the vessels of the _dura mater_, are branches of the _carotick_ or vertebral arteries. in the _os sphenoides_, or wedge-like bone, behind the hole thro' which passeth the hindermost fibre of the fifth pair of nerves lies another small hole, almost round, that gives entrance to a branch of the _external carotick_ artery, which in entring, immediately adheres to the _dura mater_, and forms many ramifications to overspread the whole portion of this membrane, which covers the sides, and the upper-part of the brain. at the bottom and top of the lateral outward part of the orbit of the eye, above the acute angle, for want of the _os sphenoides_, there is a hole thro' which passeth an artery, being a twig of a branch of the _internal carotick_, which is diffus'd in the eye, and distributed to almost the whole portion of the _dura mater_, that covers the fore-part of the brain. the vertebral artery in entring into the skull, furnisheth it on each side with a considerable branch, which is dispers'd throughout the whole portion of the _dura mater_ that covers the _cerebellum_. {88} as for the veins that accompany these arteries, they almost all go out of the skull thro' the same holes where the other enters. there are four thick arteries which convey to the brain the matter with which it is nourish'd, and that whereof the spirits are form'd, _viz._ the two _internal caroticks_, and the two _vertebrals._ the _internal carotick_ arteries enter into the skull thro a particular _ductus_ made in the temporal bone, the mouth thereof being of an oval figure and situated in the outward part of the _basis_ of the skull, before the hole of the _internal jugular._ this _ductus_ extends it self obliquely from the back-side forward, and after having made about three hairs breadth in length, is terminated in the hinder-part of the _os sphenoides_. the artery traverseth the whole winding compass of this _ductus_, which resembles the figure of the _roman_ letter s, and at the mouth of the same _ductus_ runs under the _dura mater_ along the sides of the _os sphenoides_ to the _anterior apophyses clinoides_, where it riseth up again, to perforate the _dura mater_, and to adhere to the root of the brain. these vessels, in like manner, after their departure from the bone of the temples to the place where they pierce the _dura mater_, make a second circuit in form of the _roman_ character s. at the place where these _carotick_ arteries penetrate the _dura mater_, they send forth a thick branch, which enters into the orbit of the eye, by the lower-part of the hole, thro' which the _optick_ nerve hath its passage. {89} the _vertebral_ arteries proceeding from the holes of the transverse _apophyses_ of the first _vertebra_, turn about in passing under the upper oblique _apophyses_ of the seven _vertebra's_: afterward they perforate the _dura mater_, and running under the marrow, enter into the skull thro' the occipital hole; then inclining one toward another, they are re-united, and form only one single trunk. the veins that bring back the blood from the substance of the brain, are emptied into the _sinus's_ of the _dura mater_, which are all discharg'd into those that are call'd _lateral_, which last go out of the skull immediately under the nerves of the eighth pair, thro' the hinder-part of the hole made by the meeting of the _occipital_ bone, and the _apophysis petrosa_. these lateral _sinus's_ fall into the _internal jugulars_, which are receiv'd into a considerable sinking hollow'd on each side in the outward, part of the _basis_ of the skull, which is nam'd the pit or hole of the _internal jugular_. in the upper and hinder-part of the hole, from whence the lateral _sinus's_ issue forth, is to be seen an opening in the extremity of a _ductus_, the mouth whereof lies behind the _condyli_, which are on the sides of the occipital trunk: this _ductus_ is extended about the length of two hairs breadth in the bone, and the canal enclos'd therein is open'd immediately into the _vertebral sinus_: so that one might affirm it to be as it were its original source. whence it appears that the blood contained in the lateral _sinus's_ is emptied thro' two places; the greater portion thereof descending in the _jugulars_ {90} from the neck, and the other in the _vertebral sinus's_: sometimes those _ductus's_ are four only on one side, another while both are stopt up, and the blood contain'd in the lateral _sinus's_ is discharg'd into the _internal jugulars_. behind the _apophysis mastoides_ on each side is a remarkable hole, thro' which passeth a thick vein, which brings back part of the blood that hath been distributed to the teguments and muscles, which cover part of the _occiput_ or hinder-side of the head: this vein is open'd into the lateral _sinus's_ at the place where they begin to turn about. but in the heads of some persons, this hole is found only on one side, and even sometimes not at all, in which case the blood contain'd in the vessels falls into the _external jugulars_, with which the branches of this vein have a communication. in each _parietal_ bone on the side of the _sagittal_ suture, at a little distance from the _lambdoidal_, appears a hole, thro' which passeth a vein, that brings back the blood of the teguments of the head, and dischargeth it self into the upper _longitudinal sinus_. these holes are sometimes on both; and then the blood contain'd in the branches of this vein runs into the _external jugulars_. in the middle of the _sella_ of the _os sphenoides_, we may observe one or two small holes thro' which (according to the opinion of some modern anatomists) the _lympha_ contain'd in the _glandula pituitaria_ is thrown {91} into the _sinus_ of the edge of the _os sphenoides_; nevertheless it is certain, that these holes are fill'd only with sanguinary vessels, which carry and bring back the blood of the bones and membranes, whereof those _sinus's_ are compos'd; besides that, these holes are rarely found in adult persons. between the spine of the _coronal_ suture and the _crista galli_, is a hole which serves as an entrance for a _ductus_, which sinks from the top to the bottom, the length of about two hairs breadth in the thickness of the inner table of the _coronal_: the root of the upper _longitudinal sinus_ is strongly implanted in this hole, which also affords a passage to some sanguinary vessels appointed for the nourishment of this inner table. many other small holes are found in divers places of the _basis_ of the skull; the chief whereof are those that are observ'd in the _apophysis petrosa_, and give passage to a great number of vessels that serve for the nutriment of that part of the temporal bone which is call'd the _tympanum_, or drum: the other holes are principally design'd for the vessels that are serviceable in the nourishing of divers parts of the _basis_ of the skull. _after what manner is the opening of the head or skull perform'd?_ it is done by sawing it asunder round about and above the ears; then it is taken off, after having before cut off the hair, and made a crucial incision in the skin from the fore-part to the hinder, and from one ear to the other; as also after having {92} pull'd off and laid down the four corners to the bottom. _how is the brain anatomiz'd?_ it is done by cutting it superficially, and by leaves, in order to discover by little and little the ventricles, vessels, and nerves, with their original sources, &c. or else it is taken entire out of the skull, (the nerves having been before examin'd) and laid down; so that without cutting any thing, all the parts of the brain may be set in their proper places, to find out those that are sought for. * * * * * {93} a treatise of _straps, swathing-bands, bandages, bolsters, splints, tents, vesicatories, setons, cauteries, leeches, cupping-glasses, and phlebotomy._ * * * * * chap. xvi. _of straps, swathing-bands, bandages, and bolsters._ _what is a strap?_ it is a kind of band commonly made use of for the extension of the members in the reducing of fractures and luxations; or else in binding patients, when it is necessary to confine them, for the more secure performing of some painful operation: these sorts of ligatures have different names, {94} according to their several uses, and often bear that of their inventer. _what is the matter whereof these straps are compos'd?_ they may be of divers sorts, but are usually made of silk, wooll, or leather. _what is a swathing-band?_ it is a long and broad band, that serves to wrap up and contain the parts with the surgeons dressings or preparatives. _of what matter are these swathing-bands made?_ they are made at present of linnen-cloth but in the time of _hippocrates_, were made of leather or woollen-stuff. _how many sorts of swathing-bands are there in general?_ there are two sorts, _viz._ the simple and compound; the former are those that are smooth, having only two ends; and the other are those which are trimm'd with wooll, cotton, or felt, or that have many heads, that is to say, ends, fasten'd or cut in divers places according as different occasions require. _what are the conditions requisite in the linen-cloth, whereof the swathing-bands are made?_ it must be clean, and half worn out, not having any manner of hem or lift. _what are the names of the different swathing-bands?_ there are innumerable, but the greater part them take their denominations from their figure or shape; as the long, streight, triangular, and those which have many heads, or are trimm'd. {95} _what is a bandage?_ it is the application of a swathing-band to any part. _how many sorts of bandages are there?_ as many as there are different parts to be bound; some of them being simple, and others compound: the former are those that are made with an uniform band; as the bandage call'd the _truss_, and divers other sorts: the compound are those that consist of many bands set one upon another, or sew'd together; or else those that have many heads. they have also particular names taken from the inventers of them, or from their effect; as _expulsive_ bandages to drive back, _attractive_ to draw forward, _contentive_ to contain, _retentive_ to restrain, _divulsive_ to remove, _agglutinative_ to rejoin, &c. there are others whereto certain peculiar names are appropriated; as _bridles_ for the lower jaw, _slings_ for the chin, the back part of the head, shoulder, and _perinæum_; _scapularies_ for the body, after the manner of the scapularies of monks; _trusses_ for ruptures; _stirrups_ for the ankle-bones of the feet, in letting blood, and upon other occasions. lastly, there are an infinite number of bandages, the structure whereof is learnt by practice, in observing the methods of able surgeons, who invent them daily, according to their several manners; and the first _ideas_ of these can only be taken in reading authors that have treated of them. _what are the general conditions to be observ'd in the bandages?_ {96} there are many, _viz._ 1. care must be taken that the bands be roll'd firm, and that they be not too streight nor too loose. 2. they are to be untied from time to time in fractures, they must also be taken away every three or four days, to be refitted. 3. they must be neatly and conveniently roll'd, that the patient may not be uneasie or disquieted. _what ought to be observ'd in fitting the bolsters?_ care must be taken to make them even, soft, and proportionable to the bigness of the part affected; to trimm them most in the uneven places, that the bands may be better roll'd over them, and to keep them continually moisten'd with some liquor proper for the disease as well as the bands. _in treating of every disease in particular, we shall shew the manner of making the particular bandage that is convenient for it._ * * * * * {97} a treatise of _chirurgical diseases_. * * * * * chap. i. _of tumours in general, abcesses or impostumes, breakings out, pustules, and tubercles._ _what is a tumour?_ a tumour is a rising or bloated swelling rais'd in some part of the body by a setling of humours. _how is this setling of humours produc'd?_ two several ways, _viz._ by _fluxion_ and _congestion_. _what is the setling by fluxion?_ it is that which raiseth the tumour all at once, or in a very little space of time, by the fluidity of the matter. {98} _what is the setling by congestion?_ it is that which produceth the tumour by little and little, and almost insensibly, by reason of the slow progress and thickness of the matter. _which are the most dangerous tumours, those that arise from fluxion, or those that derive their original from congestion?_ they that proceed from congestion, because their thick and gross matter always renders 'em obstinate, and difficult to be cur'd. _whence do the differences of tumours proceed?_ they are taken, _first_, from the natural humours, _simple_, _mixt_, and _alter'd_: _simple_, as the _phlegmon_, which is made of blood, and the _erysipelas_ of choler; _mixt_, as the _erysipelas phlegmon_, which consists of blood mingl'd with a portion of choler; or the _phlegmonous erysipelas_, which proceeds from choler intermixt with a portion of blood: _alter'd_, as the _melia_ which is compos'd of many humours, that can not be any longer distinguish'd by reason of their too great alteration. _secondly_, the difference of tumours is taken from their likeness to some other thing, as the carbuncle and the _talpa_, the former resembling a burning coal, and the other a mole, according to the etymology of their _latin_ names. _thirdly_, from the parts where they are situated; as the ophthalmy in the eye and the quinsey in the throat. _fourthly_, from disease that causeth 'em, as venereal and pestilential buboes. _fifthly_, from certain qualities found in some, and not in others; as the _encysted_ tumours, which have their matter clos'd within their proper _cystes_ or membranes, and so of many others. {99} _how many kinds of tumours are there that comprehend at once all the particular species?_ they are four in number, _viz._ the natural tumours, the encysted, the critical, and the malignant. _what are natural tumours?_ they are those that are made of the four humours contain'd in the mass of the blood, or else of many at once intermixt together. _what are the four humours contain'd in the mass of the blood?_ they are blood, choler, phlegm, and melancholy, every one whereof produceth its particular tumour: thus the blood produces the _phlegmon_, choler the _erysipelas_, phlegm the _oedema_, and melancholy the _scirrhus._ the mixture of these is in like manner the cause of the _erysipelatous phlegmon_, the _oedomatous phlegmon_ or _phlegmonous erysipelas_, and the _phlegmonous oedema_, according to the quality of the humours which are predominant, from whence the several tumours take their names. _what are the _encysted_ tumours?_ they are those the matter whereof is contain'd in certain _cystes_, or membranous bags; as the _meliceris_, and the _struma_ or kings-evil. _what are critical tumours?_ they are those that appear all at once in acute diseases, and terminate them with good or bad success. _what are malignant tumours?_ they are those that are always accompany'd with extraordinary and dreadful symptoms, and whose consequences are also very dangerous; as the carbuncle in the plague. {100} _what are impostumes or abcesses, breakings out and pustules?_ indeed, it may be affirm'd, that all these kinds of tumours scarce differ one from another, except in their size or bigness; nevertheless, to speak properly, by the names of impostumes or abcesses are understood gross tumours that are suppurable, or may be dissolv'd, and by those of breakings out and pustules, only simple pusteal wheals, or small tumours, that appear in great numbers, and which frequently do not continue to suppuration; some of them consisting of very few humours, and others altogether of dry matter. _what difference is there between a tumour and an impostume or abcess?_ they differ in this particular, that all tumours are not impostumes nor abcesses; but there is no impostume nor abcess that is not a tumour: as for example, wens and _ganglions_ are tumours, yet are not abcesses nor impostumes; whereas these last are always tumours in regard that they cause bunches and elevations. * * * * * chap. ii. _of the general method to be observ'd in the curing of tumours_. _what ought a surgeon chiefly to observe in tumours, before he undertake their cure?_ he ought to know three things, _viz._ 1. the nature or quality of the tumour. 2. the {101} time of its formation and 3. its situation: the quality of the tumour is to be known, because the natural one is otherwise handl'd than that which is encysted, critical or malignant. as for the time of its formation, it is four-fold, _viz._ the beginning, increase, state, and declination, wherein altogether different remedies are to be apply'd. the situation of the tumour must be also observ'd, because the dressing and opening of it ought to be as exact as is possible, to avoid the meeting with an artery or neighbouring tendon. _how many ways are all the tumours that are curable, terminated?_ they are terminated after two manners, _viz._ either by dissolving 'em, or by suppuration. _are not the_ scirrhus _and the_ esthiomenus _or gangrene, two means that sometimes serve to terminate and cure impostumes?_ yes, but it is done imperfectly, in regard that a tumour or impostume cannot be said to be absolutely cur'd, as long as there remains any thing of the original malady, as it happens in the _scirrhus_, where the matter is harden'd by an imperfect dissolving of it, or when the impostume degenerates into a greater and more dangerous distemper, as it appears in the _esthiomenus_ or gangrene that succeeds it. _which is the most effectual means of curing impostumes, that of dissolving, or that of bringing them to suppuration?_ that of dissolving 'em is without doubt the most successful, and that which ought to be us'd as much as is possible; nevertheless some cases are to be excepted, wherein the tumours {102} or abcesses are critical and malignant; for then the way of suppuration is not only preferable, but must also be procur'd by all sorts of means, even by opening; which may be done upon this occasion, without waiting for their perfect maturity. _what are the precautions whereto a surgeon ought to have regard before he undertake the opening of tumours?_ he must take care to avoid cutting the fibres of the muscles, and in great abcesses, to cause all the corrupt matter to be discharg'd at once, to prevent the patient's falling into a swoon. _ought the opening of tumours always to be made longitudinally, and according to the direct course of the fibres?_ no, it is sometimes necessary to open 'em with a crucial incision, when they are large, or when a _cystis_ or membranous vehicle is to be extirpated. _how many sorts of matter are there that issue forth in the suppuration of tumours?_ there are four sorts, _viz._ the _pus_, _ichor_, _sanies_, and _virus_. _what is_pus_?_ it is a thick matter, and white as milk. _what is _ichor_?_ it is a thick matter like the _pus_, but of divers colours. _what is _sanies_?_ it is a watery matter that riseth up in ulcers, almost after the same manner as the sap in trees. _what is _virus_?_ {103} it is a kind of watry matter, being whitish, yellowish, and greenish at the same time; which issueth out of ulcers, very much stinking, and is endu'd with corrosive and malignant qualities. _how many general causes are there of tumours?_ there are three, _viz._ the primitive, the antecedent, and the conjunct: the primitive is that which gives occasion to the tumours; as for example, a fall or a blow receiv'd. the antecedent is that which supplies it with matter, such is the mass of blood that thickens and maintains the _phlegmon_. lastly, the conjunct cause is the overflowing blood or matter, which immediately forms the tumor. _what regard ought to be had to these three sorts of causes in the cure?_ the primitive cause may be prevented by avoiding the falls, blows, or other hurts, and the antecedent by diminishing the plethory of the blood, and cooling the whole mass by phlebotomy. the conjunct cause, which is the overflowing of the blood, may be also remov'd in dispersing it by dissolving, or else in discharging it by suppuration. _what is a _crisis_?_ it is a sudden setling of humours, which happens in diseases, whereby they are usually terminated. _how are these critical setlings effected?_ by the strength of nature, which either expels the peccant humours thro' the belly, or carries them to the habitude of the body; for in the former she causeth fluxes of humours, urine and blood; as in the other she excites sweatings, tumours, and even a gangrene it self. _in what parts do the critical tumours usually arise?_ {104} in the glandules, which the ancients call'd the _emunctories_ of the brain, heart, and liver; for they gave the name of emunctories of the brain to the thick glandules which lie under the ears, that of the emunctories of the heart to those that are under the arm-pits; and that of the emunctories of the liver to those under the groin. now malignant tumours may arise in all these parts, but the venereal happen only in the groin. * * * * * chap. iii. _of natural tumours._ * * * * * article i. _of the _phlegmon_ and its dependancies._ _what is a _phlegmon_?_ it is a red tumour occasion'd by the blood diffus'd in some part, wherein it causeth extension, pain, and heat with beating. _are_ aneurisms _and_ varices, _which are tumours, made by the blood, to be reckon'd among the_ phlegmons? no, because the blood that forms the _aneurisms_ and _varices_ is not extravasated nor accompany'd with inflammation, but only a tumour of blood proceeding from the dilatation of the arteries and veins. {105} _may _echymoses_ or contusions consisting of extravasated blood, be esteem'd as _phlegmons_?_ by no means, in regard that it is not sufficient that the blood be extravasated for the producing of a _phlegmon_; it must also cause pain, heat, and a beating, with inflammation, which is not to be found in the _echymoses_, except in great ones, after they have been neglected for a long time; where the corrupted blood ought to be let out immediately, to prevent the inflammation, overmuch suppuration, and many other ill consequences. _is the _phlegmon_ always compos'd of pure blood?_ no, it may happen sometimes to partake of choler, phlegm, or melancholy; on which account it is nam'd an _erysipelatous_, _oedomatous_, or _scirrhous phlegmon_, always retaining the name of the predominant humour, which is the blood; and so of the others. remedies. _what are the remedies proper for a _phlegmon_?_ they are of two sorts, _viz._ general and particular; the former having regard to the antecedent cause, and the other to the conjunct. the _phlegmon_ is cur'd in its antecedent cause, by phlebotomy or letting blood, by good diet, and sometimes by purgations, by which means the plethory, heat, and alteration of the blood is diminished; but fomentations, cataplasms and plaisters facilitate the cure in the conjunct cause, either by dissolving the tumour, or bringing it to suppuration. {106} _at what time is the opening of a vein necessary?_ in the beginning and increase. _what are the remedies proper to be us'd immediately upon the first appearing of the tumour?_ they are resolvents and anodynes; such as those that are prepar'd with chervil boil'd in whey, adding a little saffron to wash the tumour, and soak the linnen cloaths apply'd thereto, which are often renew'd, and may be laid on with the chervil. or else take the urine of a healthful person, wherein is boil'd an ounce of saffron for a glass, and bath the tumour with it. the sperm of frogs is also made use of to very good purpose, either alone, or with lime-water and soap mixt together; or oak-leaves and plantane beaten small, and apply'd. but care must be more especially taken to avoid cooling medicines, oils, and grease, which are pernicious in great inflammations. _what ought to be done in the increase of the tumour and pain?_ they are to be asswag'd by mollifying and dissolving; to which end a cataplasm or pultis is to be made with the leaves of elder, wall-wort or dwarf-elder, mallows, violet-plants, camomile, and melilot; whereto is added beaten line-seed; causing the whole mass to be boil'd in whey, and allowing to every pint, or thereabout, a yolk of an egg, twenty grains of saffron, a quarter of a pound of honey, and the crum of white bread, till it comes to a necessary consistence. or else take cow's dung instead of the above-mention'd {107} herbs, and mix with it all the other ingredients, to make a cataplasm, which must be renew'd at least every twelve hours. _what is to be done in the state?_ if the tumour cannot be dissolv'd (as was intended) it must be brought to suppuration by cataplasms, consisting of these ingredients, _viz._ garlick, white lillies roasted under embers, milk, and _unguentum basilicon_. or else only take a glass of milk, in which an ounce of soap is dissolv'd, to wet the linnen apply'd to the tumour; and let it be often reiterated: otherwise make use of sorrel boil'd with fresh butter, and a little leaven or yeast. the plaister _diasulphuris_ is also most excellent either alone, or, if you please, mixt with _diachylon_ and _basilicon_. _what is to be done in the declination after the suppuration?_ the ulcer must be at first gently dry'd with a plaister of _diasulphuris_ or _diachylon_, and afterward that of _diapalma_ may be us'd, and ceruse or white lead. _what method is to be observ'd in case there be any disposition toward a gangrene?_ it is requisite during the great inflammation to make use of good vinegar, in an ounce whereof is dissolv'd a dram of white vitriol, with as much _sal ammoniack_, to bath the tumour: or else take the tincture of myrrh and aloes, with a little _unguentum ægyptiacum_, and afterward make a digestive of turpentine, the yolk of an egg, and honey, mingling it with a little spirit of wine, or brandy, if there remains any putrifaction or rottenness. {108} _remedies for _aneurisms_ and _varices_._ _what is to be done in order to cure an _aneurism_?_ when it is little, as that which happens after an operation of phlebotomy or letting blood ill perform'd, it may be sufficient to lay upon the affected part a thin plate of lead, or else a piece of money or counter wrapt up in a bolster, and to bind it on very streight: but a piece of paper chew'd is much better for that purpose. if the _anuerism_ be considerable, an astringent plaister may be us'd, such as the following. take _bolus_, dragon's blood, frankincence, aloes, and _hypocystis_, of each a dram; mingle the whole with two beaten eggs, and add wax to give it the consistence of a plaister, which may be apply'd alone, or mixt with an equal portion of _emplastrum contra rupturam_, always making a small bandage to keep it on. _emplastrum de cicuta_ hath also a wonderful effect. when the _aneurism_ is excessive, it is absolutely necessary to proceed to a manual operation, the manner whereof shall be shewn hereafter in the treatise of great operations. _what is requisite to be done in the _varices_?_ _varices_ are not generally dangerous, but even conduce to the preservation of health; nevertheless, if they become troublesome by reason of their greatness, and the pains that accompanie 'em, they may be mollify'd with the following remedy. take the mucilages of the seeds of _psyllium_ and line, of each two ounces; of _populeon_ {109} two ounces; _oleum lumbricorum_ & _hyperici_, of each one ounce; and of the meal of wheat one ounce, adding wax to make the consistence of a plaister; part of which spread upon linnen or leather, must be apply'd to the _varix_, and ty'd thereto with a small band. if the blood abound too much, it may be discharg'd by the application of leeches, or by a puncture made with a lancet: afterward lay upon the part a piece of lead sow'd up in a cloth, and let it be kept close with a proper bandage. otherwise you may make use of an astringent, such as this. take a pomegranate, cut it in pieces, and boil it with as much salt as may be taken up with the tip of your fingers, in a gallon of strong vinegar; then dip a spunge in this vinegar, apply it to the _varix_, bind it on, and continue the use of it twice a day for a month together. _remedies for _echymoses_, contusions, or bruises._ _how are _echymoses_ to be treated?_ all possible means must be us'd to dissolve 'em, by laying slices of beef upon the part, renewing 'em very often, or applying linnen rags dipt in spirit of wine impregnated with saffron. they may be also dissolv'd with the roots of briony grated and apply'd thereto, or else with plaister or mortar, soot, oil of olives and _unguentum divinum_, a mixture whereof being made, is to be put between two rags, and laid upon the tumour or swelling. {110} if the _echymosis_ happens in a nervous part, balsam of _peru_ may be us'd, or, for want thereof, _oleum lumbricorum_ & _hyperici_, with luke-warm wine, with which the bolsters must be soak'd, to be laid upon it. when the _echymosis_ is great, and much blood is diffus'd between the skin and the flesh, the safest way is to make an opening to let it out, lest a too plentiful and dangerous suppuration should ensue, or even a gangrene it self. however, a surgeon ought to proceed in the curing of an _echymosis_ in the face with great circumspection, which must be always prepar'd for incision. _of phlegmonous tumors or impostumes, and of remedies proper for 'em._ _what are the tumours or impostumes that partake of a _phlegmon_?_ they are the _bubo_, carbuncle, _anthrax_, _furunculus_, _phyma_, _phygeton_, _panaritium_ or _paronychia_, burn, gangrene, and kibe or chilblain. _what is a _bubo_?_ a _bubo_ is a tumour which ariseth in the groin, being accompany'd with heat, pain, hardness, and sometimes a feaver. _what is a carbuncle?_ a carbuncle is a hard swelling, red, burning, and inseparable from a fever: it is cover'd with a black crust or scab, that afterward falls off at the suppuration, leaving a deep and dangerous ulcer, and which sometimes doth not suppurate at all. {111} _what is an _anthrax_?_ the _anthrax_ is very near the same thing as the carbuncle, only with this difference, that the latter always appears in the glandulous parts, and the _anthrax_ every where else. _what is a _furunculus_?_ it is a kind of boil, or benign carbuncle, which somewhat resembles the head of a nail, and is on that account call'd _clou_ by the _french_, causing pains, as if a nail were driven into the flesh. _what is a _phygeton_?_ the _phygeton_ is a small, red, and inflam'd exuberance, situated in the miliary glandules of the skin, where it causeth a pricking pain, without suppuration. _what is a _phyma_?_ the _phyma_ appears after the same manner as the _phygeton_, and suppurates. _what are the remedies proper for all these sorts of phlegmonous tumours and impostumes?_ they are cataplasms and plaisters anodyn, emollient, resolvent, and suppurative, which are us'd proportionably as in the _phlegmons_. _what is a _gangrene_, _sphacelus_, or _esthiomenus_?_ the _gangrene_ and _sphacelus_ signifie the same thing, nevertheless are commonly distinguish'd; the former being a mortification begun, and the _sphacelus_ an entire or perfect mortification; call'd also _necrosis_ and _sideratio_. an _esthiomenus_ is a disposition to mortification, discover'd by the softness of the part; and a gangrene is defin'd to be a mortification of a part, occasion'd by the {112} interception of the spirits, and the privation of the natural heat. _what are the causes of a gangrene in general?_ every thing that can hinder the natural heat from exerting it self in a part; as strong ligatures, astringent or resolvent medicines, not conveniently us'd in great inflammations; a violent hæmorrhage; or old age, whereby the spirits are exhausted; the bitings of mad dogs; excessive cold, _&c._ _by what signs is the gangrene known?_ it is discover'd by the livid colour of the skin, which departs from the flesh, the softness, coldness, and insensibility of the part; and sometimes by its dryness and blackness, from whence exhales a cadaverous stench, with _sanies_ issuing forth after punctures or scarifications made therein. lastly, a gangrene is perceiv'd by the cold sweats, swoonings, _syncope's_, and _delirium's_ that invade the patient, and which are all the fore-runners of approaching death. _is a gangrene only found in the flesh, and soft parts of the body?_ it happens also in the bones; and is then call'd _caries_. _how is this _caries_ or gangrene of the bone discover'd, when it lies hid under the flesh?_ it is known by the black colour of the neighbouring flesh, the stink of the _sanies_ that comes forth, the intolerable pains felt thereabouts, which are fix'd and continual before the impostume and ulcer appear; but when the ulcer is made, a kind of roughness may be perceiv'd in the bone. {113} _remedies._ _what are the remedies proper for a gangrene?_ they are those that take away the mortify'd and corrupt parts, and recall the natural heat; both which indications are exactly answer'd in the extirpation of what is already corrupted, with the incision-knife; and the restauration of the natural heat by the following remedies. take an ounce of good vinegar, steeping therein a dram of white vitriol, with as much _sal ammoniack_: let it be us'd in bathing the part; and apply thereto bolsters well soak'd in the same liquor. this remedy is convenient in the first disposition toward a gangrene: or, if you please, you may make use of the yellow water, which is made with corrosive sublimate and lime-water; taking, for example, half a dram of corrosive sublimate to be infus'd in a pint of lime-water. but a tincture of myrrh and aloes is more efficacious, wherein _unguentum ægyptiacum_ is steep'd; or else lime-water kept for that purpose, in which have been boil'd two ounces of sulphur or brimstone, with two drams of _mercurius dulcis_; adding four ounces of spirit of wine, to make an excellent _phegedænick_ water, with which the part may be bathed, and the bolsters soak'd. if the gangrene passeth to the bone, the ulcer must be immediately cleans'd with brandy, and _euphorbium_ afterward put into it, laying also some upon the bolsters, and {114} abstaining from all sorts of oils and greases. but if these remedies prove unprofitable, recourse is then to be had to the incision-knife, fire, or amputation; the manner of performing which several operations, is explain'd hereafter. _what are kibes or chilblains?_ they are painful tumours, which are often accompany'd with inflammation; they happen more especially in the nervous and outward parts, as the heel, and are so much the more sensibly felt, as the air and cold are more sharp and vehement. _what is to be done in order to cure these kibes or chilblains?_ the heel or affected part must be wash'd and dipt in wine boil'd with allum and salt, whereof a cataplasm may be afterward made, by adding meal of rye, honey, and brimstone. the juice of a hot turnep apply'd with _unguentum rosatum_, is also very good, or _petroleum_ alone. _what is a _panaritium_?_ _panaritium_ or _paronychia_, is a tumour which generally ariseth in the extremity of the fingers, at the root of the nails: it is red, and accompany'd with very great pain, even so exquisite, that the whole arm is sensible thereof, insomuch that a fever sometimes ensues, and a gangrene; the humour being contain'd between the bone and the _periosteum_, or that little membrane with which it is immediately invested. _what remedies are convenient for the curing of _panaritium_?_ {115} anodyn cataplasms are to be first apply'd, that is to say, such as serve to asswage excessive pain, as that which is compos'd of millk, line-seeds beaten, large figs, the yolk of an egg, saffron, honey and _oleum lumbricorum_, with the crum of white bread. afterward you may endeavour to dissolve it, by applying oil of almonds, _saccharum saturni_, and ear-wax, or else balsam of sulphur. the plaister of mucilages, and that of sulphur or brimstone, dissolv'd in wine, is also a most excellent resolvent and anodyn. if it be requisite to bring this tumour to suppuration, white lillies roasted under embers may be added to the preceeding cataplasm; or else a new cataplasm may be made with sorrel boil'd, fresh butter, and a little leaven. _what is a burn_? a burn is an impression of fire made upon a part, wherein remains a great deal of heat, with blisters full of serous particles, or scabs, accordingly as the fire hath taken more or less effect. _what are the remedies proper for a burn_? a burn is cur'd by the speedy application of fresh mud re-iterated many times successively; by that of peel'd onions, _unguentum rosatum_, and _populeon_, mixt with the yolk of an egg and unslack'd-lime: cray-fishes or crabs pounded alive in a leaden-mortar; and a great number of other things. if the burn be in the face, you may more especially take the mucilages of the seeds of quinces and _psyllium_, and frog's-sperm, of {116} each an equal quantity, adding to every four ounces twenty grains of _saccharum saturni_. this composition may be spread on the part with a feather, and cover'd with fine brown paper. it is an admirable and approved receipt. if the burn hath made an escar or crust, it may be remov'd with fresh butter spread upon a colewort or cabbage leaf, and apply'd hot. but in case the scab is too hard, and doth not fall off, it must be open'd, to give passage to the _pus_ or corrupt matter, the stay of which would occasion a deep ulcer underneath. the same method is to be observ'd in the pustules or blisters, two days after they are rais'd, applying also the ointment of quick lime, oil of roses, and yolks of eggs. * * * * * article ii. _of the _erysipelas_ and its dependances._ _what is an _erysipelas_?_ an _erysipelas_, commonly call'd _st. anthony's fire_, is a small elevation produc'd by a flux of choler dispers'd and running between the skin and the flesh. it is known by its yellowish colour, great heat and prickings. _remedies._ _what are the remedies proper for an _erysipelas_?_ an _erysipelas_ that ariseth in the head and breast is not without danger, and the cure of {117} it ought to be undertaken with great care in the application as well of internal as external remedies: for it is requisite to take inwardly a dose of the diaphoretick mineral, crabs-eyes, egg-shels, powder of vipers, and other medicines; as also potions that have the like virtues, such as the following. take four ounces of elder-flower-water, adding thereto a scruple of the volatile salt of vipers or hart's-horn with an ounce of syrrup of red poppies. phlebotomy or blood-letting hath no place here, unless there be a great plethory, but frequent clysters are not to be rejected, _viz._ such as are made of whay, chervil, succory, and violet-plants, adding a dram of mineral crystal dissolv'd with two ounce of honey of violets. as for outward applications, linnen-rags dipt in the spirit of wine impregnated with camphire and saffron, are to be laid upon the tumour, and renew'd as fast as they are dry'd. an equal quantity of chalk and myrrh beaten to powder, may also be strew'd upon a sheet of cap-paper over-spread with honey, and apply'd to the part. if the heat and pain grow excessive, take half a dram of _saccharum saturni_, twenty grains of camphire, as much _opium_, with two drams of red myrrh, to be infus'd in a gallon of white-wine: let this liquor be kept to soak the cloaths that are laid upon the _erysipelas_, and often renew'd. but to dress the face, a canvass cloth may be us'd, which hath been dipt in a medicine prepar'd with a {118} gallon of whey, two yolks of eggs, and a dram of saffron. moreover amidst all these remedies, it is necessary to oblige the patient to keep to a good diet, and to prescribe for his ordinary drink a diet-drink made of hart's-horn, the tops of the lesser centory, pippins cut in slices with their skins, and liquorish; a little good wine may be also allow'd, with the advice of the physician. _of _erysipelatous_ tumours or impostumes, and their remedies._ _what are the tumours or impostumes that partake of the nature of an _erysipelas_?_ they are the dry and moist _herpes_, the former being that which is call'd the tetter or ring-worm; and the other a kind of yellow-bladders, pustules, or wheals, that cause itching, and raise small corroding ulcers in the skin: to these may be added divers sorts of scabs and itch. the remedies prescrib'd for the _erysipelas_ may be us'd for both these kinds of _herpes_; as also lotions or bathing-liquors made of lime-water, and a decoction of wormwood and _sal ammoniack_, allowing half a dram to four ounces of liquor. or else take half a dram of _sal saturni_, and put it into a glass of the decoction of fumitory or chervil. you may also make use of the oil of tartar _per deliquium_, to make a liniment either alone, or mingl'd with the above-mention'd decoctions. * * * * * {119} article iii. _of the _oedema_._ _what is the _oedema_?_ it is a white soft tumour, with very little sense of pain, which ariseth from the settling of a pituitous humour. _what are the remedies proper for an _oedema_?_ they are fomentations, cataplasms, liniments, and plaisters. the fomentations are made with bundles of wall-wort or dwarf-elder, thrown into a hot oven after the bread is bak'd, and sprinkled with wine: afterward being taken out smoaking, they are unty'd, open'd, and wrapt about the part, putting a warm linnen cloth over 'em. this operation is to be re-iterated; and by this means the humour is dissolv'd thro' transpiration by sweat. the cataplasms are compos'd of camomile, melilot, st. _john_'s-wort, sage, wall-wort, pellitory of the wall, roots of briony and onions, all boil'd together in white wine with honey, adding, if you please, a few cummin or fennel seeds beaten. cataplasms are also made of horse-dung and the seeds of cummin beaten, which are boil'd in strong vinegar, and mixt with barly-meal to the consistence of pap. the plaisters are prepar'd with an ounce of _diapalma_, half on ounce of _martiatum_, a pint of oil of lillies, half an ounce of {120} cummin-seeds powder'd, half a dram of _sal ammoniack_, and an ounce of yellow wax to make a consistence. if any hardness remains, the plaister of mucilages may be apply'd, or that which is made of the gums _bdellium_, _ammoniack_, and _galbanum_, dissolv'd in vinegar. but care must be taken not to omit the purgatives of jalap to the quantity of a dram in a glass of white-wine; or of half an ounce of lozenges of _diacarthamum_, which are effectual in drawing out the bottom of pituitous and serous humours that nourish the _oedema's_. _of _oedomatous_ tumours and impostumes._ _what are the kinds of tumours that partake of the nature of an _oedema_?_ they are the _phlyctæna_, the _emphysema_, the _batrachos_ or _ranunculus_, the wen, the _talpa_, the _bronchocele_, the _ganglion_, the _fungus_, the scurf, the _scrophula_ or king's-evil, and all sorts of dropsies both general and particular. _what are _phlyctæna's_?_ they are pustules or blisters fill'd with a white and somewhat yellowish humour. _what is an _emphysema_?_ it is a kind of flatuous tumour, wherein wind is contain'd, with a little slimy phlegm. _what is a _batrachos_ or _ranunculus_?_ it is a blister fill'd with slimy water, that ariseth under the tongue near the string, and in _french_ is call'd _grenouillette_, or _the little frog_; which is the same with its _greek_ and _latin_ names. {121} _what is a wen?_ it is a tumour consisting of thick plaistry phlegm, which is reckon'd among the _encysted_. _what is a _talpa_?_ it is a soft and very broad tumour, which usually appears in the head and face, containing a white, thick and pituitous matter. _what is a _bronchocele_?_ it is a bunch'd tumour which ariseth in the throat, and causeth it to swell extremely; being compos'd of thick phlegm mix'd with a little blood, and ranked among the _encysted_ tumours. _what is a _ganglion_?_ it is a very hard tumour, void of pain and wavering, produc'd by thick phlegm: but it is always found upon some nerve or tendon. _what is a _fungus_?_ it is a spungy tumour that grows upon tendons bruis'd or weaken'd by some hurt. _what is the scurf?_ it is a whitish and scaly tumour rais'd in the skin of the head by a viscous and mixt phlegm, having its root in the bottom of the skin. _what is the _scrophula_ or king's-evil?_ _scrophulæ_ or _strumæ_, commonly call'd _the king's-evil_, are tumours that generally shew themselves in the glandules of the neck, and in all those parts where there are any. they consist of a viscous, serous, and malignant phlegm, the source or root whereof is suppos'd to be in the glandules of the mesentery. they are also of the number of the _encysted_ tumours. {122} _what is the dropsie?_ it is a soft tumour occasion'd by the setling of abundance of serous matter in the parts where it appears. _how many sorts of dropsies are there?_ there are three general _species_, _viz._ the _ascites_, _tympanites_, and _leucophlegmatia_. _what is an ascites?_ it is a kind of dropsy that forms the tumour or swelling of the _abdomen_ or lower belly, by a mass of water. _what is a _tympanites_?_ it is a kind of dropsy, which in like manner causeth a tumour or swelling in the lower belly, with this difference, that a great deal of wind is mixt with the water, which renders the tumour transparent, and sounding, as it were a drum; whence this disease hath taken its name. _what is the dropsy call'd _leucophlegmatia_?_ it is a tumour, or, to speak more properly; a general swelling or bloating of all the other parts of the body, as well as of the lower belly. it is produc'd by a viscous and mucilaginous sort of phlegm; whence it happens that the print of the fingers remains in those places that have been press'd. _what are the particular kinds of dropsies?_ they are those that are incident to different parts, of which they bear the names; as the _hydrocephalus_, which is the dropsy of the head; the _exomphalus_, of the navel, and the _hydrocele_ of the _scrotum_. there is also a dropsy of the breast, and that of the _matrix_. {123} _what are the remedies proper for all these sorts of tumours or dropsies?_ they are in general all those that are agreeable to the _oedema_, which are variously us'd, as liniments, fomentations, cataplasms, and plaisters: internal medicines ought also to be much consider'd, as diaphoreticks, sudorificks, and purgatives, when they are assisted by a regular diet. a decoction of the roots of briony with cinnamon and liquorish, provokes urine very much; as well as a decoction of turneps and carrets, and an infusion of sage in white-wine. * * * * * article iv. _of a _scirrhus_, and its peculiar remedies._ _what is a _scirrhus_?_ it is a hard unmoveable tumour, almost altogether void of pain, and of a livid dark colour; which is form'd of a melancholick humour, frequently succeeding _phlegmons_ and _oedema's_ that have not been well dress'd with convenient remedies. _how is a _scirrhus_ cur'd?_ by mollifying or dissolving it, and seldom by bringing it to suppuration. it may be mollify'd by the application of a cataplasm or pultis, compos'd of the leaves of violet-plants, mallows, beets, elder, rue, and wormwood, with camomile-flowers, {124} horse-dung, cow-dung, and white lillies. the whole mass is to be boil'd together in wine, afterward adding honey and hogs-lard, to make a cataplasm thereof with the crum of white bread. it is dissolv'd with plaisters compos'd of those of _diachylon_, melilot, and mucilages, to which is added _oleum lumbricorum_, and flower of brimstone. to render the remedy more effectual, oil of tobacco may be also mixt with it, and gum _ammoniack_ dissolv'd in vinegar. furthermore, these topical or outward medicines are to be accompany'd with others taken inwardly, which serve to prepare the humours for convenient evacuations; such are crab's-eyes, the decoctions of _sarsaparilla_, the use of good wine, and light meats of easie digestion. _of _scirrhous_ tumours, and their remedies._ _what are the tumours that partake of the nature of a _scirrhus_?_ they are the _polypus_, _carcinoma_, _sarcoma_, _natta_, and _cancer_. _what is a _polypus_?_ it is an excrescence of fungous flesh arising in the nostrils: but _hippocrates_ confounds the _carcinoma_ and _sarcoma_ with the _polypus_, of which he says they are only a _species_. _what is the _natta_?_ it is a tumour or excrescence of flesh that appears in the buttocks, shoulders, thighs, face, and every where else, the various figures {125} of which cause it to be call'd by different names. for one while it resembleth a gooseberry, at another time a mulberry, and at another time a melon or cherry. sometimes also these swellings are like trees, fishes, birds, or other sorts of animals, according to the ardent desire that women with child have had for things that they cou'd not obtain when they longed for 'em. _what are the remedies proper for the _polypus_, and other kinds of excrescences of the like nature?_ the _polypus_ may be cur'd in the beginning, but it is to be fear'd lest it degenerate into an incurable cancer, when it hath been neglected or ill dress'd. besides the general remedies, which are letting blood a little, and reiterated purgations, with an exact regulation of diet, there are also particular medicaments which dry up and insensibly consume the excrescence; as a decoction of bistort, plantain, and pomegranate-rinds in claret-wine, which is to be snuff'd up the nose many times in a day, and serves to soak the small tents that are put up therein, as also often to cool the part, adding a little allum and honey. the patient must sometimes likewise keep in his mouth a sage-leaf, sometimes a piece of the root of pellitory of _spain_; and at another time tobacco or some other thing of this nature, which causeth salivation. if the tumour continues too long, and doth not yield to the above-mention'd remedies, it is necessary to proceed to a manual operation, {126} which is very often perform'd with good success. as for the _natta's_, it is most expedient not to meddle with 'em at all; nevertheless these marks which infants bring along with 'em into the world, are frequently defac'd by an application of the after-burdens, whilst they are as yet warm, as soon as their mothers are deliver'd. _what is a cancer?_ it is a hard, painful, and ulcerous tumour, produc'd by an adult humour, the malignity whereof can scarce be suppress'd by any remedies. _how many sorts of cancers are there?_ there are two kinds, _viz._ the primitive and the degenerate; the primitive cancer is that which comes of it self, and appears at first about the bigness of a pea or bean, which nevertheless doth not cease to cause an inward pain, continual, and pricking by intervals; during this time it is call'd an occult cancer; but when grown bigger, and open'd, it bears the name of an ulcerated cancer; which is so much the less capable of being cur'd or asswag'd, as it makes it self more conspicuous by its dreadful symptoms, or concomitant circumstances. the degenerate cancer is that which succeeds an obstinate and ill-dress'd tumour or impostume, and which becomes an ulcerated cancer, without assuming the nature of a blind or occult one. _what remedies are requisite to be apply'd to a blind cancer?_ {127} in regard that it cannot be known in this condition without difficulty, it is often neglected; nevertheless it is a matter of great moment to prevent its consequences, more especially by a good diet, and by general remedies, which may gently rectifie the intemperature of the bowels: afterwards baths may be prescrib'd, together with the use of whey asses-milk, and specificks in general, as powders of crab's eyes, vipers, adders, and others. as for topical remedies, none are to be administer'd, except it be judg'd convenient to apply to the tumour a piece of lead rubb'd with quick-silver; all others serving only to make the skin tender, and apt to break. the patient may also take for his drink water of _scorzonera_ and hart's-horn, with the flowers of bugloss or borage, and liquorice: or else quick-silver-water alone, boiling an ounce of it in a quart of water every time, the quick-silver always remaining at the bottom of the vessel. _what are the remedies for an ulcerated cancer?_ besides the general ones, that are the same with those of the blind cancer, there are also topical, which may take place here. the powders of toads, moles, frogs, and crabs calcin'd, cleanse the ulcers perfectly well. a decoction of vipers and crabs may serve to bath 'em, and some of it may be taken inwardly. detersives made of lime-water, or whey clarify'd, and boil'd with chervil are very good; and (if you please) you may add camphire or _saccharum saturni_. {128} if the pains grow violent, recourse is to be had to _laudanum_, one or two grains whereof may be given in a little conserve of roses. when the cancer is situated in the glandules or flesh, the extirpation of it may also be undertaken with good success. as for the manner of handling degenerate cancers, respect must be always had to the kind of tumour, from whence it deriv'd its original. * * * * * chap. iv. _of bastard or _encysted_ tumours._ _what is an _encysted_ or bastard tumour or impostume?_ it is that which is made of a setling of mixt and corrupt humours, the matter whereof is contain'd in certain proper _cystes_ or membranous bags. _what are the kinds of these tumours?_ they are the _steatoma_, the _atheroma_, the _meliceris_, the wen, the _bronchocele_, and the _scrophula_ or king's-evil. _how is the difference between these tumours discern'd?_ the _steatoma_ is known by its matter resembling suet; as that of the _atheroma_ resembleth pap; and that of the _meliceris_ is like honey: these three tumours cannot be well distinguish'd on the outside, in regard that they do not change the natural colour of the skin, which {129} equally retains in all three the print of the fingers that press it. but the _bronchocele_ is discover'd by the place and part which it possesseth; that is to say, the throat; as also by its somewhat hard consistence without the alteration of the skin. the _scrophulæ_ or king's-evil swellings are known by their unequal hardness, and their situation in the glandules, either in the neck, arm-pits or elsewhere, without alteration likewise of the skin. _remedies._ _want is the method to be observ'd in curing these sorts of tumours?_ an attempt is to be made to dissolve 'em, as in all the others; nevertheless the safest way is to bring 'em to suppuration, and to extirpate the _cystes_, which are apt to be fill'd again after the dissipation of the humour. _what are the medicines proper to dissolve these tumours?_ they are all such as may be us'd for the _oedema_ and _scirrhus_; but the specificks or particular remedies are these: take rosemary, sage, wormwood, elder, great celandine, camomile, melilot, st. _john_'s-wort, and tobacco; boil 'em in white-wine with soot and mercurial honey, adding, thereto cummin-seeds beaten, and _oleum lumbricorum_, to make a cataplasm, which is to be renew'd twice a day. afterward if the tumour be not dispers'd, you may apply the following plaister, which hath an admirable effect. {130} take an equal portion of the plaister of _diachylon_, _devigo_, and four times as much _mercury_, and _emplastrum divinum_; let 'em be dissolv'd together; then intermix saffron, and oil of tobacco, to make a plaister with the whole mass, which may be spread upon thin leather, and apply'd to the tumour, without taking it off only once every eighth day, to cool it; so that it must be laid on again after having wash'd and bath'd the part with warm urine or brine. but it is to be always remember'd that external remedies take effect only imperfectly, unless they are assisted by internal, such as in this case are reiterated purgations, join'd with a regular diet. _what are the remedies proper to excite suppuration?_ to this purpose those may be us'd that serve in other kinds of tumours: but as for the extirpation of the _cystis_, it is done by dividing the tumour into four parts, by procuring suppuration, and by consuming the bag by little and little. the _bronchocele_ alone will not admit this extirpation, by reason of the great number of nerves, veins, and neighbouring arteries amidst which the tumour is settl'd. however _bronchotomy_, or opening the throat, may be perform'd; which is an operation peculiar to this tumour. * * * * * {131} chap. v. _of critical, malignant, pestilential, and venereal tumours and impostumes._ _what difference is there between critical, malignant, pestilential, and venereal tumours?_ it consists in these particular circumstances, _viz._ that critical tumours or impostumes are indifferently all such as are form'd at the end or termination of diseases, in whatsoever place or part they appear. malignant impostumes or tumours are those that are obstinate, and do not easily yield to the most efficacious remedies. pestilential impostumes or tumours are those that are accompany'd with a fever, swooning, head-ach, and faintness: they usually arise in the time of a plague or pestilence, and are contagious. venereal tumours or impostumes are those that appear only at the bottom of the groin, and are the product of an impure _coitus_. however, the critical impostume may be malignant, pestilential, and venereal; the malignant impostume may be neither critical, nor pestilential, nor venereal: but the pestilential and venereal tumours are always malignant. {132} _what are the ordinary kinds of critical tumours or impostumes?_ they are the _anthrax_, the boil, the _phlegmon_, and the _parotides_ or swellings in the almonds of the ears. _what are the kinds of malignant tumours or impostumes?_ they are the _cancer_, the _scrophula_ or king's-evil; and others of the like nature. _what are the kinds of pestilential tumours or impostumes?_ they are carbuncles that break out every where; a sort of _anthrax_ which appears under the arm-pits, and bubo's in the groin. _what are the kinds of venereal tumours or impostumes?_ they are botches or bubo's and cancers that arise in the yard; as also wens and _condyloma's_ in the fundament. _what is the difference between a pestilential and a venereal buboe?_ they may be distinguish'd by their situation, and respective accidents; the pestilential lying higher, and the venereal lower: besides, a fever, sickness at the heart, and an universal faintness or weakness, are the ordinary concomitant circumstances of the former; whereas the venereal buboe is always the consequence of an impure _coitus_, and is attended with no other symptoms than those of common tumours, _viz._ pain, heat, shootings or prickings, &c. as for the remedies, they may be sought for among those that have been already prescrib'd for tumours. * * * * * {133} chap. vi. _of the scurvy._ this disease is known by the ulcers of the mouth, which are very stinking; as also by excessive salivation, great pains in the head, dizziness, frequent epilepsies, apoplexies, and palsies. the face, being of a pale red, and dark colour, is sometimes puff'd up or bloated, inflam'd, and beset with pustules: the teeth are loose and ake, the gums are swell'd, itch, putrifie, exulcerate, and are eaten with the canker; and the jaw is almost unmoveable: the members are bow'd, and cannot be extended: the patients become stupid and drowsie, so that they fetch their breath with difficulty, are obnoxious to palpitations of the heart and coughs, and fall into swoons: the ulcers sometimes are so malignant, that their cheeks are entirely eaten up, and their teeth seen: they are also much inclin'd to vomitting, looseness, and gripes; and their entrails are swell'd: they have red and livid pustules on their belly and privy-parts, which sometimes break out into ulcers; their whole body being dry'd, _&c._ this disease may be easily cur'd in the beginning; but when it is grown inveterate, and invades the bowels, it becomes incurable; as well as when it is the epidemical disease of {134} the country, or the persons afflicted with it, are old, or well advanc'd in years. in undertaking the cure, it is requisite to begin with a good diet, and to sweeten the blood, let the patient take the broth of boil'd fowl; eating pullets and eggs; in the broth may also be put divers sorts of antiscorbutick herbs; _viz._ cresses, spinage, parsly-roots, sparagus, smallage, _scorzonera_, scurvy-grass, _&c._ let him eat nothing that is high season'd, nor acid or sharp; let him drink pure claret, without any adulterate mixture; let him use moderate exercise and rest; lastly, let him keep his mind sedate, and free from all manner of violent passion. the following remedies taken inwardly are very good for the scurvy, _viz._ the tincture of flints from ten grains to thirty; diaphoretick antimony, from six grains to thirty; sweet sublimate, from six grains to thirty; _mars diaphoreteus_, from ten grains to twenty; _crocus martis aperitivus_, from ten grains to two scruples; prepar'd coral, from ten grains to one dram; volatile spirit of _sal ammoniack_, from six drops to twenty; water of cresses, from fifteen drops to one dram; spirit of scurvy-grass, from ten drops to one dram; tincture of antimony, from four drops to twenty; oily volatile _sal ammoniack_, from four grains to fifteen; spirit of _guyacum_, from half a dram to a dram and a half; vitrioliz'd _tartar_, from ten grains to thirty; the volatile salt of _tartar_, urine, vipers, and hart's-horn, of each from six grains to fifteen; the spirit of gum _ammoniack_, from eight drops to sixteen; white {135} _mercury_ precipitate, from four to ten grains; _mercurial panacæa_, from six grains to two scruples. we shall shew the manner of compounding 'em in our treatise of venereal diseases. it is also expedient to give emollient and detersive clysters to the patient at night going to bed, his body being always kept open with convenient diet-drinks: afterward let him take gentle sudorificks, such as are made of the decoctions of fumitory, wild cicory, dandelion, hart's-tongue, scabious, the lesser house-leek, germander, borage, _scorzonera_-root, and polypody, with flowers of broom, elder, and marygold. these are stronger for cold constitutions, _viz._ decoctions of scurvy-grass, _lepidium_, arse-smart, the lesser celandine, wormwood, little house-leek, _trifolium febrinum_, angelico, juniper-berries, _&c._ convenient decoctions to wash the mouth may be made with sage, rosemary, hyssop, oak-leaves, scurvy-grass, cresses, tobacco, roots of bistort, _aristolochy_ or birth-wort, tormentil, flower-de-luce, _balaustia_ or pomegranate-flowers, red roses, _&c._ to corroborate the gums, gargarisms are made of anti-scorbutick plants; as of spirit of scurvy-grass two drams, one scruple of spirit of vitriol, one scruple of common salt, four ounces of rose-water and plantane-water. but if the gums are putrefy'd, they are to be rubb'd with honey of roses, and some drops of spirit of salt. to asswage the pains of the members, bathings and fomentations are to be us'd; and a {136} decoction of saxifrage taken inwardly, with some grains of _laudanum_ is good for that purpose. to allay the gripes, clysters may be given with whey, sugar, yolks of eggs, syrrop of poppies, and oils of earth-worms, scurvy-grass, camomile, _&c._ against the scorbutick dropsy, take the essence of _trifolium febrinum_ and elicampane, from twenty four drops to thirty, and continue the use thereof. milk taken inwardly hinders vomitting; and a broth or gelly of crabs sweetens the blood. the looseness may be stopt with the essence of wormwood, and spirit of _mastick_; as also the fever with febrifuges and anti-scorbuticks. the spots may be fomented with decoctions of aromatick and anti-scorbutick herbs and nitre. for the ulcers of the legs, pulverize an equal quantity of _saccharum saturni_, _crocus martis_, myrrh, and _mercurius dulcis_, and lay it upon the bolsters that are to be apply'd to the sores. to mollifie the sharpness of acid humours, this is a good remedy: prepare half an ounce of spirit of scurvy-grass, two drams of tartariz'd spirit _ammoniack_, a dram of the tincture of worms. take thrice a day fifteen or twenty drops of this liquor, in a decoction of the tops of firr. against the tubercles, take two handfuls of the flowers of camomile and elder, three drams of briony-root, and an handful of white-bread crum; boil the whole composition in milk, and make cataplasms thereof. {137} to mitigate the pains in the head, take twenty or thirty five drops of the tincture of amber, in anti-scorbutick spirits or waters. the difficulty of respiration may be remov'd by a medicinal composition made of two drams of an anti-scorbutick water, two drams of the essence of elicampane, and half a dram of the spirit of gum _ammoniack_; take three or four spoonfuls thereof several times in a day. to prevent the putrefaction of the gums, take one dram of the tincture of gum _lacca_, three drams of the spirit of scurvy-grass, with fifteen or twenty drops of oil of tartar made _per deliquium_, and rub the gums with this composition many times in a day. brandy in which camphire is infus'd, or spirit of wine, is likewise a most excellent remedy; as also all lotions or washes made with the waters or decoctions of anti-scorbutick plants. for leanness, goat's-milk with the spirit of scurvy-grass may be us'd, and other waters drawn from anti-scorbutick plants. the apozemes or decoctions of endive, cicory, sorrel, _becabunga_, and snail-water, are in like manner very good for the same purpose. ointment of _styrax_ is frequently us'd in the hospital call'd _hôtel-dieu_ at _paris_, and apply'd to spots and callous swellings that arise in the legs. * * * * * {138} a treatise of _wounds, ulcers, and sutures_. * * * * * chap. i. _of sutures._ sutures or stitches are made only in recent, and as yet bleeding wounds, when they cannot be re-united by bandage, as are the transverse; provided there be no contusion, nor loss of substance, nor great hæmorrhages, as also that the wounds were not made by the biting of venomous beasts, that there be no violent inflammations, and that the bones are not laid open; because generally 'tis necessary to cause 'em to be exfoliated; neither is this operation to be perform'd in the breast, by reason of its motion. the instruments proper for the making of stitches, are streight and crooked needles, {139} with waxed thread; and these sutures are of four sorts, _viz._ first the _intermittent stitch_ for transverse wounds; the second for the hare-lip; the third, commonly call'd the _dry stitch_, for superficial wounds; and the fourth, term'd the _glover's stitch_. the intermittent stitch is that which is made at certain separated points, according to the following manner: after having taken away all extraneous bodies out of the wound, let a servant draw together its sides or lips; and let a needle with waxed thread be pass'd thro' the middle from the outside to the inside, several points being made proportionably to its length. it is requisite to pierce a good way beyond the edge of the wound, and to penetrate to the bottom, lest any blood shou'd remain in the space, that might hinder the reuniting. if the wound hath corners, the surgeon begins to sow there; and before the knot is made, causeth the lips of the wound to be drawn exactly close one to another: the knots must be begun with that in the middle, and a single one is first made on the side opposite to the running of the matter; laying upon this knot (if it be thought convenient) a small bolster of waxed linnen, on which is tied a slip-knot, to the end that it may be untied if any bad accident should happen. if a plaister be apply'd to the wound after the stitching, a small bolster is to be laid over the knots, to prevent their sticking to the plaister. in case any inflammation happens in the wound, the knots may be loosen'd and ty'd again when the symptoms cease: but {140} if the inflammation continue, the threads are to be cut by passing a probe underneath: when the wound is clos'd, the threads are cut in like manner with a probe; and in drawing 'em out, a finger must be laid near the knot, lest the wound should open again. to make the second sort of stitch for the hare-lip, a small streight needle is pass'd into the sides of the wound, and the thread is twisted round the needle, by crossing it above at every stitch. to form the _dry stitch_ in very superficial wounds, a piece of new linnen-cloth is to be taken, wherein are made digitations, or many corners; the selvedge or hem ought to be on the side of these corners or digitations; and a small thread-lace is ty'd to every one of 'em. afterward this cloth is dipt in strong glue, and apply'd about a finger's breadth from the edges of the wound; so that a piece thereof being stuck on each side, the laces may be ty'd together, to cause the lips of the wound to meet. to make the _glover's stitch_, the operator having drawn together the lips of the wound, holds 'em between two fingers, passeth a needle underneath 'em, and soweth 'em upward all along, after the manner of _glovers_. * * * * * {141} chap ii. _of wounds in general._ _what is a wound?_ a wound is a recent, violent, and bloody rupture or solution of the natural union of the soft parts, made by a pricking, cutting, or bruising instrument. _what ought to be observ'd before all things in the curing of wounds?_ it is requisite to take notice of their differences, as well as of the instruments with which they were made; to the end that consequences may be drawn from thence for the application of proper remedies. _from whence arise the differences of wounds, and which be they?_ they are taken either from their figure or situation: with regard to their figure, they are call'd long, broad or wide, triangular great, little, superficial, or deep; and with respect to their situation, they are term'd simple, complicated, dangerous, or mortal. _what is a simple and a complicated wound?_ a simple wound is that which only opens the flesh, and hath no other concomitant circumstances; but a complicated wound, on the contrary, is that which is attended with grievous symptoms, as hæmorrhages, fractures of bones, dislocation, lameness, and others of the like nature. {142} _what is a dangerous and mortal wound?_ a dangerous wound is that which is complicated the accidents whereof are dreadful: as when an artery is open'd or prick'd, when a nerve or tendon is cut, or when the wound is near a joynt and accompanied with a dislocation or fracture. a mortal wound is that which must be inevitably follow'd by death; as is that which is situated deep in a principal part necessary for the preservation of life. _what are the parts wherein wounds are mortal?_ they are the brain, the heart, the lungs, the _oesophagus_ or gullet, the diaphragm, the liver, the stomach, the spleen, the small guts, the bladder, the womb, and generally all the great vessels. _wherein doth the cure of wounds consist?_ in helping nature readily to procure the reuniting of the parts that have been divided, after having taken away or asswag'd every thing that might cause an obstacle. _what are the things that hinder the speedy reunion of the parts?_ they are extraneous bodies found therein, as bullets, flocks, and pieces of wood or stone, &c. as also sometimes the accidents which attend 'em; as an _hæmorrhage_ or flux of blood, inflammation, _esthiomenus_ or mortification, _hypersarcosis_, or an excrescence of flesh, dislocation, the fracture of a bone, the splinter of a bone, & sometimes a contrary air. {143} _remedies._ _what are the remedies proper for stopping an _hæmorrhage_ or flux of blood?_ the common remedy is a kind of cataplasm, made up with the powders of aloes, dragons-blood, bole armenick and whites of eggs, which are mix'd together and laid upon the wound. but the following is an excellent one. take two ounces of vinegar, a dram of _colcothar_, two drams of _crocus martis astringens_; beat the whole together, steeping _muscus quercinus_ therein; then throw upon it the powder of mushrooms, or of _crepitus lupi_: apply this remedy, and you'll soon stop the _hæmorrhage_, taking care nevertheless to bind the part well, otherwise the astringents do not readily take effect. to this purpose you may also make use of cobwebs, mill-dust, and the powder of worm-eaten oak; or else take oven-soot mixt with the juice of the dung of an ass or ox, adding only thereto the white of an egg. besides these remedies there are also actual and potential cauteries, or simple ligatures, which are infallible. indeed the actual cautery is not always sure; because when the escar made by the fire, falls off the hæmorrhage breaks out again as before: but the potential cautery is almost always successful; such as the following. take about an equal quantity of vitriol and powder of mushrooms; apply 'em upon a little lint to the place where the blood issueth {144} forth, and you'll see it stop immediately: but care must be taken to avoid touching a nerve or tendon; by reason that the vitriol is apt to excite convulsions. _how is the inflammation and mortification of a wound suppress'd?_ if the inflammation proceeds from the presence of an extraneous body, it must be taken away as soon as possible with a pair of forceps, and if from the quantity of _pus_ or corrupt matter, it must be let out. but in case the inflammation ariseth from extreme pains, they are to be asswaged with cataplasms or pultises and anodyn liniments, such as those that have been already prescribed in the cure of the _phlegmon_: or else the part may be bath'd with camphirated spirit of wine, mixt with as much water: _saccharum saturni_ infus'd in lime-water, performs the same effect, and the water of crabs alone is admirable in its operation. against the _esthiomenus_ or mortification, make use of wine boil'd with wormwood, st. _john_'s wort, rosemary and aloes; or else take the tincture of aloes and myrrh, or spirit of wine alone impregnated with camphire and saffron. _what is to be done in case a convulsion happens by reason of a wounded nerve or tendon?_ if the convulsion be caus'd by the presence of an extraneous body that bruiseth the part it must be taken away; and if from the wounding of a nerve, pour into the wound some drops of the oil of lavender distill'd, which in that case is of singular use; this oyl may be also taken inwardly in an appropriated liquour, such as a {145} decoction of wormwood and the tops of the lesser centory. balsam of _peru_ us'd in the same manner, is an excellent remedy, and the oyls of worms, snails, st. _john_'s-wort and turpentine are frequently apply'd with good success. if the convulsion proceeds from the biting of some venomous creature, cupping-glasses or leeches are to be immediately applied, putting into the wound treacle with the spirit of wine or even fire it self, and leaving to the physician's care the prescription of other vulnerary remedies proper to be taken inwardly. _what is to be done to draw the extraneous bodies out of a wound?_ when they cannot be taken away with the fingers or forceps, the patient must be set in the same station or posture wherein he was when he receiv'd the wound, in order to get some farther light to discover 'em; or else such plaisters may be us'd as are endu'd with an attractive quality: particularly this: take an ounce of treacle, half a dram of gum _ammoniack_, one dram of _bdellium_, and two drams of bore's grease, adding a quarter of a pound of wax to make 'em up into the form of a plaister. it is reported that hare's grease alone hath the same effect, and that it goes for a secret among the surgeons but you may (if you please) mix it with ointment of betony. however it hath been observed that leaden bullets may sometimes remain in a man's body, during his whole life-time without doing any harm. {146} _how are excrescences to be taken away?_ they may be consum'd with powder of allom, _unguentum ægyptiacum_, or _lapis infernalis_. _after having remov'd every thing that hinders the reuniting of the lips of a wound, what is to be done to attain thereto?_ the re-union in wounds is properly the work of nature; but it may be promoted by putting into 'em a little balsam of _peru_, and drawing together their lips with the fingers. afterwards the lips must be kept closed with a bandage, a glutinous plaister or a dry stitch, provided the wound be only superficial, hindring the air from penetrating into it. for want of balsam of _peru_, an excellent one may be made with the flowers here specified. take the flowers of henbane, st. _john's-wort_, and comfry and let 'em be digested in the sun during the whole summer-season in the oyl of hemp-seed, which oyl, the longer it is kept, proves so much the better, if it be set forth in the sun every summer, the vessel that contains it being well stop'd. there is also the balsam of balsams, or the balsam of _paracelsus_ call'd _samech_. to avoid the exposing of wounds to the air, it is requisite to cover 'em over the dressings with some sort of plaister, which is usually termed the surgeon's plaister, such is that which is effectual in dissolving, corroborating and allaying pain or inflammation. take the mucilages of the roots of great comfrey and fenegreek, half a pound of ceruse or white lead, two drams of crude _opium_, one dram of camphire, as much of saffron, two drams of sandarack, one of the oyl of {147} bays, one half pound of rosin, and as much turpentine and wax. boil all these ingredients together in a sufficient quantity of lin-seed-oyl, and make a plaister according to art. in great wounds it is expedient to lay over the dressings a cataplasm or pultiss, such as this: take the leaves and flowers of camomile, and melilot, the tops of wormwood, common mallows and marsh-mallows, with the seeds of line and cummin powder'd: then boyl the whole composition in wine, and add thereto barly-meal, to give it a due consistence. if there be any cause to fear a gangrene, you may also intermix saffron, myrrh and aloes with spirit of wine. _is it necessary to put tents into all wounds, and to make use of digestives and suppuratives?_ no: it is sufficient to procure the re-uniting of the parts simply by the means of balsam in small wounds; because they ought not to be brought to suppuration: so that digestives and suppuratives are only necessary in great wounds, and those that are accompanied with contusion, avoiding the ill custom of some country-surgeons, that stuff up their wounds too much with tents and pledgets, whereas they might well be content with simple bolsters or dossels which shou'd be dipt in the ordinary digestive composed of turpentine and the yolks of eggs with a little brandy, or else with the tincture of myrrh and aloes. suppuration may also be promoted by mundifying and quickening the wound, especially if the bolsters be steep'd in the following composition. {148} take half an ounce of aloes and myrrh powder'd, two drams of _sal saturni_, twenty grains of _sal ammoniack_, the same quantity of beaten cloves, a dram of queen of _hungary_ water and half an ounce of _unguentum basilicon_, and let the whole mass be mingled together. in fine, the whole mystery consists in well cleansing the wounds with a linnen cloth, or with the injections of the tinctures of myrrh and aloes; or with simple decoctions of wormwood, _scordium_ or water-germander, bugle, sanicle and hore-hound in white-wine; as also by prescribing the vulnerary decoctions of powder of crab's-eyes, and _saccharum saturni_, to be taken inwardly, to consume the acid humours, which are a very great obstacle that hinders the speedy cure of wounds. _what are the vulnerary plants, the decoctions of which is to be taken inwardly?_ they are _alchymilla_ or lion's-foot, ground-ivy, _veronica_ or fluellin, st. _john_'s-wort, wormwood, centory, bugle, sanicle, chervil, and others. the broth of crabs may also be prescrib'd, which is an excellent remedy, and may serve instead of a vulnerary potion. sometimes sutures or stitches contribute very much to the re-uniting of the lips of wounds, when they cannot be join'd by bandage. * * * * * {149} chap. iii. _of particular wounds of the head._ _what ought first to be consider'd in a wound of the head?_ two things, that is to say, the wound it self, and the instrument with which it was made; for by the consideration of the wound, we may know whether it be superficial or deep; and by that of the instrument, we are enabled to make a truer judgment concerning the nature of the same wound. _what is a superficial, and what is a deep wound in the head?_ that is call'd a superficial wound in the head, which lies only in the skin; and that a deep one which reacheth to the _pericranium_, skull, or substance of the brain. _what is to be apply'd to a superficial wound?_ it is cur'd with a little queen of _hungary_ water; or else with a little balsam, laying upon it the surgeon's plaister, or that of betony. but if the wound or rent be somewhat large, it must be clos'd with a stitch. _what is to be done to a deep wound?_ if it be situated in the _pericranium_, the wound must be kept open, waiting for suppuration; but if it enter the skull, an enquiry is to be made, whether there be a simple contusion, or a fracture also. in the contusion it is necessary to wait for the suppuration, and the {150} fall of the splint, and to keep the wound open; as in the fracture, to examine whether it be in the first table only, or in both; it is known to be only in the first, by the application of an instrument, and of ink, as also in regard that there are no ill symptoms; but a fracture in both tables shews it self by the signs; and it may be found out by making a crucial incision in the flesh, to discover the fissure. _what are the signs of the fracture of the two tables of the skull, and of the overflowing of the blood upon the membranes of the brain?_ they are the loss of the understanding at the very moment of receiving the wound; an hæmorrhage or flux of blood thro' the nose, mouth, or ears; drowsiness and heaviness of the head, and more especially vomitting of phlegm; from whence may be inferr'd the necessity of making use of the trepan. _what consequence may be drawn from the knowledge of the instrument with which the wound was made?_ it is according to the quality of this instrument; as it is proper to cut, prick, or bruise; if it be cutting, the wound is more superficial, and not subject to a great suppuration: if it be pricking, the wound is deeper, but of small moment: if it be a battering or bruising instrument, the wound is accompany'd with contusion, producing a great suppuration, besides the concussion and commotion of the part, which are inseparable, and often cause very dangerous symptoms. {151} inferences may be made also from the disposition of the wounded person; for a strong robust man may better bear the stroke than a weak one; and even anger causeth an augmentation of vehemency; so that all such circumstances are not to be despis'd, in regard that they give occasion to profitable conjectures. _what particular circumstance is there to be observ'd in undertaking the cure of wounds in the face?_ it is, that a more nice circumspection is requir'd here than elsewhere, in abstaining from incisions, as well as in making choice of proper medicines, which must be free from noisome smells; and it is in this part chiefly that balsams are to be used, avoiding suppuration, to prevent scars and other deformities. * * * * * chap. iv. _of the particular wounds of the breast._ _what is to be observ'd in wounds of the breast?_ two things, _viz._ whether they penetrate into the cavity of the _thorax_ or not, which may be discover'd by the probe, and by a wax-candle lighted, and apply'd to the entrance of the wound, obliging the patient to return to the same posture wherein he receiv'd the hurt, as also to keep his nose and mouth shut: for then the flame may be perceiv'd to be wavering, the orifice of the opening being full of {152} bubbles; a judgment may be also made from the running out of the blood. _what is to be done when it is certainly known that the wound penetrates into the cavity of the breast?_ it is necessary to examine what part may be hurt, by considering the situation of the wound, and its symptoms: if the lungs are pierc'd, a spitting of froathy vermilion-colour'd blood ensues, with difficulty of respiration, and a cough. if any of the great vessels are open'd, the wounded person feels a weight at the bottom of his breast, is seiz'd with cold sweats, being scarce able to fetch his breath, and vomits blood, some portion whereof issueth out of the wound. if the _diaphragm_ or midriff be cut in its tendinous part, he is suddenly hurry'd into convulsions: and if the heart be wounded either in its _basis_ or ventricles, he falls into a swoon, and dies incontinently. but if the probe doth not enter, and none of the above-mentiond symptoms appear, it may be taken for granted that the wound is of no great consequence. _what is to be done when the wound penetrates into the chest, yet none of the parts are hurt, only there is an effusion of blood over the _diaphragm_?_ it is necessary to make an _empyema_, or otherwise the diffus'd blood in corrupting, wou'd inevitably cause an inflammation, gangrene, and death it self. _what is an _empyema_?_ it is an operation whereby any sorts of matter are discharg'd with which the diaphragm is over-spread, by making a puncture or opening in the breast. * * * * * {153} chap. v. _of the particular wounds of the lower belly._ _what is to be done to know the quality of a wound made in the lower belly?_ it is requisite to make use of the probe, to observe the situation of the wound, and to take notice of all the symptoms: for by the help of the probe, one may discover whether it hath penetrated into the cavity or not, after having enjoyn'd the patient to betake himself to the same posture wherein he was when he first receiv'd the wound: by its situation a conjecture may be made that such a particular part may be hurt; and by a due examination of the symptoms, one may attain to an exact knowledge. as for example; it is known that one of the thick guts is open'd, when the hurt is found in the _hypogastrium_, and the excrements are voided at the wound; as it is certain that one of the thin guts is pierc'd, when the wound appears in the navel, and the chyle issueth forth from thence; and so of the others. _what method ought to be observ'd in curing wounds in the lower belly?_ it is expedient at first to prevent letting in the air, and to dilate the wound, in order to sow up the perforated gut, and afterward to {154} restore it to its place; as also to bind the caul, which is let out at the opening, and to cut it off, lest in putrifying it should corrupt the neighbouring parts. then these parts may be bath'd with lees of wine, wherein have been boil'd the flowers of camomile and roses with wormwood: the powders of aloes, myrrh, and frankincense may be also thrown upon 'em; and the wound must be sow'd up again to dress it on the outside, the patient in the mean time being restrain'd to a regular diet. but clysters must be forborn on these occasions, especially when one of the thick guts is wounded, making use rather of a suppository or laxative diet-drinks, to avoid dilation and straining. * * * * * chap vi. _of wounds made by guns or fire-arms._ these wounds are always bruis'd and torn, with the loss of substance, and commonly with the splitting and breaking of a bone: they are red, black, livid, and inflam'd, not being usually accompany'd with an hæmorrhage: they are generally round, and streighter at their entrance than at their end; at least if they were not made with cross-bar-shot, or quarter-pieces. {155} _of the prognostick of wounds by gun-shot._ when these wounds penetrate into the substance of the brain, or marrow of the back-bone, or into the heart, _pericardium_, great vessels, and other noble parts, death always inevitably follows, and often happens at the very instant. but one may undertake the cure of those that are superficial, and which are made in the neck, shoulders, arms, and all other parts of the body. _of the cure of wounds by gun-shot._ for the better curing of these sorts of wounds, it is requisite to be inform'd of the quality of the fire-arms by which the wounds were made, in regard that a musquet is more dangerous than a pistol, and a cannon much more than a musquet; as also to examine their situation and concomitant accidents; for by how much the more complicated they are, so much the greater is the danger. then the patient must be set (as near as can be) in the very same situation and posture wherein he remain'd when the wound was receiv'd, in order to discover the direct passage of the wound by the help of the probe, with which a search is to be made, whether a bullet, or any other extraneous bodies, as wood, flocks, linnen, or stuff as yet stick in the wound; so that endeavours may be us'd to take 'em out thro' the same hole where they enter'd, care being more especially had to avoid making {156} dilacerations in drawing 'em out: but if the operator hath endeavour'd to no purpose to remove these extraneous bodies, let him make a counter-opening in the opposite part, where he shall perceive any hardness, nevertheless without touching the vessels; thus the incision being made, he may readily draw 'em out with his fingers, or some other instrument. if the bullet sticks so far in a bone that it cannot be taken away without breaking the same bone, it is more expedient to let it lie therein; but if the leg or arm-bones are very much split or shattered, then the amputation of 'em becomes absolutely necessary. the pain and inflammation of the part may be asswag'd by letting blood, topical anodyns, cooling clysters and purgations; but in case much blood hath been already lost, phlebotomy must be omitted. the clysters may be made with decoctions of mercury, mallows, beets, a handful of barley and honey of roses. some surgeons are of opinion that the patient ought to be purg'd every other day, and even on the very same day that he receiv'd the wound, if his strength will permit; however very gentle purges are to be us'd upon this occasion, such as cassia, manna, tamarins, syrrup of violets, and that of white roses. in the mean while anodyns may be compounded to mitigate the pain; as cataplasms or pultisses made with the crum of white bread, milk, saffron, the yolk of an egg, and oil of roses us'd hot; which last ingredient is of it self a very good anodyn. but to asswage great inflammations, oil of {157} roses, the white of an egg and vinegar beaten all together, may be laid on the neighbouring parts. at first it is necessary to apply spirituous medicines to the wound, and pledgets steep'd in camphirated brandy, are admirable for that purpose; but if there be a flux of blood, styptick waters, or other astringent remedies may be us'd, still remembring that all these medicaments must be apply'd hot. to promote the suppuration of these contused wounds, a digestive may be made of _oleum rosatum_, the yolk of an egg, and _venice_ turpentine. if the wound be in the nerves, tendons, or other nervous parts, it is requisite to use spirituous and drying medicines, never applying any ointments, which will not fail to cause purtrefaction in those parts: but a cataplasm may be made with barley-meal, _orobus_, lupins and lentils boil'd in claret, adding some oil of st. _john_'s-wort. the balsam of _peru_, oil of turpentine destill'd, oil of wax, destill'd oil of lavender, _oleum philosophorum_, oil of bays destill'd, balsam of st. _john_'s-wort, spirit of wine, and gum _elemi_, are excellent medicaments for the nerves: or else, take four ounces of _unguentum althææ_ with a dram and a half of destill'd bays; mingle the whole composition, and apply it: or else, take an ounce of destill'd oil of turpentine, a dram of spirit of wine, and half an ounce of camphire; let all be intermixt, and dropt into the wound: or else, {158} take a scruple of _euphorbium_, half an ounce of _colophonia_, and a little wax; let 'em be mingl'd together, and apply'd very hot to the nervous parts. if the wounds are deep, injections may be made with this vulnerary water, which is very good for all sorts of contusions, as also for the gangrene and ulcers. take the lesser sage, the greater comfrey, and mugwort, of each four handfuls; plantane, tobacco, meadowsweet, betony, agrimony, vervein, st. _john_'s-wort, and wormwood, of each three handfuls; fennel, pilewort bugle, sanicle, mouse-ear, the lesser dazy, the lesser centory, and all-heal, of each three handfuls; three ounces of round birth-wort, and two ounces of long: let the whole composition be digested during thirty hours, in two gallons of good white-wine, and afterward destill'd in _balneo mariæ_, till one third part be consumed. if a gangrene happens in the part, spirit of mother-wort may be put into it, which is compounded with two drams of mastick, myrrh, _olibanum_, and amber, and a quart of rectify'd wine, the whole being destill'd. this fomentation may be apply'd very hot to very good purpose, _viz._ an equal quantity of camphirated wine and lime-water, with three drams of camphire. this is also an excellent cataplasm: take a pint of lye, and as much spirit of wine, half an handful of rue, sage, _scordium_, and wormwood, a dram of each of the roots of both sorts of birth-wort, and two drams of {159} _sal ammoniack_. let the whole composition be boil'd till a third part be consum'd; adding half a dram of myrrh and aloes, and a little brandy. _of a burn made by gun-powder._ if the burn be recent, and the skin not exulcerated, spirit of wine or brandy is to be immediately apply'd; or else an ointment may be made with oil of olives, or bitter almonds, salt, the juice of onions, and verjuice. if the skin be ulcerated, and little bladders or pustules arise, an ointment may be compounded with the second bark of elder boil'd in oil of olives. after it hath been strain'd, add two parts of ceruse or white-lead, and one of burnt lead, with as much litharge, stirr'd about in a leaden-mortar, to make a liniment. but it is not convenient to take out the grains of powder that remain in the skin, because they are apt to break, and to be more confounded or spread abroad; so that they must be left to come forth in the suppuration. when the wound is superficial, and the skin as yet whole, peel'd onions with common honey are an excellent remedy; but if the skin be torn, it is not to be us'd, by reason that the pain wou'd be too great; in which case oil of tartar _per diliquium_ hath a very good effect. if the burn be accompany'd with a fever, it may be allay'd with fixt nitre, nitre {160} prepar'd with antimony, and gun-powder taken inwardly, which are very effectual in their operation. crab's-eyes prepar'd, and even some of 'em unprepar'd, are in like manner admirable remedies. as for external medicaments, when the burn is only superficial, take onions and unslack'd lime, quench'd in a decoction of rapes, and apply this liquor very hot, with double bolsters dipt therein. or else take what quantity you please of quick lime well wash'd, and pound it thoroughly in a leaden-mortar, with may-butter without salt, to make an ointment, which may be laid altogether liquid upon the affected part: or else, take as much quick lime as you can get up between your fingers at two several times; milk-cream and clarify'd honey, of each about half the like quantity; let the whole be intermix'd to the consistence of an ointment, and apply'd: it is an approv'd remedy; as also is the following; take unslack'd lime, and put it into common water, so as the water may appear four or five finger's breadth above it. after the effervescence, pour in oil of roses; whereupon the whole mass will be coagulated in form of butter, and may be apply'd. a good lotion or washing-liquor may be prepar'd with the juice of garlick and onions, in recent burns; otherwise make use of this ointment. take an ounce and an half of raw onions, salt, and _venice_ soap, of each half an ounce; mingle the whole composition in a mortar, pouring upon it a sufficient {161} quantity of oil of roses, to make a very good ointment: or else, dissolve _minium_ or litharge in vinegar, filtrate this liquor, and add thereto a quantity of rape-oil newly drawn off, sufficient to give it the consistence of a liquid liniment; then stir it about in a leaden-mortar till it become of a grey colour, and keep it for use as an excellent liniment: or else, pound crey-fishes or crabs alive in a mortar to get their blood, and foment the part with it hot; it is a good remedy: otherwise intermix the pounded crabs with may-butter without salt, and let 'em be boil'd up together, and scumm'd, till a red ointment be made, which may be drawn off, or strain'd for use. and indeed, all manner of ointments, and other medicinal compositions wherein crabs are an ingredient, are true specificks against burns made by gun-powder. the mucilages of the seeds of _psyllium_, or rather those of quince-seeds prepar'd with frog's sperm, and a little _saccharum saturni_, spread with a feather upon the affected part, have a wonderful operation in burns. a medicament compounded with one third part of the oil of olives, and two of the whites of eggs well beaten and mixt together, is a very simple and singular remedy. otherwise take half an ounce of line-seed-oil infus'd in rose-water, with four yolks of eggs; beat 'em together, and let the whole be apply'd to the burnt part. if the burn be very violent, and hath many pustules, _etmullerus_ is of opinion that they {162} ought to be open'd, and that an ointment shou'd be apply'd, which is made of hen's-dung boil'd in fresh butter: otherwise, take a handful of fresh sage-leaves, two handfuls of plantane, six ounces of fresh butter without salt, three ounces of pullet's-dung newly voided, and the whitest that can be found; then fry the whole composition for a quarter of an hour; squeeze it out, and keep it for use: otherwise, take two ounces of sweet apples roasted under embers, barly-meal, and fenugreek, of each half an ounce, and half a scruple of saffron; let the whole mass be mingled to make a liniment or soft cataplasm, which may serve to asswage pain, and mollifie the skin. if the wound be yet larger, and hath a scab, open all the pustules, and endeavour the two first days to cause the escar to fall off by the application of a liniment made of the mucilages of quince-seeds steept in frog's-sperm, with fresh butter, the oil of white lillies, and the yolk of an egg: otherwise, make a liniment with fresh butter well beaten in a leaden-mortar, with a decoction of mallows, which being spread upon hot colewort-leaves, and apply'd to the escar, it will fall off. but if the escar be too hard and obstinate, it is requisite to proceed to incisions to make way for the _sanies_, lest a deep and putrid ulcer shou'd be engender'd underneath. as soon as the humour is evacuated, the above-mention'd {163} emollient medicines may be us'd, till the separation of the escar; then the ulcer may be consolidated with digestives and mundificatives; such as the ointment of quick lime with oil of roses, and the yolks of eggs. the white camphirated ointments, and that of alabaster, are also good for the same purpose. if a gangrene ensueth, sudorificks must be taken inwardly; such are camphirated spirit of treacle, the essence and spirit of elder-berries, the spirit of hart's-horn with its own proper salt, treacle impregnated with the spirit of camphirated wine, scorpion-water, hart's-horn, citron with camphire, &c. as for external remedies in the beginning of the gangrene, the spirit of wine apply'd hot is excellent; and yet better if aloes, frankincense, and myrrh be intermixt therein. it ought also to be observ'd, that camphire must always be mingled in the topical medicines for the cure of the gangrene. a decoction of unslack'd lime, in which brimstone hath been boil'd, with _mercurius dulcis_, and the spirit of wine, is a very efficacious remedy. in a considerable gangrene, after having made deep scarifications, let horse-dung be boil'd in wine, and laid upon the part in form of a cataplasm. this is an approved remedy. if a _sphacelus_ be begun, scarifie the part, and apply thereto abundance of _unguentum ægyptiacum_ over and above the ointments and cataplasms already describ'd; remembring {164} always, that when the gangrene degenerates into a _sphacelus_, all the mortify'd parts must be incontinently separated or cut off from the sound. * * * * * chap. vii. _of ulcers in general._ _what is an ulcer?_ an ulcer is a rupture of the natural union of the parts made a long while ago, which is maintain'd by the _sanies_ that runs out of its cavity; or an ulcer takes its rise from a wound that cou'd not be well cur'd in its proper time, by reason of the ill quality of its _pus_ or corrupt matter. _what difference is there between a wound and an ulcer?_ it is this, that a wound always proceeds from an external cause, and an ulcer from an internal, such as humours that fall upon a part; or else a wound in growing inveterate degenerates into an ulcer. _whence is the difference of ulcers deriv'd?_ it is taken from the causes that produce 'em, and the symptoms or accidents with which they are accompany'd. thus upon account of their causes they are call'd benign or malignant, great, little, dangerous, or mortal; and by reason of their accidents, they are term'd putrid, corrosive, cavernous, fistulous, cancerous, _&c._ {165} _do ulcers always proceed from external causes, or from an outward wound degenerated?_ no they sometimes also derive their origine from internal causes, as the acrimony of humours, or their malignant quality; the retention of a splint of a bone, and other things of the like nature. these ulcers are commonly call'd primitive, and the others degenerate. _what are putrid, corrosive, cavernous, fistulous and cancerous ulcers?_ the putrid ulcer is that wherein the flesh is soft and scabby, the _pus_ and _ichor_ being viscous, stinking, and of a cadaverous smell. the corrosive ulcer is that which by the acrimony and malignity of its _sanies_, corrodes, makes hollow, corrupts and mortifies the flesh. the cavernous ulcer is that the entrance of which is streight and the bottom broad wherein there are many holes fill'd with malignant _sanies_, without any callosity or hardness in its sides. the fistulous ulcer is that which hath long, streight, and deep holes, with much hardness in its sides; the _sanies_ whereof is sometimes virulent, and sometimes not. the cancerous ulcer is large, having its lips bloated, hard, and knotty, of a brown colour, with thick veins round about, full of a livid and blackish sort of blood. in the bottom are divers round cavities, which stink extremely, by reason of the ill quality of the _sanies_ that runs out from thence. _are there no other kinds of ulcers?_ {166} yes, there are also verminous, _chironian_, _telephian_, pocky, scorbutick, and others, which have much affinity with, and may well be reckon'd among the five kinds already specify'd. _what are the means to be us'd in the curing of ulcers?_ ulcers ought to be well mundify'd, dry'd and cicatriz'd; but with respect to the several causes and accidents that render 'em obstinate, and difficult to be cur'd, it is also requisite to make use of internal medicines, which may restrain and consume 'em. if their sides grow callous, they are to be scarify'd, in order to bring 'em to suppuration; and if there be any excrescences, they must be eaten away with corroding powders, such as that of allom; or by the infernal cautery. _what are the remedies proper to cleanse and dry up ulcers?_ to this purpose divers sorts of liquors may be us'd, as also powders and plaisters: the liquors are usually made of briony-roots, the greater celandine, lime, and yellow water; a tincture of myrrh, aloes and saffron, and whey, whereto is added _saccharum saturni_; so that the ulcers may be wash'd or bath'd with these liquors; and very good injections may be compounded of 'em. the powders are those of worm-eaten-oak, allom, and cinoper, the last of these being us'd by burning it, to cause the fume to be convey'd to the ulcer thro' a funnel. the country people often make use of potter's-earth to dry up their ulcers, with good {167} success; but then they must must be of a malignant nature. the plaisters are _emplastrum de betonica_, _diasulphuris_, _dessiccativum rubrum_, and others; and the ointments are such as these; take three yolks of egg, half an ounce of honey, and a glass of wine, and make thereof a mundifying ointment, according to art: otherwise, take lime well wash'd and dry'd several times, let it be mingled with the oil of line and _bolus_, and it will make an excellent ointment to mundifie and dry; a little _mercury precipitate_ may be intermixt (if you please) to augment the drying quality; and _mercurius dulcis_ may be added in the injections. for ulcers in the legs, and cancerous ulcers, take plantain-water and allom-water, or else spirit of wine, _unguentum ægyptiacum_, and treacle; or else an extract of the roots of round birth-wort made in the spirit of wine. gun-powder alone dissolv'd in wine, is of singular use to wash the ulcers, and afterwards to wet the pledgers which are to be apply'd to 'em. but here are two particular and specifick medicines to mollifie a cancer. take _saccharum saturni_, camphire, and soot; let 'em be incorporated with the juice of house-leek and plantain, in a leaden-mortar; then make a liniment thereof, and cover the part affected as lightly as is possible to be done, as with a simple canvass-cloth, or a sheet of cap-paper: or else, {168} take the destill'd water of rotten apples, and mingle it with the extract of the roots of round birth-wort made in spirit of wine; reserving this liquor to wash the part, and to make injections. * * * * * chap. viii. _of venereal diseases._ _of the _chaude-pisse_ or _gonorrhæa_._ the signs of this disease are a painful distention of the _penis_ or yard, and a scalding pain in making water, the urine being pale, whitish, and full of filaments or little threads: sometimes the testicles are swell'd as well as the _glans_ and _præputium_; and sometimes there is a flux of a kind of matter yellowish, greenish, _&c._ if there be a great inflammation in the yard, endeavours must be us'd to allay it by letting blood; and afterward the patient may take a cooling and diuretick diet-drink, as also emulsions made with cold seeds in whey. a very good decoction may be prepar'd in all places, and without any trouble, by putting a dram of _sal prunella_ into every quart of water, whereof the patient is to drink as often as he can: this decoction is very cooling and diuretick; and the use of it ought to be continu'd till the inflammation be asswag'd. then some gentle {169} purges are to be prescrib'd in the beginning; such as an ounce of _cassia_, and as much _manna_, infus'd in two glasses of whey, which are to be taken one or two hours one after another. afterward the patient must be often purg'd with twelve grains of scammony, and fifteen grains of _mercurius dulcis_; and these purgations must be continu'd, till it appears that the fluxes are neither yellowish nor greenish, nor of any other bad colour. when they are become white, and grown thready, they may be stopt with astringents: amber and dry'd bones beaten to powder, eighteen grains of each, with one grain of _laudanum_, the composition being taken in conserve of roses, are very good for this purpose. _crocus martis astringens_, or else its extract, taken from half a dram to a whole dram, in like manner performs the same operation. as soon as the _gonorrhæa_ is stopt, to be certain of a perfect cure, a dram of the _mercurial panacæa_ is to be taken, from fifteen to twenty grains at a time, in conserve of roses. in the mean while, if a small salivation shou'd happen, it must be let alone for the present, since it may be stopt at pleasure by the purgations. when it is requisite to restrain the _gonorrhæa_, _mercury_ must not be given any longer, in regard that it is a dissolvent, which is only good when the glandules of the groin or testicles are swell'd, or else when it is expedient to set the _chaude-pisse_ a running, after it hath been too suddenly stopt. at the same time that the astringents are taken with the mouth, {170} injections also are to be made into the yard; such as are prepar'd with _lapis medicamentosus_, of which one dram is put into eight ounces of plantane-water. all astringents that are not causticks, are proper for the syringe. _of shankers._ they are round ulcers, and hollow in the middle, which appear upon the _glans_ and the _præputium_. to cure 'em, they must be touch'd with the _lapis infernalis_, and brought to suppuration by the means of red precipitate mixt with the ointment of _andreas crucius_. _oleum mercurii_ laid on a pledget or bolster, is very efficacious to open skankers, and consume their flesh. the patient must be well purg'd with _mercurius dulcis_ and scammony, taking twelve or fifteen grains of each in conserve of roses; and after these purgations are sufficiently reiterated, he may take the _mercurial panacæa's_. it is an excellent remedy for all sorts of pocky distempers not yet consummated, or arriv'd at the greatest height of malignity. _of _bubo_'s._ _bubo's_ are gross tumours or abcesses that arise in the groin, the perfect maturity of which is not to be waited for in order to open 'em; because it is to be fear'd lest the corrupt matter remaining therein too long, might be convey'd into the blood by the circulation, and so produce the grand pox: therefore it is {171} necessary to open 'em betimes with a lancet, or else with a train of potential cauteries, if they are too hard. they ought to be suppurated for a considerable time: the patient must be well purg'd with scammony and _mercurius dulcis_: he must also take the _mercurial panacæa's_. _of the pox._ this loathsome disease begins sometimes with a virulent _gonorrhæa_, and a weariness or faintness at the same time seizeth on all the members of the body: it is usually accompany'd with salivation and the head-ach, which grows more violent at night: pricking pains are also felt in the arms and legs, the palate of the mouth being sometimes ulcerated. if it be an inveterate pox, the bones are corrupted, and _exostoses_ happen therein; divers spots with dry, round and red pustules appear in the skin; and the cartilages or gristles of the nose are sometimes eaten up. but when this disease is come to its greatest height of malignity, the hair falls off; the gums are ulcerated; the teeth are loose, and drop out; the whole body is dry'd up; the eyes are livid; the ears tingle; the nose become stinking; the almonds of the ears swell; the _uvula_ or palate is down; ulcers break out in the privy-parts; bubo's arise in the groin; as also warts in the _glans_ and _præputium_; and _condyloma's_ in the _anus_. indeed the pox may be easily cur'd in the beginning; but when it hath taken deep root {172} by a long continuance, it is not extirpated without much difficulty, more especially if it be accompany'd with ulcers, _caries_, and _exostoses_; the person afflicted with it being of an ill constitution, and his voice grown hoarse. the spring and summer are the proper seasons of the year for undertaking the cure of this disease: in order to which, it is necessary that the patient begin with a regular diet, lodging in a warm place, and taking such aliments as yield a good juice; as jelly-broath made with boil'd fowl: let him drink sudorifick decoctions, prepar'd with the wood of _guayacum_, _china_-root, and _sarsaparella_, and let him abstain from eating any thing that is high season'd: let him take clysters to keep his body open; sometimes also he may be let blood, and purg'd with half a dram of jalap, and fifteen grains of _mercurius dulcis_. the purgations may be re-iterated as often as it shall be judg'd convenient; and then the patient may be bath'd for nine or ten days, every morning and evening; during which time he may take volatile salt of vipers, the dose being from six to sixteen grains; or else viper's-grease from half a dram to a whole dram in conserve of roses. afterward it will be necessary to proceed to fluxing, which is caus'd by the means of frictions with _vuguentum mercurii_, which is made of crude _mercury_ stirr'd about in a mortar with turpentine, and then the whole mingled with hog's-grease, one part of _mercury_ being usually put into two parts of hog's-grease. the rubbing is begun at the sole of the feet, {173} by a long continuance, it is not extirpated without ascending to the legs, and the inside of the thighs; but the back-bone must not be rubb'd at all; when the persons are tender, or of a weak constitution, a single friction may be sometimes sufficient. thus the patient must be rubb'd at the fire, after he hath taken a good mess of broath; but i would not advise it to be done with more than one or two drams of _mercury_ at a time, without reckoning the grease. then the patient must be dress'd with a pair of linnen-drawers or pantaloons, and laid in his bed, where his mouth may be lookt into from time to time, to see whether the _mercury_ hath taken effect; which may be easily known, by reason that his tongue, gums, and palate swell and grow thick, his head akes, his breath is strong, his face red, and he can scarce swallow his spittle; or else he begins to salivate. if none of these signs appear, the rubbing must be begun again in the morning and evening; then if no salivation be perceiv'd, for sometimes four or five frictions are made successively, a little _mercurial panacæa_ may be taken inwardly, to promote it. during the frictions, the patient is to be nourish'd with eggs, broaths, and gellies; he must also keep his bed in a warm room, and never rise till it shall be thought fit to stop the salivation, which continues twenty or twenty five days; or rather till it becomes laudable; that is to say, till it be no longer stinking, nor colour'd, but clear and fluid. if a looseness shou'd happen during the salivation, it wou'd cease, so that to renew it, {174} the looseness may be stay'd with clysters made of milk and the yolks of eggs; and in case the salivation shou'd not begin afresh, it must be excited with a slight friction: but if it shoul'd be too violent, it may be diminish'd by some gentle purge, or with four or five grains of _aurum fulminans_, taken in conserve of roses. three or four pints of rheum are commonly salivated every day in a bason made for that purpose, which the patient holds in his bed near his mouth, so as the spittle may run into it. but if the fluxing shou'd not cease of it self at the time when it ought, he must be purg'd to put a stop thereto. if any ulcers remain in his mouth, to dry 'em up, gargarisms are to be often us'd, which are made of barley-water, honey of roses, or luke-warm wine. the warts are cur'd by binding 'em, if a ligature be possible, or else they may be consum'd with causticks, such as the powder of savine, or _aqua-fortis_, by corroding the neighbouring parts; sometimes they are cut, left to bleed for a while, and bath'd with warm wine. when the patient begins to rise, he must be purg'd, his linnen, bed, and chamber being chang'd; and afterward his strength is to be recruited with good victuals, and generous wine. if he were too much weaken'd, let him take cow's-milk with _saccharum rosatum_. if the pox were not inveterate, the fluxing might be excited by the _panacæa_ alone, without any frictions: for after the phlebotomy, {175} purgations, and bathings duly administer'd; the patient might take ten grains of the _mercurial panacæa_ in the morning, and as many at night; on the next day fifteen grains might be given, and the like quantity at night; on the third day twenty grains might be given both morning and evening; on the fourth day twenty five grains in the morning, and as many at night; and on the fifth day thirty grains in the morning, and the very same quantity in the evening; continuing thus to augment the dose, till the fluxing comes in abundance; and it may be maintain'd by giving every two or every three days twelve grains of the _panacæa_. this course must be continually follow'd till the salivation becomes laudable, and the symptoms cease. _the manner of making the _mercurial panacæa_._ to prepare this _panacæa_, it is requisite to take _mercury_ reviv'd from _cinnabar_, because it is more pure than _mercury_ which is immediately dug out of the mine. the _mercury_ is reviv'd with _cinnabar_, after this manner: take a pound of artificial _cinnabar_ pulveriz'd, and mingled exactly with three pounds of unslack'd lime, in like manner beaten to powder: let this mixture be put into a retort of stone, or glass luted, the third part of which at least remains empty; let it be plac'd in a reverberating furnace; and after having fitted a recipient fill'd with water, let the whole be left during twenty four hours at least; then let the fire be {176} put under it by degrees, and at length let the heat be very much augmented, whereupon the _mercury_ will run drop by drop into the recipient: let the fire be continu'd till nothing comes forth, and the operation will be perform'd generally in six or seven hours: then pour the water out of the recipient, and having wash'd the _mercury_, to cleanse it from some small quantity of earth that may stick thereto, let it be dry'd with cloaths, or else with the crum of bread: thus thirteen ounces of _mercury_ may be drawn off from every pound of artificial cinnabar. the _panacæa_ is made of sweet sublimate, and the later of corrosive sublimate: to make the corrosive sublimate, put sixteen ounces of _mercury_ reviv'd from cinnabar, into a matrass, pour upon it eighteen ounces of spirit of nitre; place the matras upon the sand, which must be somewhat hot, and leave it there till the dissolution be effected: then pour off this dissolved liquor, which will be as clear as water, into a glass vial, or into a stone-jug, and let its moisture evaporate gently over the sand-fire, till a white mass remains; which you may pulverize in a glass mortar, mingling it with sixteen ounces of vitriol calcin'd, and as much decrepited salt: put this mixture into a matras, two third parts of which remain empty, and the neck of which hath been cut in the middle of its height; then fix the matras in the sand, and begin to kindle a gentle fire underneath, which may be continu'd for three hours; afterwards let coals be thrown upon it till the fire burn very vehemently, and a sublimate {177} will arise on the top of the matras; so that the operation may be perform'd within the space of six or seven hours. let the matras be cool'd, and afterward broken; avoiding a kind of flower or light powder, which flyes up into the air as soon as this matter is remov'd; whereupon you'll find nineteen ounces of very good corrosive sublimate; but the red _scoria_ or dross which settleth at the bottom must be cast away as unprofitable. this sublimate being a powerful _escarotick_, eats away proud flesh, and is of singular use in cleansing old ulcers. if half a dram thereof be dissolv'd in a pint of lime-water, it gives a yellow tincture; and this is that which is call'd the _phagedonick-water_. the sweet sublimate, of which the _panacæa_ is immediately compos'd, is made with sixteen ounces of corrosive sublimate, pulveriz'd in a marble or glass-mortar, intermixing with it by little and little, twelve ounces of _mercury_ reviv'd from cinnabar: let this mixture be stirr'd about with a wooden pestle, till the quick-silver become imperceptible; then put the powder, which will be of a grey colour, into divers glass-vials, or into a matras, of which two third parts remain empty; place your vessel on the sand, and kindle a small fire in the beginning, the heat of which may be afterward encreas'd to the third degree: let it continue in this condition till the sublimate be made; and the operation will be generally consummated {178} in four or five hours: whereupon you may break your vial, and throw away as useless, a little light earth that lies at the bottom. you must also separate that which sticks to the neck of the vials, or of the matras, and keep it for ointments against the itch; but carefully gather together the white matter which lies in the middle, and having pulveriz'd it, cause it to be sublimated in the vials or matras, as before. this matter must also be separated again (as we have already shown) and put into other vials to be sublimated a third time. lastly, the terrestrial parts in the bottom, and the fuliginous in the neck of the vials, must be, in like manner, separated, still preserving the sublimate in the middle, which will then be very well dulcify'd, and amount to the quantity of twenty five ounces and an half: it is an efficacious remedy for all sorts of venereal diseases; removes obstructions, kills worms, and purgeth gently by stool, being taken in pills from six grains to thirty. _of the proper composition of the _mercurial panacæa_._ take what quantity you please of sweet sublimate, reduce it to powder in a marble or glass-mortar, and put it into a matras, three quarters whereof remain empty, and of which you have cut off the neck in {179} the middle of its height: then place this matras in a furnace or _balneum_ of sand, and make a little fire underneath for an hour, to give a gentle heat to the matter, which may be augmented by little and little to the third degree: let it continue in this state about five hours, and the matter will be sublimated within that space of time. then let the vessel cool, and break it, throwing away as unprofitable a little light sort of earth, of a reddish colour, which is found at the bottom, and separating all the sublimate from the glass. afterward pulverize it a second time, and let it be sublimated in a matras, as before: thus the sublimations must be reiterated seven several times, changing the matrasses every time, and casting away the light earth. then having reduc'd your sublimate to a very fine impalpable powder, by grinding it upon a porphyry or marble stone, put it into a glass cucurbite or gourd, pour into it alkaliz'd spirit of wine to the height of four fingers; cover the cucurbite with its head, and leave the matter in infusion during fifteen days, stirring it about from time to time with an ivory _spatula_. afterward set your cucurbite in _balneo mariæ_, or in a vaporous bath, make fit a recipient to the mouth of the alembick; lute the joints exactly with a moistened bladder, and cause all the spirit of wine to be destill'd with a moderate fire: let the vessels be cool'd, and unluted, and the _panacæa_ will appear at the bottom of the cucurbite. if it be not {180} already dry enough, you may dry it up with a gentle fire in the sand, stirring it with an ivory or wooden _spatula_ in the cucurbite it self till it be reduc'd to powder. it may be kept for use in a glass-vessel, as a remedy of very great efficacy for all sorts of venereal diseases, as also for obstructions, the scurvy, _scrophula_ or kings-evil, tettar, scab, scurf, worms, _ascarides,_ inveterate ulcers, _&c._ the dose is from six grains to two scruples, in conserve of roses. * * * * * {181} a treatise of the diseases of the bones. * * * * * chap. i. _of the dislocation of the bones._ _what are the diseases incident to the bones?_ they are five in number, _viz._ dislocation, fracture, _caries_ or ulcer, _exostosis_, and _nodus_. _what is a dislocation or luxation?_ it is the starting of the head of one bone out of the cavity of another, with an {182} interdiction of the proper motion of the part: or else it is the disjointing of two bones united together for the motion of a part. _how many causes are there of dislocation in general?_ two, that is to say, one violent, and the other gentle; thus the dislocation is made violently in falls, strains, knocks, and blows; but it is done gently and slowly in defluctions of rheum; as also by an insensible gathering together of humours between the joints, and upon the ligaments, the relaxation or loosening of which gives occasion afterward to the head of the bone to go out of its place; whence this consequence may well be drawn, _viz._ that a violent dislocation usually depends upon an external cause, and a gentle dislocation upon an internal. _after how many manners doth a dislocation happen?_ two several ways; _viz._ the first is called compleat, total, and perfect; and the second incompleat, partial, and imperfect: but both may happen before, behind, on the inside, and without; and may also be simple or complicated. _what are the signs of a perfect, total, and compleat dislocation?_ it is when a hard tumour or swelling is perceiv'd near a hole in the place of the joint, great pain being felt in the part, and the motion of it abolish'd. _what are the signs of an imperfect, partial, and incompleat dislocation?_ {183} it is when the motion is streighten'd, and weaker than ordinary, so that some pain is felt in the joynt, and a deformity may be discern'd therein, by comparing the hurt part with the opposite which is found: this dislocation is otherwise call'd a sprain, when it proceeds from an external cause; or else it is termed a relaxation, when it happens by an internal. _what is a simple, and what is a complicated dislocation or luxation?_ the dislocation is properly simple, when it hath no concomitant accidents; and it is complicated when accompany'd with some ill symptoms or accidents, such as swellings, inflammations, wounds, fractures, &c. _what are the means proper to be us'd in a simple dislocation?_ a speedy and simple reducing thereof, which is perform'd by stretching out the dislocated or luxated member, and thrusting back the head of the bone into its natural place. afterward the joynt must be strengthen'd with a fomentation made with provence roses, the leaves of wormwood, rosemary, camomile, st. _john_'s-wort, and oak-moss boil'd in the lees of wine and forge-water, keeping the part well bound up, and sustain'd in a convenient situation. but if any ill consequence is to be fear'd, apply _emplastrum oxycroceum_, or _diapalma_ dissolv'd in wine. _what is to be done in a complicated dislocation?_ {184} the accidents must be first remov'd, and then the bone may be set, which is impossible to be done otherwise; it being dangerous even to make an attempt before, by reason of the too great violence with which it is effected, and which would infallibly produce a convulsion or a gangrene. _if the dislocation be accompany'd with a wound, must the wound be cur'd before any endeavours are us'd to reduce it?_ no, but the symptoms of the wound, which hinder the operation, must be taken away, as the swelling, inflammation, and others of the like nature; and then it may be reduc'd, and the wound may be dress'd according to the usual method. _if the dislocation be complicated with the fracture, what is to be done then?_ it is necessary to begin with reducing of the dislocation, and afterward to perform that of the fracture, by reason of the extension which must be made to reduce the dislocation, which would absolutely hinder the setling of the fracture. _how is the inflammation and swelling to be asswag'd?_ with linnen cloaths dipt in brandy and common water, which must be often renew'd; or else with the tops of wormwood and camomile, with sage and rosemary boil'd in the lees of wine, wherein the bolsters and bands are to be steep'd. but all repercussives and astringents must be avoided. _how doth it appear that the reduction is well perform'd?_ {185} by the re-establishment of the part in its natural state; by its being free from pain; by its regular motion; and by its conformity to the opposite part which is found. _what dislocations of parts are most difficult to be reduc'd?_ they are those of the thighs with the huckle-bones, which are almost never perfectly set; that of the first _vertebra's_ is extremely difficult to be reduc'd; and those of the lower-jaw and soles of the feet are mortal. the reducing of dislocations is perform'd with greater facility in infants than in persons advanc'd in years; but it becomes most difficult when it is deferr'd for many days, by reason of the overflowing of the _lympha_ and nutritious juice. if an inflammation shou'd happen before the member is reduc'd, nothing can be done till it be allay'd, as we have already intimated; but to prevent and mitigate it, the dislocated joynt, and the neighbouring parts, may be bath'd with luke-warm wine, in which hath been boil'd the tops of st. _john_'s-wort, camomile, rosemary, _stoecas arabica_, and other ingredients of the like nature; the bands must be also steept in the same liquor. if an _oedematous_ tumour arise in the luxated member after the joint hath been set, it is requisite to take internal sudorificks, and to apply liniments made with the destill'd oil of tartar, and of human bones, which may be rectify'd with burnt hart's horn, or some other part of animals, to take away its stink: or else take yellow-wax, and very white rosin, {186} melt the whole mass, and put into it white amber and gum _elemi_, a sufficient quantity of each to make a composition to be incorporated with balsam of _peru_; a plaister of which may be prepar'd, and apply'd to the dislocated member; but the plaister must not be laid a cross, lest it shou'd contract the part too much. the whole member may be also anointed with oil of st. _john_'s-wort, or with the destill'd oil of turpentine; or rather with a simple decoction of nervous plants in wine. if the bone be put out of its place by a coagulated sort of matter like mortar or plaister, resolutives and attenuants are to be us'd, such as the volatile spirit of tartar prepar'd with the lees of wine, volatile spirit of tartar destill'd with nitre in a retort with a long neck, or spirit of tartar prepar'd by fermentation with tartar, and its proper _alkali_: this last is the best of all, and the use thereof ought to be continu'd. the volatile salt of human bones is also very efficacious; but it is necessary to begin first with the taking of laxative and sudorifick medicines, appropriated according to the respective circumstances. the spirit of earth-worms may be also apply'd outwardly, which is made by fermentation, and may be often laid on the part either alone, or with the spirit of _sal ammoniack_. if a dislocated bone be not set in good time, a _coagulum_ or kind of curdled substance is form'd in the cavity, which hinders the reducing of it to its place; but this _coagulum_ may be dissolv'd with the following medicament, before you attempt to set the bone. take one {187} part of the destill'd oil of human bones, two parts of foetid oil of tartar; mingle the whole, and add quick lime to be destill'd in a retort: let the parts be fomented with this oil. if the dislocation happen'd by the relaxation of the ligaments, recourse may be had to universal sudorificks taken inwardly; as also to such medicines as are full of an unctuous and volatile salt, particularly aromatick oils, and spirit of _sal ammoniack_. in the mean while aromaticks, resolutives, and moderate astringents may be apply'd outwardly. * * * * * chap. ii. _of the fractures of bones._ _what is the fracture of a bone?_ it is the division of the continuity of its parts. _after how many different manners may a bone be broken?_ three several ways, _viz._ cross-wise, side-wise, in its length, and perhaps in shatters or splinters. _by what means may a bone be fractured?_ it may happen to be done by three sorts of instruments, _viz._ such as are fit for bruising, cutting, or wresting; that is to say, a bone may be divided in the continuity of its proper parts, by contusion, incision, or contorsion. _how is the fracture of a bone discover'd?_ {188} divers ways, _viz._ by the ill disposition of the part, which becomes shorter; by its want of motion; by its flexibility or pliantness elsewhere than in its articulations; by the unevenness that may be perceiv'd in its continuity; by the cracking which is heard; sometimes also by the shooting forth of one of its ends thro' the flesh which it hath open'd; and lastly by a comparison made thereof with the sound part on the other side, as that of the right arm with the left. _what kind of fracture is most difficult to be discern'd?_ it is that which happens in the length of the bone, commonly call'd a cleft or fissure, which gives occasion to very great symptoms when it is unknown: but it may be found out by the pain and swelling felt at the bottom of the cleft in touching it; besides the conjectures which may be made from the relation of the person who hath had a fall, and might have heard the cracking of the bone. _what sort of fracture is most difficult to be cur'd?_ the shattering or splitting of a bone in pieces, by reason of the great number of splints which daily cause new pains and suppurations. _what is a simple and what is a complicated fracture?_ the simple fracture is that whereby the bone is broken, without any other accident; and the complicated fracture is that which is follow'd by some accident; as that in which there is a splitting of the bone in pieces, or {189} where the bone is broken in two several places, or else when the fracture is accompany'd with a luxation, a wound, an inflammation, or other circumstances of the like nature. _are old men or children most subject to these fractures of the bones?_ old men, because their bones are drier; whereas those of infants are almost cartilaginous, and yield or give way to the violence offer'd to 'em; from whence proceed the sinkings and hollowness that happen in their skulls, especially in the mould of their heads, or elsewhere; for which a remedy is found out by the means of plaisters, splints, and bandages, fitted to the shape of the parts. it is also on the same account that bones are more easily broken in the winter than in the summer. _in what parts are the fractures of bones most dangerous?_ they are those that happen in the skull and joints; in the former by reason of the brain; and in the latter in regard of the nervous parts. _what course is to be taken by a surgeon who is sent for to cure a fracture?_ he ought to do three things, that is to say, at first he must incessantly endeavour to reduce it, to the end that nature may re-unite the parts with greater facility, and that its extremities may be brought together again with less trouble, before a swelling, inflammation, or gangrene happen in the part. afterward he is to use means to retain the parts in their proper figure, and {190} natural situation, and to prevent all sorts of accidents. _how is the setting of a broken bone to be perform'd?_ when the fracture is cross-wise, it must be reduc'd by extension and contra-extension; and when it is in length, the coaptation or bringing together again of the sides, is only necessary. _what is to be done in a fracture complicated with a wound?_ the operator must first reduce it, and then administer the other helps, as in a simple fracture. _how may it be known that the reducing of the fracture is well perform'd?_ when the pain ceaseth; when the part hath resum'd its natural shape; when no unevenness is any longer perceiv'd therein; and when it is conformable to the sound part on the other side. _what are the signs which shew that the splints remain in the fracture after it hath been reduc'd?_ they are the secret and continual workings of the fibres, or twitchings, that are felt by intervals in the part, with great pains, which are the indications of an abcess arising therein; and when a wound is join'd to the fracture, the lips of it are puff'd up, and become more soft and pale, the purulent matter abounding also more than ordinary. _when the splints appear, must they be drawn out by force?_ {191} by no means; for great care ought to be taken to avoid all manner of violent operations; it being requisite to wait for their going out with the purulent matter; or at most to facilitate their passage by the use of injections of the tincture of myrrh and aloes; by the application of _emplastrum andreæ crucii_, and by the help of the _forceps_. _how is a simple fracture to be dress'd, after it hath been reduc'd?_ the parts are to be strengthen'd and consolidated with liniments of _oleum lumbricorum_, or of oil of st. _john_'s-wort mingled with wine, brandy, or _aqua-vitæ;_ with fomentations of red roses, rosemary, and st. _john_'s-wort boil'd in wine; and with _emplastrum contra rupturam_, or _de betonica_, carefully wrapping up the broken member, but after such a manner that the two extremities may not cross one another; and that a small space may remain open between both. afterward the splints and bands are to be apply'd, taking care to avoid binding 'em too hard, and to take 'em off every three days, in order to refit 'em, to abate troublesome itchings, and to give air to the part; by these means preventing the gangrene, which might happen by the suffocation of the natural heat. if the thighs or legs are broken, scarves are to be us'd to support and stay 'em in the bed. _what space of time may there be allow'd for curing the fracture of a bone?_ the cure will take up more or less time, according to the variety of the parts, or the different thickness of the bones: thus to form {192} the _callus_ of the broken jaw-bone, twenty days may well be allotted; for that of the clavicle, or that of the shoulder-bone, twenty four; for that of the bones of the elbow, thirty; for that of the arm-bone, forty; for that of the wrist-bone, and those of the fingers, twenty; for that of the ribs, twenty; for that of the thigh-bone, fifty; for that of the leg-bone, forty; for that of the bones of the _tarsus_ and toes, twenty. _what ought to be done in particular to promote the formation of the _callus_?_ the fractur'd part must be rubb'd with _oleum lumbricorum_ and spirit of wine heated and mingled together: the decoctions of agrimony, sayine, and saxifrage are also to be us'd, and the _lapis osteocolla_ is a specifick: it is usually given in great comphrey-water, or in a decoction of perewinkle made with wine, and is often re-iterated. * * * * * chap. iii. _of the particular fractures of the skull._ _what is a fracture of the_ cranium _or skull?_ it is a wound of the head complicated with a fracture of the skull-bone. _after how many manners may the skull be fractur'd?_ {193} three several ways, _viz._ by contusion, by incision, and by puncture. _what is the most dangerous of these fractures?_ it is that which happens by contusion; because the concussion and commotion is greater. _do all the fractures of the skull require the use of the trepan?_ no, the fractures must be deep which stand in need of the help of such an instrument; for those that are superficial may be cur'd by a simple exfoliation. _what is that deep fracture, wherein the use of the trepan is absolutely necessary?_ it is that which is made in the two tables of the skull, penetrating to the _meninges_ of the brain; upon which at that time the blood is diffus'd, and must be taken away by the operation of the trepan. _how may it be discover'd that the two tables of the skull are broken?_ by the eyes, and by ratiocination. _are not the eyes sufficient alone, and are they not more certain than ratiocination?_ yes; but forasmuch as things are not always seen, there is often a necessity of making use of rational deductions to find out that which the eyes cannot discern. _when doth it happen that the eyes alone discover the fracture?_ when the wound is large and wide, so that it may be immediately view'd. _when doth it happen that ratiocination supplies the defect of the eyes?_ {194} when the wound is so small that the bone cannot be seen, and nothing appears but the accidents. _what are the accidents or signs of the fracture of the skull?_ they are a dimmness of the sight, and loss of the understanding, which happen at the very moment when the fall or blow is receiv'd; with the phlegmatick vomittings that follow soon after: these signs are call'd _univocal_. and there are others that bear the name of _equivocal_, and which confirm the former; as a flux of blood thro' the nose, eyes, and ears, redness of the eyes, heaviness of the head, and puffing up of the face; as also afterward drowsiness, shivering of the whole body, fever, _deliriums_, convulsions, _&c._ _must all these signs appear before a determination can be made of the necessity of using the trepan?_ no, it is sufficient to have the univocal signs to make a crucial incision in the place of the wound, and to lay bare the bone, in order to observe the fracture, which sometimes is so fine, that the operator is oblig'd to make use of ink, which insinuates it self into the cleft, and of a particular instrument, with which the black line that hath penetrated to the bottom, cannot be rubb'd out; whereas it may be easily defac'd when the fracture is only superficial. _how long time is commonly spent before the appearing of the accidents?_ in the summer season they appear in three or four days, and at the latest in seven; in winter {195} they are slower, and sometimes do not happen till the fourteenth day: but at the end of this term, it may be affirm'd that the trepan is often unprofitable. _what is requisite to be done in a doubtful occasion; must the trepan be apply'd or omitted?_ the surgeon is to have recourse to his own conscientious discretion, which ought to serve as a guide, and requires that we should always act according to the known rules of art; insomuch that after having well consider'd the accidents, with all the circumstances of the wound, if there be no good grounds for the undertaking of the operation, it is expedient to desist, and in this case to have deference to the advice of other able surgeons of the same society, rather than to rely too much upon his own judgment, to the end that he may be always secure from all manner of blame. _is the trepan apply'd upon the fracture?_ no; but on one side of it, and always in a firm place. _what course is to be taken when a fracture is found in a suture?_ a double trepan is to be made, and apply'd on each side of the suture, by reason of the overflowing of the blood, which may happen therein. _what method ought to be observ'd in the curing of the wounds of the head, and fractures of the skull?_ in simple wounds of the head, it is necessary only to make use of balsams, and to lay over 'em _emplastrum de betonica_. when there is a contusion either in the {196} _pericranium_, or in the skull, the wound must be kept open till after the suppuration or exfoliation. when there is only a bunch without any wound or accident, it must speedily be dissolv'd with plaister or mortar, chimney-soot, oil of olives, and wine, laid upon the part between two linnen-rags; or else with soot, spirit of wine, and oil of st. _john_'s-wort, wherein the bolsters are soakt, to be in like manner apply'd with a band. wounds of the head accompany'd with a fracture, absolutely require the application of the trepan, wherein it is requisite to make use of oil of turpentine to be dropt upon the membrane of the brain; or else spirit of wine mingled with oil of almonds, and not with the oil or syrrup of roses; and to endeavour to cause a plentiful outward suppuration. besides, it must not be neglected to enjoyn the wounded person to be let blood both before and after the operation, if he hath a fever or a plethory; and more especially it is to be remember'd to cause his body to be kept open at least every other day, with clysters, obliging him to keep a good diet, and to avoid all violent agitations both of body and mind, abstaining from eating flesh till the fourteenth day. all manner of venery and conjugal embraces, which prove fatal at this time, are to be prohibited during forty days, to be counted from the day of the operation; as they are also in all other considerable wounds. * * * * * {197} chap. iv. _of the _caries_ or ulcer of the bones, _exostosis_, and _nodus_._ _what is_ caries? it is the putrifaction of the substance of the bone, or else its ulcer or gangrene. _whence doth the _caries_ of the bone derive its original?_ it proceeds from an internal and external cause; the former being that which hath been produc'd at first in the substance of the bone; and the other that which takes its rise from an inveterate ulcer in the flesh, which hath communicated its malignity to the substance of the bone, and by that means corrupted it. _how is the _caries_ known which proceeds from an inward cause?_ by the continual and violent pains which are felt before, and continue for a long time without diminution; as also afterward by the alteration of the flesh that covers the bone, and which becomes soft, spongy, and livid. _by what means is a _caries_ that derives its origine from an outward cause, discover'd?_ by the quality of the purulent matter that issueth out of the ulcer in the flesh, which is blackish, unctuous, and extremely stinking; as also by the help of the probe, that discovereth {198} asperity or roughness in the bone when it is laid bare. _what means are to be us'd in order to cure a _caries_ proceeding from an external cause?_ the powder of flower-de-luce may be us'd, and it is sufficient for that purpose, when the _caries_ is superficial; but it is necessary to take _oleum guyaci_, and to soak bolsters therein, to be laid upon the ulcer when it is deep; or else _aqua-vitæ_ or brandy, in which have been infus'd the roots of flower-de-luce, cinnamon, and cloves. lastly, the actual cautery, which is fire, must be apply'd thereto. _what is to be done when the _caries_ proceeds from an internal cause?_ the flesh must be open'd to give passage to the _sanies_ that runs out of the ulcerated bone, to the end that exfoliation may be procur'd; and if the ulcer hath not as yet laid open the bone on the outside, the trepan ought to be apply'd; but the ulcer or _caries_ must be afterward handled, as we have even now declar'd. _what is _exostosis_?_ it is the swelling of a bone made by the settling of a corrupt humour in its proper substance. _what is _nodus_?_ it is a kind of gummy and wavering tumour, which is form'd by the settling of a gross humour between the bone and the _periosteum_. _are _exostoses_ and _nodus_'s suppurable tumours?_ yes, because they sometimes produce ulcers and gangrenes in the bone, which are call'd {199} _caries_, proceeding from an internal cause; nevertheless they are generally dissolv'd by frictions with _unguentum griseum_, or by the application of plaisters of tobacco, or _emplastrum de vigo quadruplicato mercurio_; taking also to the same purpose internal diaphoretick and sudorifick medicines, with convenient purgatives. * * * * * chap. v. _of cauteries, vesicatories, setons, cupping-glasses, and leeches._ _what is a vesicatory?_ the name of vesicatory may be attributed to every thing that is capable of raising bladders or blisters in the skin; nevertheless in surgery, by a vesicatory is understood a medicament prepar'd with _cantharides_ or _spanish_ flies dried, which are beaten to powder, and mingled with turpentine, plaisters, leaven, and other ingredients. _in what places, and after what manner are vesicatories usually apply'd?_ they are apply'd every where, accordingly as there is occasion to draw out or discharge some humour from a part: in defluxions of rheum upon the eyes or teeth, they are laid on the neck and temples; in apoplexies, behind the ears; and so of the rest, observing always to make frictions on the places where the {200} application is to be made, to the end that the vesicatory may sooner take effect. _how long time must the vesicatory continue on the part?_ the blisters are generally rais'd by 'em within the space of five or six hours; yet this operation depends more or less upon the fineness of the skin; and when the bladders or blisters appear, it is requisite to deferr the openning of 'em for some time, to the end that nature may have an opportunity to introduce a new scarf-skin, by which means the pain may be avoided that would be felt, if the skin were too much expos'd to the air. _what is a cautery?_ it is a composition made of many ingredients, which corrode, burn, and make an escar on the part to which they are apply'd. _how many sorts of cauteries are there in general?_ there are two kinds, _viz._ the actual and the potential; the former are those that have an immediate operation; as fire, or a red-hot iron; and the others are those that produce the same effect, but in a longer space of time; such are the ordinary cauteries compos'd of caustick medicaments. _which are the most safe, the actual or the potential cauteries?_ a distinction is to be made herein; for actual cauteries are safest in the operation, because they may be apply'd wheresoever one shall think fit, as also for as long a time, or for any purpose: whereas the potential cannot be {201} guided after the same manner. but in hæmorrhages the potential cauteries are most eligible, by reason that the escar produc'd by 'em not being so speedily form'd, the vessels are better clos'd, and they are not so subject to open again when it falls off; as it often happens in the fall of an escar made by fire. _in what places are cauteries usually apply'd?_ in all places where an attraction is to be made, or an intemperature to be corrected, or a flux of humours to be stopt, by inducing an escar on the part: however they are commonly laid upon the nape of the neck, between the first and second _vertebra_; on the outward part of the arm in a small hole between the muscle _deltoides_ and the _biceps_; above the thigh, between the muscle _sartor_, and the _vastus internus_; and on the inside of the knee, below the flexors of the leg; observing every where that the cautery be plac'd near the great vessels, to the end that it may draw out and cleanse more abundantly. _what is the composition of the potential cauteries?_ they may be made with quick lime, soap, and chimney-soot; or else take an ounce of _sal ammoniack_, two ounces of burnt _roman_ vitriol, three ounces of quick lime, and as many of calcin'd tartar; mingle the whole mass together in a _lixivium_ of bean-cod ashes, and cause it to evaporate gently to a consistence: let this paste be kept for use in a dry place, and in a well-stopt vessel. or else the silver-cautery, or _lapis infernalis_ may be prepar'd after the following manner: {202} take what quantity you please of silver, let it be dissolv'd with thrice as much spirit of nitre in a vial, and set the vial upon the sand-fire, to the end that two third parts of its moisture may evaporate: then pour the rest scalding-hot into a good crucible, plac'd over a gentle fire, and the ebullition being made, the heat of the fire must be augmented, till the matter sink to the bottom, which will become as it were an oil: afterward pour it into a somewhat thick and hot mould, and it will coagulate, so as to be fit for use, if it be kept in a well-stopt vial. this cautery is the best; and an ounce of silver will yield one ounce and five drams of _lapis infernalis_. _what is a seton?_ it is a string of silk, thread, or cotton, threaded thro' a kind of pack-needle, with which the skin of a part is to be pierc'd thro', to make an ulcer therein, that hath almost the same effect as a cautery. _what is most remarkable in the application of a seton?_ it ought to be observ'd, that the string must be dipt in oil of roses, and that one end of it must always be kept longer than the other, to facilitate the running of the humours. _in what parts is the seton to be apply'd?_ the nape of the neck is the usual place of its application, altho' it may be made in any part of the body where it is necessary. it sometimes happens that a surgeon is oblig'd to use a kind of seton in such wounds made with a sword, or by gun-shot, as pass quite {203} thro' from one side to the other; then the string or skain must be dipt in convenient ointments or medicinal compositions; and as often as the dressings are taken away, it will be requisite to cut off the part soakt in the purulent matter, which must be taken out of the ulcer. _what is a cupping-glass?_ it is a vessel or kind of vial, made with glass, the bottom whereof is somewhat broader than the top, which is apply'd to the skin to cause an attraction. there are two sorts of these cupping-glasses, _viz_, the dry, and the wet; the former are those that are laid upon the skin without opening it; and the latter those that are apply'd with scarification. _in what diseases are cupping-glasses us'd?_ in all kinds where it is necessary to make any attraction; but more especially in apoplexies, vapours in women, palsies, and other distempers of the like nature. but the applications of cupping-glasses are altogether different; for in apoplexes they are generally set upon the shoulders or upon the _coccyx_; in vapours upon the inside of the thighs; and in palsies upon the paralytick part it self. _what is a leech?_ it is an animal like a little worm which sucks the blood, and is commonly apply'd to children and weak persons, to serve instead of phlebotomy: leeches are also us'd for the discharging of a defluxion of humours in any part; as also in the hæmorrhoidal veins when they are too full; in the _varices_ and in several parts of the face. {204} _what choice ought to be made of leeches?_ it is requisite to take those that have their backs greenish, and their bellies red; as also to seek for 'em in a clear running stream, and to cast away those that are black and hairy. * * * * * chap. vi. _of phlebotomy._ _what is phlebotomy?_ it is an evacuation of blood procur'd by the artificial incision of a vein or artery, with a design to restore health. _which are the vessels that are open'd in phlebotomy or blood-letting?_ they are in general all the veins and arteries of the body, nevertheless some of 'em are more especially appropriated to this operation; as the _vena præparata_ in the forehead; the _ranulæ_ under the tongue; the jugular veins and arteries in the neck; the temporal arteries in the temples; the _cephalick_, _median_, and _basilick_ veins in the inside of the elbow; the _salvatella_ between the ring-finger and the little-finger; the _poplitæa_ in the ham; the _saphena_ in the internal _malleolus_ or ankle; and the _ischiatica_ in the external. _what are the conditions requisite in the due performing of the operation of phlebotomy?_ they are these, _viz._ to make choice of a proper vessel; not to open any at all adventures; not to let blood without necessity, nor {205} without the advice of a physician; whose office it is to determine the seasons or times convenient for that purpose; as that of intermission in an intermitting fever; that of cooling in the summer; and that of noon-tide in the winter; and lastly, to take away different quantities of blood; for in the heat of summer they ought to be lesser, and greater in the winter. _what are the accidents of phlebotomy?_ they are an impostume, a _rhombus_, an _echymosis_, an _aneurism_, lipothymy, swooning, and a convulsion. _what is a _rhombus_?_ it is a small tumour of the blood which happens in the place where the operation is perform'd either by making the orifice too small, or larger than the capaciousness of the vessel will admit. the _rhombus_ is cur'd by laying upon it a bolster dipt in fair water, between the folds of which must be put a little salt, to dissolve and prevent the suppuration. _how may it be perceiv'd that an artery hath been prickt or open'd in letting blood?_ the puncture of an artery produceth an aneurism; and the opening of it causeth a flux of vermilion colour'd blood, which issueth forth in abundance, and by leaps. _are the leaps which the blood makes in running, a certain sign that it comes from an artery?_ no, because it may so happen, that the _basilick_ vein lies directly upon an artery, the beating of which may cause the blood of the {206} _basilica_ to run out leaping: therefore these three circumstances ought to be consider'd jointly, that is to say, the vermilion colour, the great quantity and the leaps, in order to be assur'd that the blood proceeds from an artery. _how may it be discover'd that a tendon hath been hurt in letting blood?_ it is known when in opening the _median_ vein, the end of the lancet hath met with some resistance; when the patient hath felt great pain, and afterward when the tendon apparently begins to be puff'd up, and the arm to swell. a remedy may be apply'd to this accident thus; after having finish'd the operation, a bolster steep'd in _oxycratum_ is to be laid upon the vessel, a proper bandage is to be made, and the arm must be wrapt up in a scarf: if the inflammation that ariseth in the part be follow'd with suppuration, it must be dress'd with a small tent; and if the suppuration be considerable, it is necessary to dilate the wound, and to make use of oil of eggs and brandy, or _arcæus_'s liniment, with a good digestive; as also to apply _emplastrum ceratum_; to make an embrocation on the arm with oil of roses; and to dip the bolsters in _oxycratum_ to cover the whole part. _is it not to be fear'd that some nerve may be wounded in letting blood?_ no, they lie so deep that they cannot be touch'd. _under what vein is the artery of the arm?_ it is usually situated under the _basilica_. {207} _what course is proper to be taken to avoid the puncture of an artery in letting blood?_ it must be felt with the hand before the ligature is made, observing well whether it be deep or superficial; for when it lies deep, there is nothing to be fear'd; and when it is superficial, it may be easily avoided by pricking the vein either higher or lower. _what is to be done when an artery is open'd?_ if it be well open'd, it is requisite to let the blood run out till the person falls into a _syncope_ or swoon, by which means the aneurism is prevented; and afterward the blood will be more easily stopt: it remains only to make a good bandage with many bolsters, in the first of which is simply put a counter or a piece of money; but a bit of paper chew'd will serve much better, with bolsters laid upon it in several folds. _if the arteries cause so much trouble when open'd accidentally, why are those of the temples sometimes open'd on purpose, to asswage violent pains in the head?_ by reason that in this place the arteries are situated upon the bones that press 'em behind; which very much facilitates their re-union. _are not the arteries of persons advanc'd in years more difficult to be clos'd than those of children?_ yes. {208} _are there not accidents to be fear'd in letting blood in the foot?_ much less than in the arm; because the veins of the _malleoli_ or ankles are not accompany'd either with arteries or tendons; which gave occasion to the saying, _that the arm must be given to be let blood only to an able surgeon, but the foot may be afforded to a young practitioner_. * * * * * {209} a treatise of _chirurgical operations_. * * * * * chap. i. _of the operation of the trepan._ this operation is to be perform'd, when it is inferr'd from the signs of which we have already given a particular account, that some matter is diffus'd over the _dura mater_. the trepan must not be us'd in the _sinus superciliares_, by reason of their cavity; nor in the sutures, in regard of the vessels that pass thro' 'em; nor in the temporal bone without great necessity, especially in that part of it which is join'd to the parietal-bone, lest the end of this bone shou'd fly out of its place, since it is only laid upon the parietal; nor in the middle of the coronal and occipital-bones, by reason of an inner {210} prominence wherein they adhere to the _dura mater_; nor in the passage of the lateral _sinus's_ that are situated on the side of the occipital. if the fissure be very small, the trepan may be apply'd upon it, altho' it is more expedient to use this instrument on the side of the fissure in the lower part; neither is the trepan to be set upon the sinkings; and if the bones are loosen'd or separated, there needs no other trepanning than to take 'em away with the elevatory. the operation must be begun with incision, which is usually made in form of a cross, if the wound be remote from the sutures, and there are no muscles to be cut, and in the shape of the letter t. or of the figure 7. if it be near the sutures, so that the foot of the 7. or of the t. ought to be parallel to the suture, the top of the letter descending toward the temples; it is also made in the middle of the forehead. if it be sufficient to make a longitudinal incision in the forehead; its wrinkles may be follow'd, and there will be less deformity in the scar; but it is never done crosswise in this part, and the lips of the wound are not to be cut. if an incision be made on the muscle _crotaphites_, and on those of the back-part of the head, it may be done in form of the letter v. the point of which will stand at the bottom of the muscles; nevertheless it is more convenient to make a longitudinal incision, by which means fewer fibres will be cut; and it is always requisite to begin at the lower part, to avoid being hindred by the hæmorrhage. {211} the incisions are to be made with the incision-knife, and that too boldly when there are no sinkings; but if there be any, too much weight must not be laid upon 'em: thus the incision being finish'd, the lips of the skull are to be separated either with the fingers, or some convenient instrument; then if there be no urgent occasion to apply the trepan, it may be deferr'd till the next day, the wound being dress'd in the mean time with plaisters, bolsters, pledgets, and a large kerchief or upper dressing, the use of which we shall shew hereafter. the operation is begun with the perforative, to make a little hole for the fixing of the pyramid or pin which is in the round; afterward the round is to be apply'd, holding the handle of the trepan with the left-hand, and turning with the other very fast in the beginning; but when the round hath made its way, it is lifted up to remove the pin, lest this point shou'd hurt the _dura mater_: thus the round being taken off from time to time, to be cleans'd from the filings that stick thereto, is set on again, and the operator begins his work of turning anew, which must be carry'd on gently when any blood appears, to the end that the first table of the piece of bone which is remov'd may not fly from the second: when it comes near the _dura mater_, the operator must proceed, in like manner, gently, searching with a feather round about the bone, to observe whether he still continueth his course in the skull. he must also often lift up the trepan to search the hole, to cleanse the instrument, and to keep {212} it from growing hot. as often as the trepan is taken off, let him search with a feather, to see whether the bone be cut equally; and if it be not, he must lean more on that side which is least cut. if it be necessary to make use of the _terebella_, the hole must be made in the beginning, whilst the bone is as yet firm; and when the piece begins to move, the _terebella_ is to be put very gently into its hole, without pressing the bone, to draw it out; or else it may be taken away with the myrtle-leaf, which is an instrument made of a firm silver-plate somewhat crooked. when the piece is thus remov'd, the uneven parts that remain at the bottom of the hole, are to be cut with the _lenticula_; and if there be any sinkings, they may be rais'd with the elevatory. whereupon the _dura mater_ may be compress'd a little with the _lenticula_, to facilitate the running out of the blood, the wounded person being oblig'd to stoop with his head downward, stopping his nose and mouth, and holding his breath for a while, to cause the matter to run out: then the _dura mater_ may be wip'd with lint; but if any _pus_ or corrupt matter lies underneath, it must be pierc'd with a lancet wrapt up in a tent, that it may not be perceiv'd by the assistants. afterward a _sindon_ or very fine linnen rag dipt in a proper medicament, is put between the _dura mater_ and the skull; the hole is fill'd with small bolsters steept in convenient medicinal liquors; and the wound is dress'd with pledgets, a plaister, and a kerchief. {213} but the hole ought to be well stopt with bolsters, because the _dura mater_ is sometimes so much inflam'd, that it bursts forth; so that if any excrescences arise therein, and go out of the hole, having small roots, they may be bound and cut; but if their roots be large, they must be press'd close with little bolsters steept in spirituous medicines. here it may not be improper to observe, that the operation of the trepan ought to be perform'd more gently in children than in adult persons, in regard that their bones are more tender, and that oily medicines must not be us'd, but spirituous. the exfoliation is made sometimes sooner, and sometimes later; but the _callus_ usually covers the opening of the skull within the space of forty or fifty days, if no ill accident happens. in great fractures, where there is no longer any connexion between the bones, it is requisite to take 'em away. _of the bandage of the trepan._ the proper bandage to be us'd after the operation of the trepan, is the great kerchief, which is a large napkin folded into two parts after such a manner that the side which toucheth the head exceeds that which doth not touch it in the breadth of four fingers; it is apply'd to the head in the middle, whilst a servant holds the dressing with his hand: then the two upper ends of the napkin being brought under chin, the surgeon takes the two lower, and draws 'em streight by the sides, so as that side the napkin, which is four fingers broader {214} than the other, may be laid upon the forehead: afterward the two ends of the napkin are cross'd behind the head, and fasten'd at their extremities with pins, without making any folds, that might hurt the part; but the ends of the napkin which fall upon the shoulders, are rais'd up to the head near the lesser corner of the eyes; and the two ends under the chin are fasten'd with pins, or else tied in a knot. * * * * * chap. ii. _of the operation of the _fistula lachrymalis_._ this operation is perform'd when there is a fistulous ulcer in the great corner of the eye, after this manner: the patient being plac'd in a convenient posture, and having his sound eye bound up, to take away the sight of the instruments; the operator causeth the other eye to be kept steady with a bolster held with an instrument, and makes an incision with a lancet in form of a crescent upon the tumour, taking care to avoid cutting the eye-lid and the little cartilage which serves as a pulley to the great oblique muscle. if the bone be putrify'd with a _caries_, an actual cautery may be apply'd thereto, using for that purpose a small funnel or tube, thro' the canal of which the cautery is convey'd to the bone. {215} but the bone must not be pierc'd, for it is exfoliated entire by reason of its smallness; and so the hole is made without any perforation. _the dressing and bandage of the _fistula lachrymalis_._ the wound is fill'd with small dry pledgets, and cover'd with a plaister and bolster: the bandage is made with an handkerchief folded triangular-wise, the ends of which are fasten'd behind the head. if the flesh grows too fast, it may be consum'd with the _lapis infernalis_; and if there be occasion to dilate the wound, to facilitate the exfoliation, it may be done with little pieces of spunge prepar'd, and put into it. afterward causticks are to be us'd, to eat away the callous parts, which may be mingled with oily medicines, to weaken their action, taking care, nevertheless, that the eye receive no dammage by 'em. if the bone be corrupted, a little _euphorbium_ may be apply'd; or else the small pledgets steept in the tincture of myrrh and aloes; then the ulcer may be handled as all others. * * * * * {216} chap. iii. _of the operation of the _cataract_._ this operation is perform'd when there is a small body before the apple of the eye, which hinders the sight from entring into it; but it is undertaken only in blew, green, and pearl-colour'd cataracts, or in those that are of the colour of polish'd steel; and not in yellow, black, or lead-colour'd. to know whether the cataract be fit to be couch'd, the patient's eye must be rubb'd; so that if the cataract remains unmoveable, it is mature enough; but if it changeth its place, it is requisite to wait till it become more solid. the spring and autumn are the most proper seasons for performing the operation. to this purpose the patient being set down with his eyes turn'd toward the light, and having his sound eye bound up, the surgeon must likewise sit on a higher seat, whilst the patient's head is held by a servant; and his eye being turn'd toward his nose, is kept steady with a _speculum oculi_, which is a little iron-instrument made like a spoon, pierc'd in the middle, so that the ball of the eye may be let thro' this hole: then the surgeon taking a steel-needle either round or flat, accordingly as he shall judge convenient, perforates the conjunctive at the end of the corneous tunicle, on the side of the little corner of the {217} eye, and boldly thrusts his needle into the middle of the cataract, which he at first pusheth upward, to loosen it with the point of the needle; and then downward, holding it for some time with his needle below the apple of the eye. if it ascend again after it is let go, it must be depress'd a second time; but the operation is finish'd when it remains in the same place whereto it was thrust; neither is the needle to be remov'd till this be done, and the cataract entirely couch'd. in taking out the needle, the eye-lid must be pull'd down, and press'd a little over the eye. _the dressing and bandage,_ is to cause both the patient's eyes to be clos'd and bound up; then he must be oblig'd to keep his bed during seven or eight days, and some defensative is to be laid upon the sore eye, to hinder the inflammation. m. _dupré_, surgeon to the hospital of _hôtel-dieu_ at _paris_, a person well vers'd in these kinds of operations, hath observ'd, that after the same manner as cataracts were form'd in a very little space of time in perfect maturity; it happen'd also very often, that the cataracts which were suppos'd to have got up again, were not the very same with those that were couch'd, but rather a new _pellicula_ or little skin, which sometimes hath its origine in the top of the _uveous_ tunicle, and is caus'd only by a very considerable relaxation of the excretory vessels from the sources of the aqueous humour which in filtrating permits the running {218} of many heterogeneous parts, the encrease of which produceth a new cataract. _of other operations in the eyes._ sometimes a sort of purulent matter is gather'd together under the corneous tunicle; so that to draw it out, the eye must be fixt in a posture with the _speculum oculi_, and after a small incision made therein with a fine lancet, is to be press'd a little, to let out the matter; but if it be too thick, it may be drawn forth by sucking gently with a small tube or pipe, having a little vial in the middle, into which the matter will fall as it is suck'd out. sometimes a small tumour ariseth in the eye, which being ty'd at its root with a slip-knot, to streighten it from time to time, will at length be dissolv'd: but if the tumour lie in the hole of the apple of the eye, this operation must not be admitted, lest the scar shou'd hinder the passage of the light. sometimes also a somewhat hard membrane, call'd _unguis_, appears in the great corner of the eye, which when it sticks thereto, may be cut off by binding it; this is done with a needle and thread, which is pass'd thro' the membrane, and afterward ty'd. if the eye-lids are glu'd together, a crooked needle without a point may be threaded, and pass'd underneath 'em; then the ends of the thread may be drawn, to lift up the eye-lids, and they may be separated with a lancet. {219} if the hairs of the eye-lids or eye-brows offend the eye, they must be pull'd out with a pair of tweezers or nippers; and when any small, hard, and transparent tumours arise in the eye-lids, they are to be open'd, to let out the corrupt matter. * * * * * chap. iv. _of the operation of the _polypus_._ this operation is necessary, when there are any excrescences of flesh in the nostrils, which, nevertheless, when they are livid, stinking, hard, painful, and sticking very close, must not be tamper'd with, because they are cancers. but if they are whitish, red, hanging, and free from pain, the cure may be undertaken after this manner: take hold of the _polypus_ with a pair of _forceps_, as near its root as is possible, and turn 'em first on one side, and then on another, till it be pull'd off. if the _polypus_ descends into the throat, it may be drawn thro' the mouth with crooked _forceps_; and if an hæmorrhage shou'd happen after the operation, it may be stopt by thrusting up into the nostrils certain tents soakt in some styptick liquor; or else by syringing with the same liquor. * * * * * {220} chap. v. _of the operation of the _hare-lip_._ this operation is perform'd when the upper-lip is cleft; but if there be a great loss of substance, it must not be undertaken; neither ought it to be practis'd upon old nor scorbutick persons, nor upon young children, by reason that their continual crying wou'd hinder the re-union. but if any are desirous that it shou'd be done to these last, they are to be kept from taking any rest for a long time, to the end that they may fall a-sleep after the operation, which is thus effected: if the lip sticks to the gums, it is to be separated with an incision-knife, without hurting 'em; then the hare-lip must be cut a little about the edges with sizzers, that it may more easily re-unite, the edges being held for that purpose with a pair of pincers, whilst the servant who supports the patient's head, presseth his cheeks before, to draw together the sides of the hare-lip: whereupon the operator passeth a needle with wax'd thread, into the two sides of the wound, from the outside to the inside at a thread's distance from each. but care must be had that the two lips of the hare-lip be well adjusted, and very even; the thread being twisted round the needle by crossing it above. {221} _the dressing and bandage._ after the lips are wash'd with warm wine, the points of the needles must be cut off, small bolsters being laid under their ends; then the wound is to be dress'd with a little pledget cover'd with some proper balsam, putting at the same time under the gum a linnen rag steep'd in some desiccative liquor, lest the lip shou'd stick to the gum, if it be necessary to keep 'em a-part. lastly, upon the whole is to be laid an agglutinative plaister, supported with the uniting bandage, which is a small band perforated in the middle; it is laid behind the head, and afterward drawn forward, one of its ends being let into the hole which lies upon the sore: then the two ends of the band are turn'd behind the head upon the same folds where they are fasten'd, sticking therein a certain number of pins, proportionably to the length of the wound. the patient must be dress'd three days after; and it is requisite at the first time only to untwist half the needle, loosening the middle thread if there be three; to which purpose a servant is to thrust the cheeks somewhat forward. on the eighth day the middle needle may be taken off, if it be a young infant; nevertheless the needles must not be remov'd till it appears that the sides are well join'd; neither must they be left too long, because the holes wou'd scarce be brought to close. * * * * * {222} chap. vi. _of the operation of _bronchotomy_._ this operation becomes necessary, when the inflammation that happens in the _larynx_ hinders respiration, and is perform'd after this manner: the wind-pipe is open'd between the third and fourth ring, above the muscle _cricoides_, or else in the middle of the wind-pipe; but in separating the muscles call'd _sternohyodei_, care must be had to avoid cutting the recurrent nerves, lest the voice shou'd be lost; as also the glandules nam'd _thyroides_. the space between the rings is to be open'd with a streight lancet, kept steady with a little band, and a transverse incision is to be made between 'em: before the lancet is taken out, a stilet is put into the opening, thro' which passeth a little pipe, short, flat, and somewhat crooked at the end, which must not be thrust in too far, for fear of exciting a cough. this pipe hath two small rings for the fastening of ribbans, which are ty'd round about the neck; and it must be left in the wound till the symptoms cease. afterward it is taken away, and the wound is dress'd, the lips of it being drawn together again with the uniting bandage, which hath been already describ'd. * * * * * {223} chap. vii. _of the operation of the _uvula_._ when the _uvula_ or palate of the mouth is swell'd so as to hinder respiration or swallowing, or else is fallen into a gangrene, it may be extirpated thus: the tongue being first depress'd with an instrument call'd _speculum oris_, the palate is held with a _forceps_, or cut with a pair of sizzers; or else a ligature may be made before it is cut; and the mouth may be afterward gargl'd with astringent liquors. * * * * * chap. viii. _of the operation of a cancer in the breast._ the cancer at first is not so big as a pea, being a small, hard, blackish swelling, sometimes livid, and very troublesome by reason of its prickings; but when it is encreas'd, the tumour appears hard, lead-colour'd, and livid, causing in the beginning a pain that may be pretty well endur'd, but in the increase it grows intolerable, and the stink is extremely noisome. when it is ready to ulcerate, the heat is vehement, with a pricking pulsation; and the veins round about are turgid, being {224} fill'd with black blood, and extended as it were the feet of a crab or crey-fish, till death happen. when this tumour is not ulcerated, it is call'd an _occult cancer_; and an _apparent_ one when it breaks forth into an open ulcer. to palliate an occult cancer, and prevent its ulceration, a cataplasm or pultis of hemlock very fresh may be apply'd to the part. all the kinds of succory, the decoction of _solanum_ or night-shade; the juices of these plants, as also those of scabious, _geranium_ or stork-bill, _herniaria_ or rupture-wort, plantain, _&c._ are very good in the beginning. river-crabs pounded in a leaden-mortar, and their juice beaten in a like mortar, are an excellent remedy; as also are humane excrements or urine destill'd, and laid upon the occult cancer: or else, take an ounce of calcin'd lead, two ounces of oil of roses, and six drams of saffron; let the whole composition be beaten in a mortar with a leaden pestle, and apply'd. the amalgama of _mercury_ with _saturn_ is likewise a very efficacious remedy. in the mean while the patient may be purg'd with black hellebore and _mercurius dulcis_, taking also inwardly from one scruple to half a dram of the powder of adders, given to drink, with half the quantity of crab's-eyes: but very great care must be taken to avoid the application of maturatives or emollients, which wou'd certainly bring the tumour to ulceration. {225} when the cancer is already ulcerated, the spirit of chimney-soot may be us'd with good success; and the oil of sea-crabs pour'd scalding hot into the ulcer, is an excellent remedy. but if it be judg'd expedient entirely to extirpate the cancer, it may be done thus: the sick patient being laid in bed, the surgeon takes the arm on the side of the cancer, and lifts it upward and backward, to give more room to the tumour; then having pass'd a needle with a very strong thread thro' the bottom of the breast, he cuts the thread to take away the needle, and passeth the needle again into the breast, to cause the threads to cross one another. afterward these four ends of the threads are ty'd together, to make a kind of handle to take off the tumour, which is cut quite round to the ribs with a very sharp rasor. the cutting is usually begun in the lower part to end in the vessels near the arm-pit, where a small piece of flesh is left, to stop the blood with greater facility: then having laid a piece of vitriol upon the vessels, or bolsters soakt in styptick water; the sides of the breast are to be press'd with the hand, to let out the blood and humours; and an actual cautery is to be lightly apply'd thereto. _the dressing._ the wound is to be dress'd with pledgets strew'd with astringent powders, a plaister, a bolster, a napkin round the brest, and a scapulary to support the whole bandage. {226} but instead of passing threads cross-wise, to form a handle, with which the breast may be taken off, it wou'd be more expedient to make use of a sort of _forceps_ turn'd at both ends in form of a crescent, after such a manner that those ends may fall one upon another when the _forceps_ are shut. thus the surgeon may lay hold on the breast with these _forceps_, and draw it off, after having cut it at one single stroak with a very flat, crooked, and sharp knife. neither is it convenient to apply the actual cautery to stop the hæmorrhage, because it is apt to break forth again anew, when the escar is fall'n off, when the tumour is not as yet ulcerated, a crucial incision may be made in the skin, without penetrating into the glandulous bodies; then the four pieces of the glandules being separated, the cancerous tumour may be held with the _forceps_, and afterward cut off. if there be any vessels swell'd, they may be bound before the tumour is taken away; but if the tumour sticks close to the ribs, the operation is not usually undertaken. * * * * * {227} chap. ix. _of the operation of the _empyema_._ this operation is perform'd when it may be reasonably concluded that some corrupt matter is lodg'd in the breast, which may be perceiv'd by the weight that the patient feels in fetching his breath; being also sensible of the floating of the matter when he turns himself from one side to another. if the tumour appears on the outside, the abcess may be open'd between the ribs; but if no external signs are discern'd, the surgeon may choose a more convenient place to make the opening. thus when the patient is set upon his bed, and conveniently supported, the opening is to be made between the second and third of the spurious ribs, within four fingers breadth of the spine, and the lower corner of the _omoplata_; to this purpose the skin is to be taken up a-cross, to cut it in its length, the surgeon holding it on one side, and the assistant on the other. the incision is made with a streight knife two or three fingers breadth long, and the fibres of the great dorsal-muscle are cut a-cross, that they may not stop the opening. then the surgeon puts the fore-finger of his left-hand into the incision, to remove the fibres, and divides the intercostal muscles, guiding the point of the knife with his finger to pierce the _pleuron_, for fear of wounding {228} the lungs, which sometimes adhere thereto, the opening being thus finish'd, if the matter runs well, it must be taken out; but if not, the fore-finger must be put into the wound, to disjoyn those parts of the lungs that stick to the _pleuron_. to let out the matter, the patient must be oblig'd to lean on one side, stopping his mouth and nose, and puffing up his cheeks, as if he were to blow vehemently; then if blood appears, a greater quantity of it may be taken away than if it were matter, in regard that a flux of matter weakens more than that of blood. it is also worth the while to observe, that in making the incision, the intercostal muscles ought to be cut a-cross, that the side of the ribs may not be laid bare, by which means the wound will not so soon become fistulous. if it be judg'd that purulent matter is contain'd in both sides of the breast, it is requisite that the operation be done on each side; it being well known that the breast is divided into two parts by the _mediastinum_: but in this case the two holes made by the incision must not be left open at the same time, for fear of suffocating the patient. _the dressing and bandage._ the wound is dress'd with a tent of lint arm'd with balsam, being soft, and blunt at the end, which enters only between the ribs, for fear of hurting the lungs; but a good pledget of lint is more convenient than a linnen {229} tent, however a thread must be ty'd to the pledget or tent, lest it shou'd fall into the breast; and bolsters are to be put into the wound; as also a plaister or band over the whole. this dressing is to be kept close with a napkin fasten'd round the breast with pins, and supported by a scapulary, which is a sort of band, the breadth of which is equal to that of six fingers, having a hole in the middle to let in the head: one of its ends falls behind and the other before; and they are both fasten'd to the napkin. thus the patient is laid in bed, and set half upright. if the lungs hinder the running out of the matter, a pipe is us'd, and the wound afterward dress'd according to art. * * * * * chap. x. _of the operation of the _paracentesis_ of the lower-belly._ this manual operation is sometimes necessary in a dropsie, when watry humours are contain'd in the cavity of the belly, or else between the teguments. the disease is manifest by the great swelling; and the operation is perform'd with a cane, or a pipe made of silver or steel, with a sharp stilet at the end; altho' the ancients were wont to do it with a lancet. the patient being supported, sitting on a bed, or in a great elbow-chair, to the end that the water may run downward, {230} a servant must press the belly with his hands, that the tumour may be extended, whilst the surgeon perforates it three or four fingers breadth below the navel, and makes the puncture on the side, to avoid the white-line; but before the opening is made, it is expedient that the skin be a little lifted up. the pointed stilet being accompany'd with its pipe, remains in the part after the puncture; but it is remov'd to let out the water; and a convenient quantity of it is taken away, accordingly as the strength of the patient will admit. the stilet makes so small an opening, that it is not to be fear'd lest the water shou'd run out, which might happen in making use of the lancet, because there wou'd be occasion for a thicker pipe. when a new puncture is requisite, it must be begun beneath the former; but if the waters cause the navel to stand out, the opening may be made therein, without seeking for any other place. _the bandage and dressing_ are prepar'd with a large four-double bolster kept close with a napkin folded into three or four folds, which is in like manner supported by the scapulary. _the operation of the _paracentesis_ of the _scrotum__ is undertaken when those parts are full of water, after this manner: assoon as the patient is plac'd in a convenient posture, either {231} standing or sitting, the operator lays hold on the _scrotum_ with one hand, presseth it a little to render the tumour hard, and makes a puncture, as in the _paracentesis_ of the _abdomen_. in an _hydrocele_ that happens to young infants, the opening may be made with a lancet, to take away all the water at once: but in men, especially when there is a great quantity thereof, it is more expedient to do it with the sharp-pointed pipe; but the testicles are to be drawn back, for fear of wounding 'em with the point of the instrument. if the _hydrocele_ be apparently _encysted_, the membrane containing the water is to be consum'd with causticks, which is done by laying a cautery in the place where the incision shou'd be made, and afterward opening the escar with a lancet. when the puncture is made, it ought to be done in the upper-part of the _scrotum_, because it is less painful than the lower, and less subject to inflammation. * * * * * chap xi. _of the operation of _gastroraphy_._ this operation is usually perform'd when there is a wound in the belly so wide as to let out the entrails. if there be a considerable wound in the intestine, it may be sow'd up with the glover's stitch, the manner of making which we have before explain'd. if {232} the _omentum_ or caul be mortify'd, the corrupted part must be cut off; to which purpose it is requisite to take a needle with waxed thread, and to pass it into the sound part a-cross the caul, without pricking the vessels. then the caul being ty'd on both sides with each of the threads that have been pass'd double, may be cut an inch below the ligature, and the threads will go thro' the wound, so as to be taken away after the suppuration. afterward the intestines are to be put up again into the belly, by thrusting 'em alternately with the end of the fingers. but if they cannot be restor'd to their proper place without much difficulty, spirituous fomentations may be made with an handful of the flowers of camomile and melilot, an ounce of anise, with as much fennel and cummin-seeds; half an ounce of cloves and nutmegs: let the whole mass be boil'd in milk, adding an ounce of camphirated spirit of wine, and two drams of _saccharum saturni_, with two scruples of oil of anise, and bathe the entrails with this fomentation very hot. otherwise, apply animals cut open alive; or else boil skeins of raw thread in milk, and foment 'em with this decoction in like manner very hot. before the suture of stitching of the intestines is made, it is expedient to foment 'em with spirit of wine, in which a little camphire hath been dissolv'd: but if they be mortify'd, they must not be sown up again, but fomented with spirituous liquors. no clysters are to be given to the patient, for fear {233} causing the intestine to swell; but a suppository may be apply'd: or else he may make use of a laxative diet-drink, if it be necessary to open his body: he ought also to be very temperate and abstemious during the cure, so as to take no other sustenance than broths and gellies. if the intestines cannot be put up again, the wound is to be dilated, avoiding the white-line, and that too at the bottom rather than at the top, if it be above. to this purpose the intestines are to be rank'd along the side of the wound, and a bolster is to be laid upon 'em dipt in warm wine, which may be held by some assistant. then the surgeon introduceth a channel'd probe into the belly, and takes a great deal of care to fix the intestine between the probe and the _peritonæum_, which may be effected by drawing out the intestine a little; then holding the probe with his left-hand, to fit a crooked incision-knife in its chanelling, he cuts the teguments equally both on the outside and within, and thrusts back the entrails alternately into the wound with his fore-finger. the stitch must be intermitted, being made with two crooked needles threaded at each end with the same thread. the surgeon having at first put the fore-finger of his left-hand into the belly, to retain the _peritonæum_, muscles, and skin on the side of the wound, passeth the needle with his other hand into the belly, the point of which is guided with the fore-finger, and penetrates very far: then he likewise passeth the other {234} needle thro' the other lip of the wound into the belly, observing the same thing as in the former, and without taking his fingers off from the belly. if there are many points or stitches to be made, they may be done after the same manner, without removing the fingers from the part, whilst a servant draws together the lips of the wound, and ties the knots. afterward the wound may be dress'd, and the preparatives or dressings kept close to the part with the napkin and scapulary. but the patient must be oblig'd to lie on his belly for some days successively, to cicatrize the wound thereof, or that of the entrails. if the intestine were entirely cut, it wou'd be requisite to sow it up round about the wound, after such a manner that some part of it may always remain open; for if the patient shou'd recover, his excrements might be voided thro' the wound; of which accident we have an example in a soldier belonging to the hospital _des invalides_ at _paris_, who liv'd a long time in this condition. * * * * * chap. xii. _of the operation of the _exomphalus_._ this operation is necessary when the intestines or entrails have made a kind of rupture in the navel, and may be perform'd thus: when the patient is laid upon his back, an incision is to be made on the tumour to {235} the fat, by griping the skin, if it be possible, or else it may be done without taking it up. then the membranes are to be divided with a fleam to lay open the _peritonæum_, for fear of cutting the intestine; and as soon as the _peritonæum_ appears, it may be drawn upward with the nails, in order to make a small opening therein with some cutting instrument: whereupon the surgeon having put the fore-finger of his left-hand into the belly to guide the point of the sizzers, with which the incision is enlarg'd, restores the intestine to its proper place, and loosens the caul if it stick to the tumour: but if the entrails are fasten'd to the caul, it is requisite to separate 'em by cutting a little of the caul, rather than to touch the intestine; which last being reduc'd, a servant may press the belly on the side of the wound; so that if a mass of flesh be found in the caul, which hath been form'd by the sticking of the caul to the muscles and _peritonæum_, this fleshy mass must be entirely loosen'd, and then a ligature may be made to take it away, with some part of the caul, as we have already shewn in the _gastroraphy_. afterward the stitch is to be made, as in that operation, and the wound must be dress'd, observing the same precautions. the dressing is to be supported in like manner with the napkin and scapulary. * * * * * {236} chap. xiii. _of the operation of the_ bubonocele, _and of the compleat rupture._ when the intestinal parts are fall'n into the groin or the _scrotum_, the operation of the _bubonocele_ may be conveniently perform'd; to which purpose the patient is to be laid upon his back, with his buttocks somewhat high; then the skin being grip'd a-cross the tumour, the surgeon holds it on one side, and the assistant on the other, till he makes an incision, following the folds or wrinkles of the groin; when the fat appears, it is requisite to tear off either with a fleam or even with the nails, every thing that lies in the way, till the intestine be laid open, which must be drawn out a little, to see if it do not cleave to the rings of the muscles. the intestine must be gently handl'd, to dissolve the excrements; and those parts must be afterward put up again into the belly (if it be possible) with the two fore-fingers, thrusting 'em alternatively; but if they cannot be reduc'd, the wound is to be dilated upward, by introducing a channell'd probe into the belly, to let the sizzers into its channelling. if the probe cannot enter, the intestine must be taken out a little, laying a finger upon it near the ring, and making a small scarification in the ring, with a streight incision-knife guided with the {237} finger, to let in the probe, into which may be put a crooked knife, to cut the ring; that is to say, to dilate the wound on the inside; but care must be had to avoid penetrating too far, for fear of dividing a branch of arteries; and then the parts may be put up into the belly. if the caul had caus'd the rupture, it wou'd be requisite to bind it, and to cut off whatsoever is corrupted, scarifying the ring on the inside, to make a good cicatrice or scar. _the dressing and bandage._ the dressing may be prepar'd with a linnen-tent, soft and blunt, of a sufficient thickness and length, to hinder the intestines from re-entring into the rings by their impulsion, a thread being ty'd thereto, to draw it out as occasion serves. then pledgets are to be put into the wound, after they have been dipt in a good digestive, such as turpentine with the yolk of an egg, applying at the same time a plaister, a bolster of a triangular figure, and the bandage call'd _spica_, which is made much after the same manner as that which is us'd in the fracture of the clavicle. _of the compleat _hernia_ or rupture._ it happens when the intestinal parts fall into the _scrotum_ in men, or into the bottom of the lips of the _matrix_ in women. to perform this operation, the patient must be laid upon his back, as in the _bubonocele_, and the incision carry'd on after the same manner; which is to {238} be made in the _scrotum_, tearing off the membranes to the intestine. then a search will be requisite, to observe whether any parts stick to the testicle; if the caul doth so, it must be taken off, leaving a little piece on the testicle; but if it be the intestine, so that those parts cannot be separated without hurting one of 'em, it is more expedient to impair the testicle than the intestine. if the caul be corrupted, it must be cut to the sound part, and the wound is to be dress'd with pledgets, bolsters, and the bandage _spica_; as in the _bubonocele_. * * * * * chap. xiv. _of the operation of _castration_._ the mortification or the _sarcocele_ of the testicles, gives occasion to this operation; to perform which, the patient must be laid upon his back, with his buttocks higher than his head, his legs being kept open, and the skin of the _scrotum_ taken up, one end of which is to be held by a servant, and the other by the surgeon, who having made a longitudinal incision therein, or from the top to the bottom, slips off the flesh of the _dartos_ which covers the testicle, binds up the vessels that lie between the rings and the tumour, and cuts 'em off a fingers breadth beneath the ligature: but care must be taken to avoid tying the spermatick vessels too hard, for fear of a convulsion, and {239} to let one end of the thread pass without the wound. if an excrescence of flesh stick to the testicle, and it be moveable or loose, it is requisite to take it off neatly, leaving a small piece of it on the testicle; and if any considerable vessels appear in the tumour, they must be bound before they are cut. _the dressing and bandage._ the dressing is made with pledgets and bolsters laid upon the _scrotum_; and the proper bandage is the _suspensor_ of the _scrotum_, which hath four heads or ends, of which the upper serve as a cincture or girdle; and the lower passing between the thighs, and fasten'd behind to the cincture. there is also another bandage of the _scrotum_, having in like manner four heads, of which the upper constitute the cincture; but it is slit at the bottom, and hath no seams; the lower heads crossing one another, to pass between the thighs, and to be join'd to the cincture. both these sorts of bandages have a hole to give passage to the yard. * * * * * {240} chap. xv. _of the operation of the stone in the_ ureter. if the stone be stopt at the _sphincter_ of the bladder, it ought to be thrust back with a probe: if it stick at the end of the _glans_, it may be press'd to let it out; and if it cannot come forth, a small incision may be made in the opening of the _glans_ on its side. but if the stone be remote from the _glans_, it is requisite to make an incision into the _ureter_; to which purpose, the surgeon having caus'd the skin to be drawn upward, holds the yard between two fingers, making a longitudinal incision on its side upon the stone, which must be prest between the fingers to cause it to fly out; or else it may be taken out with an _extractor_. then if the incision were very small, the skin needs only to be let go, and it will heal of it self; but if it were large, a small leaden pipe is to be put into the _ureter_, lest it shou'd be altogether clos'd up by the scar: it is also expedient to anoint the pipe with some desiccative medicine, and to dress the wound with balsam. afterward a little linnen-bag or case is to be made, in which the yard is to be put, to keep on the dressing; but it must be pierc'd at the end, for the convenience of making water, having two bands at the other end, which are ty'd round about the waste. * * * * * {241} chap. xvi. _of the operation of _lithotomy_._ this operation is undertaken when it is certainly known that there is a stone in the bladder; to be assur'd of which, it may not be improper to introduce a finger into the _anus_ near the _os pubis_, by which means the stone is sometimes felt, if there be any: the finger is likewise usually put into the _anus_ of young virgins, and into the _vagina uteri_ of women, for the same purpose. but it is more expedient to make use of the probe, anointed with grease, after this manner: the patient being laid on his back, the operator holds the yard streight upward, the _glans_ lying open between his thumb and fore-finger; then holding the probe with his right-hand on the side of the rings, he guides it into the yard, and when it is enter'd, turns the handle toward the _pubes_, drawing out the yard a little, to the end that the canal of the _ureter_ may lie streight. if it be perceiv'd that the probe hath not as yet pass'd into the bladder, a finger is to be put into the _anus_, to conduct it thither. afterward in order to know whether a stone be lodg'd in the bladder, the probe ought to be shaken a little therein, first on the right-side, and then on the left; and if a small noise be heard, it may be concluded for certain that there is a stone: but if it be judg'd that the {242} stone swims in the bladder, so that it cannot be felt, the patient must be oblig'd to make water with a hollow probe. another manner of searching may be practis'd thus: let the yard be rais'd upward, inclining a little to the side of the belly; let the rings of the probe be turn'd upon the belly, and the end on the side of the _anus_; and then let this instrument be introduc'd, shaking it a little on both sides, to discover the stone. in order to perform the operation of lithotomy, the patient must be laid along upon a table of a convenient height, so as that the surgeon may go about his work standing; the patient's back must also lean upon the back of a chair laid down, and trimm'd with linnen-cloth, lest it shou'd hurt his body; his legs must be kept asunder, and the soles of his feet on the sides of the table, whilst a man gets up behind him to hold his shoulders: his arms and legs must be also bound with straps or bands. then a channell'd probe being put up into the bladder, a servant standing upon the table on the side of the chair, holds the back of the instrument between his two fore-fingers on that part of the _perinæum_ where the incision ought to be begun, which is to be made between his fingers with a sharp knife that cuts on both sides: the incision may be three or four fingers breadth on the left side of the _raphe_ or suture: but in children its length must not exceed two fingers breadth. if the incision were too little to give passage to the stone, it wou'd be more expedient to enlarge it than to stretch the wound {243} with the dilatators. when the convex part where the channelling of the probe lies, shall be well laid open, the conductors may be slipt into the same channelling, between which the _forceps_ is to be put, having before taken away the probe. some operators make use of a _gorgeret_ or introductor to that purpose, conveying the end of it into the chanelling of the probe; which is remov'd to introduce the _forceps_ into the bladder: and as soon as they are fixt therein, the conductors or _gorgeret_ must be likewise taken out. afterward search being made for the stone, it must be held fast, and drawn out of the bladder: but if the stone be long, and the operator hath got hold thereof by the two ends, he must endeavour to lay hold on it again by the middle, to avoid the great scattering which wou'd happen in the passage. the stones are also sometimes so large, that there is an absolute necessity of leaving 'em in the bladder. again, if the stone sticks very close to the bladder, the extraction ought to be deferr'd for some time; and perhaps it may be loosen'd in the suppuration. lastly, when the stone hath been taken out, an extractor is usually introduc'd into the bladder, to remove the gravel, fragments, and clots of blood. after the operation, the patient is carry'd to his bed, having before cover'd the wound with a good bolster; and if an hæmorrhage happens, it is to be stopt with astringents. a tent must also be put into the wound, when it is suspected that some stone or gravel may as yet remain therein: but if it evidently appears that {244} there is none, the wound may be dress'd with pledgets, a plaister, and a bolster, of a figure convenient for the part. the dressing may be staid with a sling supported by a scapulary; or else the bandage of the double t. may be us'd, the manner of the application of which we have shewn elsewhere. the patient's thighs must be drawn close to one another, and ty'd with a small band, lest they shou'd be set asunder again. the operation of lithotomy in women is usually perform'd by the lesser preparative, which is done by putting the fore-finger and middle-finger into the _vagina uteri_, or into the _rectum_ in young virgins, to draw the stone to the neck of the bladder, and keep it steady, so that it may be taken out with a hook, or other instrument. this operation may also be effected in women, almost in the same manner as in men; for after having caus'd the female patient to be set in the same posture or situation as the men are usually plac'd, according to the preceeding description, the conductors may be convey'd into the _ureter_, to let in the _forceps_ between 'em, with which the stone may be drawn out: but if it be too thick, a small incision is to be made in the right and left side of the _ureter_. the lesser preparative was formerly us'd in the lithotomy of men, after this manner: the finger was put into the _anus_, to draw the stone toward the _perinæum_; then an incision was made upon the stone on the side of the suture, and it was taken out with an instrument. * * * * * {245} chap. xvii. _of the operation of the puncture of the _perinæum_._ this operation is necessary in a suppression of urine, where the inflammation is so great, that the probe cannot be introduc'd. then an incision is to be made with the knife or lancet, in the same place where it is done in lithotomy; and a small tube or pipe is to be put in the bladder, till the inflammation be remov'd. * * * * * chap. xviii. _of the operation of the _fistula in ano_._ fistula's are callous ulcers: if one of these happen in the fundament, and is open on the outside, it may be cur'd thus: after the patient hath been laid upon his belly on the side of a bed, with his legs asunder, the surgeon makes a small incision with his knife in the orifice of the _fistula_, in order to pass therein another small crooked incision-knife, at the end of which is a pointed stilet with a little silver head which covers it, to the end that it may enter without causing pain. when the surgeon hath convey'd his knife into the {246} _fistula_, having the fore-finger of his left-hand in the _anus_ or fundament, he pulls off its head, holding the handle with one hand, and the stilet that pierceth the _anus_ with the other; and at last draws out the instrument to cut the _fistula_ entirely at one stroke. if the _fistula_ hath an opening into the intestine, an incision is to be made on the outside at the bottom thereof, to open it in the place where a small tumour or inflammation usually appears, or else in the place where the patient feels a pain when it is touch'd. if the tumour be remote from the _anus_, it may be open'd with the potential cautery, to avoid a greater inconvenience. after having thus laid open the very bottom, the little incision-knife and stilet, with its head, is to be pass'd therein, the end of the stilet is to be drawn thro' the _anus_, and the flesh is to be cut all at once. but if the _fistula_ be situated too far forward in the fundament, the _sphincter_ of the _anus_ must not be entirely cut, otherwise the excrements cannot be any longer retain'd. lastly, when the _fistula_ hath been treated after this manner, all its sinuosities or winding-passages ought likewise to be open'd, and the wound being fill'd with thick pledgets steept in some anodyn, is to be cover'd with a plaister and a triangular bolster; as also with the bandage call'd the t. * * * * * {247} chap. xix. _of the suture or stitching of a _tendon_._ it is requisite to undertake this operation when the tendons are cut, and when they become very thick. if the wound be heal'd, it must be open'd again to discover the tendon, and the part must be bended, to draw together again the ends of the tendons. then the surgeon taking a flat, streight, and fine needle, with a double waxed thread, passeth it into a small bolster, and makes a knot at the end of the thread, to be stopt upon the bolster. afterward he pierceth the tendon from the outside to the inside, at a good distance, lest the thread shou'd tear it, and proceeds to pass the needle in like manner under the other end of the tendon, upon which is laid a small bolster, for the thread to be ty'd in a knot over it. then he causeth the extremities of the tendons to lie a little one upon another, by bending the part, and dresseth the wound with some balsam. it may not be improper here to observe, that ointments are never to be apply'd to the tendons, which wou'd cause 'em to putrifie, but altogether spirituous medicaments; and that the part must be bound up, lest the extension of it shou'd separate the tendons. * * * * * {248} chap. xx. _of the _cæsarian_ operation._ when a woman cannot be deliver'd by the ordinary means, this bold and dangerous operation hath been sometimes perform'd with good success. the woman being laid upon her back, the surgeon makes a longitudinal incision beneath the navel, on the side of the white-line, till the _matrix_ appears, which he openeth, taking great care to avoid wounding the child: then he divides the membranes with which it is wrapt up, separates the after-burden from the _matrix_, and takes out the child. lastly he washeth the wound with warm wine, and dispatcheth the _gastroraphy_ or stitching up of the belly, without sowing the _matrix_. after the operation, injections are to be made into the _matrix_, to cause a flux of blood; and a pierc'd pessary must be introduc'd into its neck. * * * * * {249} chap. xxi. _of the operation of _amputation_, with its proper dressings and bandages._ the leg is usually cut off at the ham; the thigh as near as can be to the knee; and the arm as near as is possible to the wrist: but an amputation is never made in a joynt, except in the fingers and toes. in order to cut off a leg, the patient is to be set on the side of his bed, or in a chair, and supported by divers assistants; one of 'em being employ'd to hold the leg at the bottom, and another to draw the skin upward above the knee, to the end that the flesh may cover the bone again after the operation. in the mean while a very thick bolster is laid under the ham, upon which are made two ligatures, _viz._ the first above the knee, to stop the blood, by screwing it up with the _tourniquet_ or _gripe-stick_; and the second below the knee, to render the flesh firm for the knife. before the ligature is drawn close with the _gripe-stick_, a little piece of paste-board is to be put underneath, for fear of pinching the skin. thus the leg being well fixt, the surgeon placeth himself between both the legs of the patient, to make the incision with a crooked knife, turning it circularly to the bone, and laying one hand upon the back of the knife, which must have no edge. afterward the _periosteum_ is to be {250} scrap'd with an incision-knife, and the flesh with the vessels that lie between the two bones are to be cut. when the flesh is thus separated, a cleft band is to be laid upon it, with which the heads are cross'd, to draw the flesh upward, to the intent that the bones may be cut farther, and that it may cover 'em after the amputation, as also to facilitate the passage of the saw. then the surgeon holds the leg with his left-hand, and saweth with his right, which he lets fall upon the two bones, to divide 'em asunder at the same time, beginning with the _perone_ or _fibula_, and ending with the _tibia_. but it is necessary to incline the saw, and to go gently in the beginning, to make way for it, and afterward to work it faster. the leg being cut off, the ligature must be unty'd below the knee, loosening the _gripe-stick_, to let the blood run a little, and to discern the vessels with greater facility; and then the _gripe-stick_ may be twisted again, to stop the blood; which some surgeons effect, by laying pieces of vitriol upon the opening of the arteries, and astringent powders, on a large bolster of cotton or tow, to be apply'd to the end of the stump; but if such a method be us'd, it is requisite that some person be employ'd to keep on the whole dressing with his hand during twenty four hours. however this custom hath prevail'd in the hospital of _hôtel-dieu_ at _paris_. others make a ligature of the vessels, taking up the ends of 'em with a pair of _forceps_, having a spring; or with the _valet a patin_, which is a sort of pincers that are clos'd with a small {251} ring let down to the bottom of the branches. these pincers being held by a servant, the surgeon passeth a needle with wax'd thread, into the flesh, below the vessel, bringing it back again, and with the two ends of the thread makes a good ligature upon the same vessel; then he looseth the _gripe-stick_ and the band, the stump is to be somewhat bended, and the flesh let down to cover the bones. _the dressing and bandage._ after the operation, it is requisite to lay small bolsters upon the vessels, and dry pledgets upon the two bones, as also many other folds of linnen strew'd with astringent powders; and over all another large bolster or pledget of cotton or tow, cover'd in like manner with astringent powders; then the whole dressing is to be wrapt up with a plaister and a bolster, in form of a _malta_ cross; so that there are three or four longitudinal bolsters, and one circular. the surgeon usually begins to apply the _malta_ cross and bolster under the ham, crossing the heads or ends upon the stump, and causeth 'em to be held by a servant that supports the part; then he likewise crosseth the other heads, and layeth on the two longitudinal bolsters that cross each other in the middle of the stump, together with a third longitudinal, which is brought round about the stump, to stay the two former: these bolsters ought to be three fingers broad, and very long, to pass over the stump. afterward he proceeds to apply, {252} _the bandage commonly call'd _capeline_ by _french_ surgeons, or the head-bandage._ which is prepar'd with a band four ells long, and three fingers broad, roll'd up with one ball, three circumvolutions being made on the side of the cut part, the band is to be carry'd upward with rollers, passing obliquely above the knee; and is brought down again along its former turns; if it be thought fit to make this bandage with the same band, it must be let down to the middle of the cut part, and carry'd up again to the knee, many back-folds being made, which are stay'd with the circumvolutions, till the stump be entirely covered, and the whole bandage wrapt up with rollers or bolsters. the _capeline_ or head-bandage, having two heads, is made with a band of the same breadth, but somewhat longer. this band being at first apply'd to the middle of the cut part or wound, the heads are carry'd up above the knee; and one of the ends are turn'd backward, to bring it down, and to pass it over the end of the stump. at every back-fold which is form'd above and below the knee, a circumvolution is to be made with the other end of the band, to strengthen the back-folds, continuing to bring the band downward and upward, till the whole stump be cover'd: then rollers are made round about the stump, and the band is stay'd above the knee. afterward the part may be brought to suppuration, cleans'd and cicatriz'd. * * * * * {253} chap. xxii. _of the operation of the _aneurism_._ this operation is perform'd when the surgeon hath prickt an artery, or when a tumour ariseth in an artery. to this purpose the patient is set in a chair, and a servant employ'd in holding his arm in a posture proper for the operation; then a bolster is to be laid four double, following the progress of the artery, to the end that the ligature may better press the vessel; and the arm may be also surrounded with another single bolster, on which is made a ligature screw'd up with a _gripe-stick_, provided the arm be not too much swell'd; for in this case it wou'd be more expedient to deferr the operation for fear of a gangrene. the artery being thus well stopt, the surgeon lays hold on the arm with one hand, below the tumour, and with the other makes an incision with his lancet, beginning at the bottom of the tumour, and ending on the top along the progress of the artery. when the tumour is open'd, the coagulated blood may be discharg'd with a finger; and if there are any strings at the bottom, they may be cut with a crooked pair of sizzers, to the end that all the clods of blood, and other extraneous bodies which are sometimes form'd in _aneurisms_ when they are very inveterate may be more {254} easily remov'd. but the _gripe-stick_ must be loosen'd, to discover the opening of the artery with greater facility, and the artery separated from the membranes with a fleam; for it wou'd be dangerous to cut it with a streight incision-knife: the artery must also be supported with a convenient instrument to divide it from the nerve and membranes; and to be assur'd of the place of its opening, the _gripe-stick_ may be somewhat loosen'd, and afterward screw'd up again. in the mean time the surgeon gives the instrument to a servant to hold, whilst he passeth under the artery a crooked needle with a wax'd string, cuts the thread, and takes away the needle: then he begins to make the ligature beneath the opening of the artery, tying at first a single knot, on which may be put (if you please) a small bolster, that may be kept steady with two other knots: it is also necessary that another ligature be made in the lower part of the artery, by reason that the little lateral arteries might otherwise let out blood. the artery ought not to be cut between the two ligatures, lest the first ligature shou'd be forc'd by the impulsion of the blood; but the thread must be let fall, that it may rot with the suppuration. then the wound may be dress'd with pledgets, bolsters strew'd with astringent powders and a plaister; a bolster being also laid in the fold of the elbow. {255} _the bandage_ is made with a band six ells long, and an inch broad, roll'd with one end, being at first apply'd with divers circumvolutions under the elbow, and moderately bound. many turns are to be made, and a thick and streight bolster, is to be laid upon the tumour, (as in the bandage for phlebotomy) along the artery, till it pass under the arm-hole: the arm and bolster must be surrounded with the band, which is brought up with small rollers, to the arm-pit, and stay'd with circumvolutions round about the breast. afterward the patient is to be laid in his bed, with the arm lying somewhat bended on the pillow, and the hand a little higher than the elbow. * * * * * chap. xxiii. _of the operation of _phlebotomy_._ to perform this operation, the surgeon holds the lancet between his thumb and fore-finger, and three other fingers lying upon the patient's arm, and thrusts the point of the lancet into the vessel, carrying the same point somewhat upward, to make the orifice the greater. if a tendon, which is known by its hardness; or an artery, which is discover'd by pulsation, appear beyond the vein, and very near it, the lancet must be only set very {256} forward in the vein, and drawn back again streight, without turning it up, otherwise the artery or tendon wou'd be certainly cut with the point. if the artery or tendon lies immediately under the vein, the later must be prickt somewhat underneath, holding the lancet inclin'd side-ways, and thrusting it very little forward; so that the point will finish the opening, by turning it upward. if the artery stick too close to the vein, the later is to be prickt higher or lower than it is ordinarily done; and if the vein be superficial, and lie close upon a hard muscle, the lancet must not be thrust downright into the vein, but it is requisite to carry it somewhat obliquely, and to take the vessel above, lest the muscle and its membrane shou'd be prickt, which wou'd cause a great deal of pain, and perhaps a vehement inflammation. it is well known that the veins of the right arm are usually open'd with the right-hand, and those of the left-arm with the left-hand. _the bandage_ is made thus: the surgeon having laid a bolster upon the orifice, keeps it close with two fingers, and holds the band or fillet with the other hand; then taking one end of the fillet with the middle-finger, fore-finger, and thumb, and applying it to the bolster, he makes with the longest end of the fillet divers figures in form of the letters ky in the fold of the arm; as also a back-fold with the shorter end of the fillet, held between three {257} fingers. afterward both ends of the fillet are ty'd beneath the elbow. if an inflammation happens after the operation, the bolsters are to be dipt in _oxycratum_: but if the orifice were so small as to produce a _rhombus_, it wou'd be requisite to press the wound often with two fingers, and immediately to apply a bolster dipt in _oxycratum_. * * * * * chap. xxiv. _of the operation of _encysted tumours_._ if the tumours are small and hanging, and have a narrow bottom, a ligature may be made with horse-hair or silk, dipt in _aqua-fortis_, which will cause 'em to fall off of themselves after some time; or else they may be cut above the ligature. if the tumour or wen be thick, and its bottom large, a crucial incision is to be made in the skin, without impairing the _cystis_ or bagg; and when the incision is finish'd, the bag may be torn off with the nails, or with the handle of a pen-knife; but sometimes it is necessary to dissect it. if there be any considerable vessels at the root, they may be bound, or else cut; and the blood may be stopt with astringents. if any parts of the _cystis_ remain, they are to be consum'd with corrosives; and the lips of the wound are to be drawn together without a stitch, making use {258} only of an agglutinative plaister. but if the tumour adheres very close to the _pericranium_, it is most expedient not to meddle with it at all. _of _ganglions_._ _ganglions_ are tumours arising upon the tendons and nervous parts, which may be cur'd by thrusting 'em violently, and making a very streight bandage, provided they be very recent; a resolvent plaister is to be also apply'd to the part. * * * * * chap. xxv. _of the operation of the _hydrocephalus_._ this operation is perform'd when it is necessary to discharge watry humours out of the head: if these waters lie under the skin, a very large opening is to be made with a lancet, and a small tube or pipe left therein to let 'em run out. if the water be situated between the brain and the _dura mater_, the membrane is to be perforated with a lancet, after the trepan hath been apply'd, according to the usual method, of which we have already given some account: cauteries and scarifications may be also us'd to very good purpose in this disease. * * * * * {259} chap. xxvi. _of the operation of cutting the tongue-string._ when the ligament of the tongue in infants is extended to its extremity, they cannot suck without difficulty; and when grown up, they have an impediment in their speech. this ligament may be cut with a little pair of sizzers; to which purpose the thumb of the left-hand being laid upon the gum of the lower jaw, to keep the mouth open, the tongue may be rais'd upward with the fore-finger of the same hand, and the sizzers may be pass'd between the two fingers, to divide the string as near as is possible to the root of the tongue, avoiding the vessels: if an hæmorrhage happens, recourse may be had to styptick-waters. afterward the nurse must take care to let a finger be often put into the child's mouth, to prevent the re-uniting of the string. * * * * * {260} chap. xxvii. _of the operation of opening stopt _ductus_'s._ if there be only one membrane that stops the entrance of the _vagina_, an incision may be made, and a leaden pipe put into it, having rings to fasten it to the waste, to hinder the re-uniting of the wound. if the lips of the _pudendum_ are conglutinated or clos'd up, the patient must be laid upon her back, and her knees rais'd up, in order to make an incision with a crooked incision-knife, beginning at the top; and then a leaden pipe is to be put into the opening. if the _vagina_ be fill'd with a fleshy substance, an incision is to be made therein, till it be entirely perforated, putting at the same time a leaden tube into the orifice. if the urinary _ductus_ as well in young boys as in virgins, be stopt up, an incision is to be made therein with a very narrow lancet; and if a small leaden pipe can be conveniently introduc'd, it may be done; but it is not very necessary, in regard that children are almost always making water, which wou'd of it self hinder the closing of the orifice. if the _ductus_ of the ear be stopt with a membrane, it must be perforated, taking care not to go too far, for fear of piercing the membrane of the _tympanum_ or drum, and {261} a small leaden pipe is to be put into the opening. if there be a carnous excrescence on the outside of the ear, a ligature ought to be made therein, or else it may be cut with a pair of sizzers, to cause it to fall off; and the rest of the fleshy substance that remains in the ear must be consum'd with causticks, convey'd to the part by the means of a small tube, care being had, nevertheless, to avoid cauterizing the _tympanum_. * * * * * chap. xxviii. _of the operation of the _phimosis_ and _paraphimosis_._ when the _præputium_ is so streight that the _glans_ can be no longer uncover'd, this indisposition is call'd _phimosis_; but if the _præputium_ be turn'd back above the _glans_, after such a manner that it can no longer cover the same _glans_, it is a _paraphimosis_. if in the _phimosis_ the _præputium_ cleaves very close round about the _glans_, it is most expedient to let it alone; but if in handling the _glans_ it be perceiv'd that it is moveable, or else that some parts of it only stick together, the operation may be perform'd after this manner: the patient being set in a chair, a servant is employ'd in pulling back the skin to the root of the _penis_, to the end that the incision may be {262} made directly at the bottom of the _glans_: then the surgeon having drawn out the bottom of the _præputium_, introduceth a small instrument with a very sharp point on its flat side, at the end of which is fixt a button of wax, pierceth the _præputium_ at the bottom of the _glans_ on the side of the thread, and finisheth the incision by drawing the instrument toward himself. the _paraphimosis_ is cur'd by making fomentations on the part, to allay the inflammation if there be any; and it is to be pull'd down with the fingers. but if medicinal preparations prove ineffectual, scarifications are to be made round about the _præputium_; and afterward convenient remedies may be apply'd to remove the inflammation, and prevent the mortification of the part; so that at length the _præputium_ may be drawn over the _glans_. * * * * * chap. xxix. _of the operation of the _varix_._ in order to cure this tumour, the surgeon having first cut the skin to discover the dilated vein, separates it from the membranes, and passeth underneath a crooked needle with a double wax'd thread; then he makes a ligature both above and below the dilatation of the vein, opens the dilated part with a lancet, to let out the blood, and applies a convenient bandage: but without performing this {263} operation, the vein might be open'd with a lancet, to draw out a sufficient quantity of blood; and then the _varix_ is to be press'd with a somewhat close bandage. * * * * * chap. xxx. _of the operation of the _panaritium_._ the _panaritium_ is an abcess which ariseth at the end of the fingers; some of these tumours are only superficial, and others penetrate even under the _periosteum_; nevertheless after whatsoever manner the _panaritium_ may happen, it ought to be open'd on the side of the finger, that the tendons may not be hurt. if the abcess be extended under the _periosteum_, the opening must be made on the side, and the lancet thrust forward to the bone: afterward the _pus_ or corrupt matter is to be discharg'd, which wou'd cause the tendons to putrifie, if it shou'd remain too long upon 'em. _the dressing and bandage_ are made with a plaister cut in form of a _malta_ cross, which is apply'd at the middle to the end of the finger, the heads being cross'd round about. the bolsters must be also cut in the shape of the _malta_ cross, or of a plain cross only; the band being a finger's breadth {264} wide, and long enough to be roll'd about the whole dressing: it must be pierc'd at one of its ends, and cut the length of three fingers at the other; so that the two heads may pass thro' the hole, to surround the finger with small rollers. * * * * * chap. xxxi. _of the reduction of the falling of the _anus_._ to reduce the _anus_ to its proper place when it is fallen, the patient being laid upon his belly, with his buttocks higher than his head, the operator gently thrusts back the roll that forms the _anus_ with his fingers dipt in the oil of roses: then he applies the bolsters steept in some astringent liquor, and causeth 'em to be supported with a sort of bandage, the nature of which we shall shew in treating of the fracture of the _coccyx_, that is to say, the t. the double t. or else the sling with four heads. * * * * * {265} chap. xxxii. _of the reduction of the falling of the _matrix_._ in this operation, the patient being laid upon her back, with her buttocks rais'd up, fomentations are to be apply'd to the part; a linnen cloth is to be laid upon the neck of the fallen _matrix_; and it is to be thrust very gently with the fingers, without using much force. if the _matrix_ shou'd fall out again, it wou'd be requisite to convey a pessary into it, after it hath been reduc'd; and to enjoyn the patient to lie on her back with her legs a-cross. * * * * * chap. xxxiii. _of the application of the _cautery_._ the cautery is an ulcer which is made in the skin, by applying causticks to it, after this manner: the surgeon having moisten'd the skin for a while with spittle, or else having caus'd a light friction to be made with a warm cloth, applies a perforated plaister to the part, and breaks the cautery-stone, to be laid in {266} the little hole, leaving it for a longer or shorter time, accordingly as he knows its efficacy, or as the skin is more or less fine. afterward he scarifieth the burn with his lancet, and puts a suppurative, or piece of fresh butter into the part, till the escar be fallen off. _the dressing and bandage._ after the application of the _lapis infernalis_, or any other cautery-stone, it is necessary to lay over it a plaister, a bolster, and a circular bandage, which ought to be kept sufficiently close, to press the stone, after a pea or little piece of orrice-root, hath been put into the ulcer to keep it open. then the patient is to make use of this bandage, with which he may dress it himself. take a piece of very strong cloth, large enough to roll up the part without crossing above it: and let three or four holes be made in one of its sides, as many small ribbans or pieces of tape being sow'd to the other, which may be let into the holes, as occasion serves, to close the band. * * * * * {267} chap. xxxiv. _of the application of leeches._ it is requisite that the leeches be taken in clear running waters, and that they be long and slender, having a little head, the back green, with yellow streaks, and the belly somewhat reddish. before they are apply'd, it is also expedient to let 'em purge during some days in fair water, fast half a day in a box without water. afterward the part being rubb'd or chaf'd with warm water, milk, or the blood of some fowl, the opening of the box is to be set to the part, or the leeches themselves laid upon a cloth; for they will not fasten when taken up with the fingers. the end of their tail may be cut with a pair of sizzers, to see the blood run, and to determine its quantity, as also to facilitate their sucking. when you wou'd take 'em away, put ashes, salt, or any other sharp thing upon their head, and they will suddenly desist from their work; but they are not to be pull'd off by force, lest they shou'd leave their head or sting in the wound, which wou'd be of very dangerous consequence. when they are remov'd, let a little blood run out, and wash the part with salt water. {268} _the dressing_ is made with a bolster soakt in some styptick water, if the blood will not otherwise stop; or in brandy or _aqua-vitæ_ if there be an inflammation; and it is to be supported with a bandage proper for the part. * * * * * chap. xxxv. _of the application of the _seton_._ to perform this operation, a cotton or silk thread is to be taken, after it hath been dipt in oil of roses, and let into a kind of pack-needle; then the patient sitting in a chair, is to hold up his head backward, whilst the surgeon gripes the skin transversely in the nape of the neck with his fingers, or else takes it up with a pair of _forceps_, and passeth the needle thro' the holes of the _forceps_, leaving the string in the skin. as often as the bolster that covers the seton is taken off, that part of the string which lies in the wound is to be drawn out, and cut off. * * * * * {269} chap. xxxvi. _of _scarifications_._ scarifications are to be made more or less deep, accordingly as necessity requires, beginning at the bottom, and carrying them on upward, to avoid being hinder'd by the hæmorrhage. they must also be let one into another, that strings may not be left in the skin. * * * * * chap. xxxvii. _of the application of _vesicatories_._ vesicatories are compounded with the powder of cantharides or spanish flies, mixt with very sower leaven, or else with turpentine. before they are apply'd, a light friction is to be made on the part with a warm cloth, and a greater or lesser quantity is to be laid on, accordingly as the skin is more or less fine, leaving 'em on the part about seven or eight hours; then they are to be taken away, and the blisters are to be open'd, applying thereto some sort of spirituous liquor. * * * * * {270} chap. xxxviii. _of the application of _cupping-glasses_._ a good friction being first made with warm clothes, lighted toe is to be put into the cupping-glass, or else a wax-candle fasten'd to a counter, and then it is to be apply'd to the part till the fire be extinguish'd, and the skin swell'd, re-iterating the operation as often as it is necessary; and afterward laying on a bolster steept in spirit of wine. these are call'd dry cupping-glasses: but if you wou'd draw blood, every thing is to be observ'd that we have now mention'd, besides that scarifications are to be made, according to the usual manner; and the cupping-glass is to be set upon the scarifications: but when the cupping-glass is half full of blood, it must be taken off to be emptied, and the application thereof is to be re-iterated, as often as it is required to take away any blood. lastly, the incisions are to be wash'd with some spirituous liquor; and a bandage is to be made convenient for the part. * * * * * {271} chap. xxxix. _of the opening of _abcesses_ or _impostumes_._ an abcess or impostume ought to be open'd in its most mature part, and in the bias of the humours, endeavouring to preserve the fibres of the muscles from being cut, unless there be an absolute necessity, avoiding also the great vessels, tendons, and nerves. the opening must be rather large than small, and not too much press'd in letting out the purulent matter. if the skin be thick, as it happens in the heel, it may be par'd with a razor; and if the matter be lodg'd under the nails, it wou'd be required to scrape 'em with glass before they are pierc'd. * * * * * {272} a treatise of the operations of fractures. * * * * * chap. i. _of the fracture of the nose._ when the fracture is considerable, the nostrils are stopt up, and the sense of smelling is lost. in order to reduce it, the surgeon takes a little stick wrapt up in cotton, and introduceth it into the nostrils as gently as is possible, to raise up the bones again, laying the thumb of his left-hand upon the nose, to retain 'em in their place. the bones being thus set, he proceeds to prepare {273} _the dressing and bandage_ by conveying into the nostrils certain leaden pipes of a convenient bigness and figure, which serve to support the bones, and to facilitate respiration. but care is to be had to avoid thrusting 'em up too far, for fear of hurting the sides of the nose; and they are to be anointed with oil of turpentine mixt with spirit of wine: these pipes are also to have little handles, with which they may be fasten'd to the cap. if there be no wound in the nose, there will be no need of a bandage; but if the fracture be accompany'd with a wound, after having apply'd the proper medicines, it wou'd be requisite to lay upon each side of the nose a triangular bolster, cover'd with a little piece of paste-board of the same figure. this small dressing is to be supported with a kind of sling that hath four heads; being a piece of linnen-cloath, two fingers broad, and half an ell long; it is slit at both ends, and all along, only leaving in the middle a plain of three fingers, that is to say, a part which is not cut. the plain of this sling is to be laid upon the fracture, causing the upper heads to pass behind the nape of the neck, which are to be brought back again forward; the lower heads are likewise to be carry'd behind, crossing above the upper, and afterward to be return'd forward. if the bones of the nose be not timely reduc'd, a great deformity soon happens therein, and a stink caus'd by the excrescences and _polypus's_. * * * * * {274} chap. ii. _of the fracture of the lower jaw._ the operator at first puts his fingers into the patient's mouth, to press the prominences of the bones; and afterward doth the same thing on the outside. if the bones pass one over another, a small extension is to be made. if the teeth be forc'd out of their place, they are to be reduc'd, and fasten'd to the sound teeth with a wax'd thread. _the dressing and bandage._ if the fracture be only on one side, a bolster sow'd to a piece of paste-board is to be laid upon the flat side of the jaw, both being of the figure and size of the jaw it self. the bandage of this fracture is call'd _chevestre_, i.e. _a cord or bridle_, by the _french_ surgeons, and is made by taking a band roll'd with one head or end, three ells long, and two fingers broad; the application of it is begun with making a circumvolution round about the head in passing over the fore-head; then the band is let down under the chin, and carry'd up again upon the cheek, near the lesser corner of the eye in passing over the fracture; afterward it is rais'd up to the head, and brought down again under the chin, {275} to form a roller or bolster upon the fracture: thus three or four circumvolutions and rollers being made upon the fracture, the band is let down under the chin, to stay and strengthen its several turns, and is terminated round the head, in passing over the fore-head. if the jaw be fractur'd on both sides, it wou'd be requisite to apply thereto a bolster and paste-board, perforated at the chin, and of the figure of the entire jaw; the bandage which we have even now describ'd, may be also prepar'd in making rollers on both sides of the jaw: or else the double _chevestre_ may be made with a band of five ells long, and two fingers broad, roll'd up with two balls, that is to say, with the two ends. the application of this band is begun under the chin, from whence it is carry'd up over the cheek, cross'd upon the top of the head, and brought down behind the head, where it is cross'd again; then it is let down under the chin, cross'd there, and carry'd up over the fracture; afterward the band being pass'd three or four times over the same turns, in making rollers upon the jaws, is turn'd upon the chin, and stay'd upon the forehead round about the head. * * * * * {276} chap. iii. _of the fracture of the _clavicle_._ the patient is to be set in a chair, and his arm is to be drawn backward, whilst an assistant thrusts his shoulder forward: in the mean time the operator sets the bones again in their place, by thrusting the protuberances, and drawing out the sunk bone. or else a tennis-ball may be taken, and put under the patient's arm-pit, whose elbow is then to be press'd against his ribs, whilst the surgeon reduceth the fracture. otherwise, the patient may be laid upon his back, putting a convex body under both his shoulders, as a bowl, or large wooden porrenger; and then the shoulders may be prest, to raise up the two ends of the bones, which the surgeon must take care to reduce. _the dressing and bandage._ the cavities which are above and below the clavicle, are to be fill'd with bolsters trimm'd with paste-boards; another is to be also laid upon the bone, which is almost of the same figure with the clavicle, and a large bolster, to cover the three others: this dressing is to be secur'd with the bandage call'd the _capeline_ or head-bandage, provided the fracture be in the middle of the clavicle. a band {277} being taken about six ells long, and four fingers thick, roll'd with two balls; it is apply'd in the middle to the fracture; one of its heads or ends is let down upon the breast, whilst the other is pass'd behind the back, below the arm-hole, opposite to the indispos'd arm-hole and above the breast, to be carry'd over the other end of the band, which is rais'd up, to make a roller or bolster upon the fracture: the other end is pass'd under the indispos'd arm-pit, and upon the band that made the roller, which is elevated by making a third roller upon the clavicle: these circumvolutions around about the body are continu'd, as also these rollers upon the clavicle, till it be entirely cover'd. some circumvolutions are also made upon the upper part of the arm, near its head: the space that lies between the rollers and the circumvolutions of the arm, and which bears the name of _geranium_ or stork's-bill, is likewise cover'd with some circumvolutions, and the band is stay'd by making circumvolutions quite round about the body. if the fracture were near the head of the _humerus_ or arm-bone, a sort of bandage might be prepar'd, which is call'd _spica_, with a band roll'd with one ball five ells long, and four fingers broad; one end of this band is pass'd under the arm-pit opposite to the indispos'd one behind the back: the other end is convey'd under the indispos'd arm-pit; the figure of the letters ky or x is made on the shoulder; the band is return'd below the other shoulder behind; it is brought back again before, to form a second ky upon the {278} fracture; three or four more ky's are wrought upon the fracture; two circumvolutions are made in the upper part of the _humerus_, which constitute a triangle call'd _geranium_; this triangle is cover'd with rollers, and the band is terminated round about the breast. * * * * * chap. iv. _of the fracture of the _omoplata_ or shoulder-blade._ the _acromion_ is usually fractur'd, but it may be known that the middle of the _omoplata_ is broken by a numness which is felt in the whole arm: whereupon the surgeon, after having examin'd the place of the fracture, thrusts back the prominences of the bones into their place; and if any splints happen to prick the part, he makes an incision to take 'em out, or to cut off their points. _the dressing and bandage._ a bolster is laid upon the _omoplata_, as also a large piece of paste-board of the bigness and figure of this bone, and a sort of bandage is prepar'd, known by the name of _the star_, with a band roll'd with one head four ells long, and as many fingers broad. this band is convey'd behind the back, one of its ends lying under the arm-hole, opposite to the indispos'd one; but the other is pass'd under the {279} shoulder, and afterward above it, to make a ky in the middle of the back; then passing under the other arm-hole, it is brought up to the shoulder, to be let down, and to form a second ky upon the middle of the back: these turns are continu'd in making rollers, till the _omoplatæ_ are all cover'd: circumvolutions are also made round the upper part of the _humerus_, as in the _spica_; and the bandage is finish'd by circumvolutions round about the breast. * * * * * chap. v. _of the fracture of the ribs._ when a rib is broken, one of the ends pusheth into the breast, sometimes on the outside; and sometimes the ends lie against each other. in order to reduce it, the patient being laid upon the sound rib, a plaister of mastick is apply'd to the fracture; and it is drawn out violently; so that sometimes this attraction brings back the bone, which is advanc'd into the breast; but the surest way is to make an incision therein, to raise it up with the finger. if the rib appear without, the patient is to be set in a a chair, and oblig'd to bend his body on the side opposite to the fracture, holding his breath, with which he must puff strongly, without letting it forth, in order to dilate the breast, whilst the surgeon thrusts the rib into its place. {280} _the dressing and bandage._ a bolster is to be apply'd to the fracture, with two little pieces of paste-board pass'd in form of a st. _andrew's_ cross; and another bolster upon the whole dressing, on which is also laid a large square paste-board cover'd with a bolster. the bandage is made with a napkin folded into three folds, which is put round the breast, being sow'd and supported by the scapulary; which is a band six fingers broad, perforated in the middle, to let in the head. the two ends of the scapulary are fasten'd before and behind to the napkin. * * * * * chap. vi. _of the fracture of the _sternum_ or breast-bone._ to reduce this fracture, the patient is to be laid upon his back, with a convex body underneath; both his shoulders are to be press'd with some weight, to push 'em backward, and to raise up the _sternum_, which is sunk down; or else an incision may be made upon the bone, to discover it; and then a _vectis_ is to be apply'd thereto very gently, in order to heave it up into its place. {281} _the dressing and bandage._ a bolster and paste-board are to be laid upon the _sternum_, almost of the same figure with the part; and the bandage is to be prepar'd with a napkin supported with a scapulary. or else the bandage call'd _quadriga_ may be made with a band roll'd with two heads, five ells long, and four fingers broad: the application of this band is begun under the arm-pit; the figure of ky is form'd under the shoulder; the band is carry'd downward with the two balls, once before, and the other behind; it is pass'd under the other arm-hole; the heads are cross'd upon the shoulder, and it is brought down backward and forward, forming a ky before and behind. afterward the bank is roll'd about the breast in making rollers or bolsters; these rollers are continu'd till the band be terminated; and it is stay'd by a cirumvolution round the breast. * * * * * chap. vii. _of the fracture of the _vertebra_'s._ the _apophyses_ of the _vertebra's_ are commonly broken, and their bodies but seldom: it may be known that the body of the _vertebra_ of the neck and back is fractur'd by the palsie of the arm, accompany'd with the loss of feeling; by the suppression of urine; {282} and by the palsie of the _sphincter_ of the _anus_; so that the excrements cannot be any longer retain'd. if these symptoms appear, it may well be conceiv'd that the marrow is compress'd, and prickt with points; for the removing of which, it is necessary to make an incision upon the body of the _vertebra_ in the fractur'd place. if the _apophyses spinosæ_ are only fractur'd, these accidents will not happen, only some pain will be felt: to reduce 'em, the patient is to be laid upon his belly, and the surgeon must use his utmost endeavours to raise up the bone again, and to set it in its natural situation. _the dressing and bandage._ if the _apophysis spinosa_ were fractur'd, it wou'd be requisite to apply to each side of it a small long bolster, which is to be cover'd with a paste-board of the same figure with the bolster; another bolster lying upon each paste-board. the bandage is to be made with a napkin sustain'd by its scapulary; or else the _quadriga_ may be prepar'd, according to the manner we have already describ'd in the fracture of the _sternum_. * * * * * {283} chap. viii. _of the fracture of the _os sacrum_._ it is reduc'd as the other _vertebra's_; but its dressing and bandage are made with the t perforated at the _anus_, or else with the h or double t. it is made with a band two fingers broad, and long enough to encompass the body above the hips; so that to the middle of this band is fasten'd another band of the same breadth, and of a sufficient length to pass over the dressing of the _os sacrum_, as also between the thighs, to be join'd in the fore-part to the first cincture. the double t is made by fastening two bands at a finger's breadth distance one from another, to the band which ought to be roll'd about the body; and this sort of bandage is to be supported with a scapulary. * * * * * chap. ix. _of the fracture of the _coccyx_ or rump-bone._ this bone is usually broken by falls, and sinks into the inside; so that to reduce it, the fore-finger of one hand is to be put into the _anus_ or fundament as far as the {284} fracture, to thrust it back again into its place, whilst the other hand setleth it on the outside. _the dressing and bandage._ are the same with those in the fracture of the _os sacrum_; but the patient must be oblig'd to lie on one side, and to sit in a perforated chair, when he hath a mind to rise. if the _os innominatum_ be broken, the _spica_ is to be us'd after it hath been dress'd, of which bandage we have given an account in the fracture of the clavicle. * * * * * chap. x. _of the fracture of the _humerus_ or arm-bone._ to set this bone, a strong extension is to be made, if the two ends cross one another, to which purpose the patient is to be plac'd on a little stool or seat, and supported by a servant, two other assistants being employ'd to draw, one at the upper-part, and the other at the lower, above the elbow, and not beneath it. in the mean time the operator reduceth the two bones, by closing 'em on all sides with the palms of his hands, and afterward prepareth {285} _the dressing and bandage._ it is necessary at first to lay round the fracture a bolster steept in some proper liquor, as claret or _oxycratum_; then three several bands are to be taken, three or four fingers broad, and an ell and a half long: the first of these is to be laid upon the fracture, round which are to be made three very streight circumvolutions; then it is to be carry'd up with small rollers to the top of the arm, and stay'd round the body. the second band being apply'd to the fracture, on the side opposite to the first, two circumvolutions are to be made upon the fracture; so that the same band may be brought down along the whole length of the arm, making divers rollers, and at last stay'd below the elbow, which, nevertheless, it must not cover. afterward our longitudinal bolsters must be laid upon the fracture round about the arm, which are to be kept close with a third band; it being of no great importance whether the application of this third band be begun at the top or at the bottom; but it may be stay'd round the body, or else beneath the elbow. the arm ought also to be encompass'd with two thick pieces of paste-board made round at the ends, and of the length of the arm; but they must not cross one another. these paste-boards are to be fasten'd with three ribbands, and the arm is to be put into a scarf made with a large napkin, which is to be first apply'd in the middle under the arm-pit, the arm resting upon it, so that {286} the four ends may be rais'd up, and fasten'd to the opposite shoulder; but the hand must lie higher than the elbow. * * * * * chap. xi. _of the fracture of the bone of the elbow._ if both the bones of the elbow be broken, a stronger extension is to be made than if only one of 'em were so hurt; to which purpose a servant is to be appointed to grasp the arm above the elbow with both his hands, and another to hold it above the wrist, whilst the surgeon sets the bones with the palms of both his hands, till no unevenness be any longer felt in the part. _the dressing and bandage_ are the same with those in the fracture of the arm; but the bands which are carry'd upward are to be stay'd above the elbow. if the patient be desirous to keep his bed, it is requisite that his arm be laid upon a pillow, the elbow lying somewhat higher than the hand. * * * * * {287} chap. xii. _of the fracture of the _carpus_ or wrist-bone._ if the bones of the _carpus_, or those of the _metacarpium_ be fractur'd, a servant must hold the arm above the wrist, and another the fingers; whilst the operator sets the bones in their place, so as no unevenness may appear in the part. _the dressing and bandage._ of the fracture of the wrist are to be prepar'd with a band roll'd with one head, being six ells long, and two fingers broad; so that three circumvolutions are to be made upon the wrist; the band is to be pass'd over the hand, between the thumb and the fore-finger, making the figure of ky upon the thumb. then after having made divers rollers upon the _carpus_, a bolster is to be apply'd, with a little piece of paste-board of the same shape with the wrist; several rollers are to be form'd on the top of the elbow, to stay the band above it; and the arm is to be put into a scarf. * * * * * {288} chap. xiii. _of the fracture of the bone of the _metacarpium_._ two servants are to hold the hand, after the same manner as in the setting of the _carpus_ or wrist-bone, whilst the surgeon reduceth the broken bone by fixing it in its natural situation. _the dressing and bandage_ are made with a band roll'd up with one head, five ells long, and two fingers broad: this band being fasten'd to the wrist, with a circumvolution, is to be laid on the _metacarpium_, between the thumb and the fore-finger, and the figure of ky is to be made upon the hand: then the forming of rollers and ky's is to be continu'd till the _metacarpium_ be cover'd; a bolster and paste-board are to be laid upon the same _metacarpium_; as also one in the hand, of the shape of the part: the inside of the hand is to be trimm'd; and the whole contexture is to be cover'd as before, with rollers; which are continu'd till above the elbow, where the band is stay'd. * * * * * {289} chap. xiv. _of the fracture of the fingers._ a light extension is to be made in the fingers to reduce 'em, and a small dressing is to be prepar'd for every finger, almost like that of the arm. the fingers are to be somewhat bent, and the inside of the hand is to be trimm'd with a bolster, to retain 'em in this situation. the bolster is also to be stay'd with a band, and the arm to be put into a scarf. * * * * * chap. xv. _of the fracture of the thigh._ if the thigh-bone be broken near its head, the fracture is very difficult to be discover'd; but if the bone pass one over another, it may be soon known, because the hurt leg will be shorter than the other. therefore a very great extension is to be made; and if the hands are not sufficient for that purpose, recourse may be had to straps and engines. in the mean time the operator is to lay his thumbs upon the fractur'd bone, to thrust it back into its place, and afterward to apply {290} _the dressing and bandage._ the cavity of the thigh is to be fill'd with a thick bolster, of the length of its bending; and three bands four fingers broad are to be provided, the first being three ells long, and the second four, as well as the third: then three circumvolutions are to be made upon the fracture with the first band, carrying it up with small rollers, and it is to be stay'd round the body. the second band is to make two circumvolutions upon the fracture, and is to be brought down with small rollers, which are terminated above the knee; or else they may be continu'd all along the leg; it is also to be pass'd under the foot, and to be drawn up again upon the leg: then a bolster is to be apply'd to the lower part of the thigh, being thicker at bottom than at top, to render the thigh everywhere even; and four longitudinal bolsters are to be added, on which are laid splints of the same length and breadth, which are to be wrapt up with a single bolster. the third band is to be roll'd upon these splints, beginning at the bottom, and ascending with rollers. then two large paste-boards are to be us'd, which may embrace the whole dressing, without crossing one another, being fasten'd with three ribbands. afterward a pair of pumps is to be put under the foot, and the heel to be supported with a small roll, the thigh and leg being let into the scarves, the inner of which is to extend to the groin, and the {291} outermost is to be somewhat longer: two little cushions are also to be laid on each side below the knee, and two others below the ankles, to fill up the cavities. these cushions or large bolsters are to lie between the scarves; and a thick bolster is to be laid upon the leg all along its length, as also on upon the thigh. the scarves are to be bound with three ribbands for the legs, and as many for the thighs; the knots being ty'd without, and on the side. * * * * * chap. xvi. _of the fracture of the knee-pan._ the knee-pan is cleft or broken in divers pieces in its length, and cross-wise: if it be broken cross-wise or obliquely, the two pieces fly out one from another; and on this occasion a strong extension is to be made; whilst the surgeon at the same time thrusts back again the upper-part of the knee-pan into its place. if the knee-pan be fractur'd in its length, no extension can be made, because the pieces of the bones remain in their place. _the dressing and bandage._ if the knee-pan be broken cross-wise, a band is to be provided three ells long, and two fingers broad, which may be roll'd with {292} one or two heads. the application is to be begun above the knee-pan; the figure of ky is to be made in the ham, and a circumvolution under the knee; then the band is to be continually carry'd up and down, till the knee-pan be entirely cover'd. if the knee-pan be fractur'd in its length, that is to say, from the top to the bottom, the uniting-band must be us'd, being two or three ells long, and two fingers broad, perforated in the middle. it is to be at first apply'd under the knee, and one of the balls is to be pass'd thro' the hole; it must also be well clos'd, and divers circumvolutions are to be made upon the knee-pan, so as it may be altogether cover'd. * * * * * chap. xvii. _of the fracture of the leg._ if the _tibia_ be only broken, it pushes into the inside; but if both bones be fractur'd they are sometimes separated on both sides, or else they pass one upon another; and in this case the leg is shorter than it ought to be. if the _perone_ be broken, it pushes to the outside. if one bone be only fractur'd, so strong an extension is not requisite as when they are both shatter'd, and it is to be drawn only on one side; whereas the drawing ought to be equal on both sides when both bones are concern'd. {293} thus whilst the assistants are employ'd in drawing, the surgeon performs the operation, by laying the ends of the bones exactly against one another; and they are known to be reduc'd when the great toe remains in its natural situation. _the dressing and bandage._ a simple bolster dipt in a convenient liquor is at first apply'd, and three bands three fingers broad are prepar'd, the first being two ells long, the second three, and the third three and a half. three very streight circumvolutions are to be made upon the fracture; the band is also to be carry'd up with rollers, and stay'd above the knee. the application of the second band is to be begun upon the fracture with two circumvolutions; it is to be brought down with rollers, to pass under the foot, afterward carry'd up again, and stay'd where it is terminated. the leg is to be fill'd with a bolster thicker at the bottom than at the top; and then are to be laid on the four longitudinal bolsters, two fingers broad, and as long as the leg; to which are to be apply'd the splints of a plyable and thin wood: these are wrapt up with a simple bolster, and strengthen'd with the third band, which is apply'd indifferently either at the top or bottom, opposite to the former; so that it is carry'd up or else down in making rollers, and stay'd at its end. the whole contexture is to be encompass'd with large paste-boards made round at the ends, which are not to cross one another, {294} but must be streighter at the bottom than at the top, and are to be ty'd with three ribbands or pieces of tape, beginning at the middle; so that the knots be ty'd on the outside. afterward the leg is to be put into the scarves, and the heel is to be supported with a linnen-roll, to which are fasten'd two ribbands that are ty'd upon the scarves: these rolls are made with a small piece of cloth, which is doubl'd, and roll'd up with the ends, in which is contain'd some straw, and a little stick in the middle, to consolidate 'em. the foot is supported with a paste-board or wooden sole, trimm'd with a bolster, or small quilt sow'd over it. divers strings are also fasten'd to the middle of the sides of the sole or pump, which are cross'd to be joyn'd to the scarves; and another is fixt at the end of the sole, which is ty'd to a ribband that binds the middle of the scarf. these scarves are likewise fasten'd with three ribbands, beginning with that in the middle, the knots being without, and trimm'd with four bolsters, that is to say, two on each side, to fill up the cavities that are below the knee, and above the ankle. lastly, the leg is to be plac'd somewhat high, and a cradle to be laid upon it, to keep off the bed-cloaths, the scarves passing over the knee and foot. _the dressing of complicated fractures_ of the arms, legs, and thighs is prepar'd with a bandage having eighteen heads or ends, in order to make which, a linnen-cloth is to {295} be taken of the length of the part, and broad enough to cause it to be cross'd thereby: it is to be folded into three doubles, and cut in three places on each side, leaving the middle plain; so that eighteen heads or small bands are form'd, every one of which will be four fingers broad, the upper heads being a little shorter than the lower. this band of eighteen heads is to be laid upon the scarves, and a bolster is to be apply'd to it four fingers broad, as long as the scarves. the leg is laid upon this bolster, and it hinders the corrupt matter from falling on the bandage. when the wound hath been dress'd, the fracture is to be incontinently surrounded with one of the heads, which ought to cross one another: then after the leg hath been bound with the first heads, two longitudinal bolsters are to be apply'd to the side of it; and the other heads are to be rais'd up, with all the rest of the dressing, which hath been describ'd in the simple fracture. * * * * * chap. xviii. _of the fracture of the bone of the foot._ the reduction of the bone of the foot is perform'd after the same manner as that of the hand. {296} _the dressing and bandage_ are made with a band roll'd with two heads, being three ells long, and two fingers broad: the application of it is begun with a circumvolution above the ankles; it is pass'd on the foot, and in like manner makes a circumvolution round it: afterward the same band is cross'd over the _metatarsus_, upon which are made some folds in form of a _rhombus_ or diamond; as also on the toes, and it is stay'd above the ankle-bone; or else it is carry'd up along the leg, to be stay'd above the knee. this bandage serves for all fractures of the bones of the foot, and is call'd the _sandal_. * * * * * {297} a treatise of the operations which are perform'd in luxations. * * * * * chap. i. _of the luxation of the nose._ the bones of the nose may be separated from that of the fore-head by a fall, or some violent blow; and the surgeon in order to set 'em, at first lays his thumb upon the root of the nose, and then he introduceth a little stick trimm'd with cotton, into the nostrils, and by the means thereof thrusts back the bones into their place. {298} _the dressing and bandage_ are the same with those that have been already describ'd in the fracture of the bones of the nose. * * * * * chap. ii. _of the luxation of the lower-jaw._ the jaw may be luxated either on both sides, or only on one. when the dislocation happens on both sides, it hangs over the _sternum_ or breast-bone, and the spittle runs abundantly out of the mouth: to reduce it, the patient must sit down, and his head is to be supported by a servant; then the operator or surgeon having wrapt up his two thumbs, puts 'em into the mouth upon the molar teeth, his other fingers lying under the jaw, which is to be drawn down by raising it up, having before set two small wooden wedges upon the two molar teeth on both sides of the jaw, lest the surgeon's fingers shou'd be hurt, as the bone is returning to its place. if the luxation be forward, a band or strap is to be put under the chin, an assistant having his knees upon the patient's shoulders, where he is to draw the strap upward, to facilitate the extension; which the surgeon makes with his hands, at the same time thrusting the bone back again into its place. {299} when the jaw is luxated only on one side, the chin stands a-cross, and the dislocated side is squash'd down, a small cavity being perceiv'd in it, and a rising on the other side; so that the mouth cannot be shut close, but remains somewhat open, the lower teeth appear farther out than the upper; and the canine or dog-teeth lie under the incisive. this luxation is reduc'd by giving a blow with the hand upon the luxated bone, which is sufficient to cause it to re-enter its natural place. _the dressing and bandage_ are altogether the same with those us'd in the fracture of the bones of the lower jaw. * * * * * chap. iii. _of the luxation of the _clavicle_._ the _clavicle_ is oftner loosen'd from the _acromion_ than from the _sternum_; when it hath left the former the arm cannot be lifted up; the _acromion_ makes a prominence, and the clavicle descends downward, a cavity appearing in its place. to reduce this luxation, the patient is to be laid upon some convex body put between his shoulders; both which are to be press'd backward, to raise up the clavicle: afterward he is to be set in a chair, that his arm may be drawn backward, whilst the {300} surgeon is employ'd in pressing the clavicle and _acromion_, to join 'em together. _the dressing and bandage_ are the same with those that we have already shewn, in treating of the fracture of the clavicle. * * * * * chap. iv. _of the luxation of the _vertebra's. in the luxation of the _vertebra_'s of the neck, the head stands to one side, and the face is swell'd and livid, with a difficulty of respiration. to reduce this dislocation, the patient is to be set upon a low seat, an assistant leaning on his shoulders, to keep his body steady, whilst the surgeon or operator draws his head upward, and turns it from one side to another: then if the accidents or symptoms cease, the cure is perform'd; so that fomentations may be apply'd to the part; and the patient being laid in his bed, must take care to avoid moving his head. when the _vertebra_'s of the back or loins are luxated on the inside, a sinking of the bone is soon perceiv'd; whereupon the patient being laid on his belly, the extension is to be made with napkins pass'd under the arm-pits, and upon the _os ileum_, whilst the surgeon with {301} a strong extension makes some efforts on the spine, endeavouring to draw back the _vertebra_. if that be not sufficient, an incision is to be made upon the _apophysis spinosa_ of the _vertebra_; so that after having laid open this process of the bone, it may be taken out with a pair of _forceps_. then the wound is to be dress'd with pledgets, a plaister, and a napkin, which must not be bound too close, for fear of pushing back the spine. when the _vertebra_ is luxated on the outside, a prominence appears; so that to reduce this dislocation, the extension is to be made as before, the patient lying in like manner upon his belly; but in order to push back the _vertebra_, two little sticks trimm'd with linnen-cloth are to be prepar'd, and laid along the two sides of the spine of the _vertebra_; yet these sticks ought to be thick enough to remain more elevated than the _apophysis spinosa_; and a large wooden roller is to be often roll'd upon 'em, which by its turning backward and forward, may thrust the _vertebra_'s inward; so that when all the _vertebra_'s are of an equal height, the reduction is finish'd. if the _vertebra_'s are luxated on the side, the same extensions are to be made, and the prominence is to be push'd, to re-establish the _vertebra_ in its place. _the dressing and bandage._ the dressing is prepar'd by laying two thin plates of lead on each side of the spinous process of the _vertebra_, to maintain it in its place, and a long bolster over 'em. the {302} proper bandage is the _quadriga_, which hath been before describ'd, in treating of the fractures of the breast-bone. * * * * * chap. v. _of the luxation of the _coccyx_ or rump-bone._ if the _coccyx_ be sunk on the inside, it is to be rais'd with the fore-finger of the right-hand put into the _anus_; and if the luxation be on the outside, it may be gently thrust back again. an account of its proper dressing and bandage hath been already given in the fracture of the _coccyx_. * * * * * chap. vi. _of the _bunch_._ the _bunch_ is nothing else but an exterior luxation of the _vertebra_'s, and for the cure thereof, it wou'd be requisite to keep emollients for a long time upon the _vertebra_'s, to loosen the ligaments, and to wear iron-bodice; which in compressing the _vertebra_'s by little and little, might perhaps drive 'em back into their natural place. * * * * * {303} chap. vii. _of the luxation of the ribs._ the ribs are luxated either on the outside, or on the inside: if they be dislocated on the inside, a cavity is perceiv'd near the _vertebra_'s, the patient drawing his breath with pain, and not being able to bend his body. when the luxation is on the outside, and happens in the upper ribs, the patient's hands are to be hoisted upon the top of a door, to raise up the ribs, whilst the surgeon presseth the prominence of the rib to restore it to its place. when the lower ribs are luxated, the patient must be oblig'd to stoop, laying his hands upon his knees, and the prominence of the bone is to be thrust back. if a rib be luxated on the inside, an incision is to be made to draw it out with the fingers. _the dressing and bandage_ are the same with those that are us'd in the fracture of the ribs. * * * * * {304} chap. viii. _of the sinking of the _xiphoides_, or sword-like cartilage_. to raise up the _xiphoid_ cartilage, it must be fomented before for some time with oil of turpentine, or other fomentations, made with aromaticks; then the patient is to be laid upon his back, with a convex body underneath, and the shoulders, and sides of the breast are to be press'd, to lift up the cartilage. when this operation is not sufficient, dry cupping-glasses are usually apply'd, till the part be elevated, and a strengthening plaister is afterward laid upon it. * * * * * chap. ix. _of the luxation of the _humerus_, or arm-bone_. the head of the _humerus_ generally falls under the arm-pit, so that the luxated arm becomes longer than the other, the _acromion_ appears pointed on the outside; the elbow starts from the ribs, and cannot be mov'd without great pain. to reduce this bone, the {305} patient is to be set upon a low seat, or else on the ground, whilst some person supports his body with a napkin: in the mean time the surgeon is to lay hold on the upper-part of the _humerus_, a servant kneeling behind him, who is to hold the patient's arm above the elbow, which is to pass between the surgeon's legs, and is to be drawn down by the assistant as much as is possible, whilst the surgeon in like manner draws the arm, to remove the head of the bone out of the place where it was stopt; insomuch that the bone sometimes makes a noise in re-entring its cavity. or else the patient's arm may be laid upon the shoulder of a taller man than himself, who is strongly to draw the luxated arm upon the fore-part of his breast; during which time, the operator is to push the head of the _humerus_, to cause it to re-enter its cavity. otherwise the patient may lie on the ground, a tennis-ball being put under his arm-pit, which a servant is to draw strongly with a handkerchief pass'd under the shoulder, whilst another assistant stands behind the patient, to thrust down the shoulder with his foot; at the same time the surgeon sitting between the patient's legs, is to push strongly with his heel the ball that lies under the arm-hole. or else, a thick battoon or leaver may be laid on the shoulders of two men, after a tennis-ball hath been nail'd on the middle of it; otherwise a bunch may be made therein, and cover'd with linnen-cloth; two wooden pins being also fixt on each side of the ball: {306} then the patient's arm-pit is to be set between those two pins, and upon the ball, where he is to remain hanging, whilst his arm is pull'd down by main force. the same thing may be done by laying the patient's arm-pit upon a door, or else upon the round of a ladder. _the dressing and bandage_ a little ball of linnen is to be laid under the arm-pit, and underneath a bolster with four heads, which are cross'd upon the shoulder; as also a bolster under the sound arm-hole, that it may not be gall'd by the bandage _spica_, the nature of which we have shewn in treating of the fracture of the clavicle. * * * * * chap. x. _of the luxation of the elbow._ when the elbow is luxated on the inside, the arm flies out, and the hand is turn'd outward; but in the luxation on the outside, the arm is shortned: if the luxation be lateral, a prominence appears in the dislocated, and a cavity in the opposite part. to reduce the internal luxation, the _humerus_ and _cubitus_ are drawn, and at the same time the surgeon bends the elbow, by carrying {307} the hand toward the shoulder; or else a tennis-ball may be laid in the fold of the elbow, and the arm drawn toward the shoulder. for the external luxation, the extension is to be made, whilst the surgeon thrusts back the elbow into its place: or else a round stick may be taken, and trimm'd with linnen-cloth, with which the bone is to be push'd back into its place during the extension. this stick may be also us'd in the reducing of the internal luxation. for the lateral luxations, the extension may be made in like manner; the surgeon at the same time thrusting back the bone into its natural situation. _the bandage_ is made with a band five ells long, and two fingers broad, roll'd with one ball: the application of it is begun with a circumvolution at the lower part of the _humerus_, it is pass'd over the fold of the arm; a circumvolution is also form'd in the upper-part of the elbow, and the figure of ky in its fold. afterward the rollers are continu'd upon the elbow, and the ky's in the inside of the arm, till the elbow be entirely cover'd: the band is likewise carry'd up to the top of the arm with rollers, and stay'd round about the body. the patient must be oblig'd to keep his bed, or else his arm may be put in a scarf, after the same manner as in the fracture of the arm. * * * * * {308} chap. xi. _of the luxation of the wrist._ if the luxation be internal, the hand is turn'd back to the outside, so that for the reduction thereof, it wou'd be requisite to cause the back of the hand to be laid upon a table, and the extension to be made by drawing the elbow and hand, whilst the surgeon takes care to press the prominence. if the luxation be external, the hand is bended on the inside; so that to reduce it, the inside of the hand is to be laid upon a table, and the surgeon is to press it after the extension. if the luxation be on the sides, the hand is turn'd to one side; so that the extension must be made, and the hand turn'd on the side opposite to the luxation. but the fingers are usually drawn one after another, to the end that the tendons may be set again in their place. the eight bones of the _carpus_ may be in like manner dislocated both on the inside and without; and to set 'em right, the hand is to be laid upon a table, and the extension to be made, so as to press the protuberances on the inside, if the luxation be internal, and on the outside if it be external. {309} _the bandage_ is prepar'd with a band six ells long, and two fingers broad; so that three circumvolutions may be made upon the luxation; as also divers rollers in passing thro' the inside of the hand between the thumb and the forefinger, and in forming the figure of ky upon the thumb, after having made many rollers upon the wrist. two pieces of paste-board are also to be laid on the sides of the wrist, which are bound with the same band in making rollers; and the hand is to be trimm'd with a linnen-ball, to keep the fingers in their mean situation. then the band is to be pass'd above, to strengthen it, and carry'd up with rollers along the whole length of the elbow, to be stay'd below the same elbow. * * * * * chap. xii. _of the luxation of the fingers._ if the fingers be luxated, it is necessary to make an extension to reduce 'em, and afterward to use the following _bandage._ if the luxation be in the first articulation or joint, the bandage _spica_ is to be apply'd, being made of a band roll'd with one head, an {310} ell long, and an inch broad: it is begun with circumvolutions round about the wrist, and brought over the luxation in passing between the fingers. these circumvolutions are also continu'd to form a _spica_ upon the luxation; and the band is stay'd at the wrist. if all the first _phalanges_ were dislocated, it wou'd be requisite to make as many upon every _phalanx_, and with the same band: this sort of bandage is call'd the _demi-gantlet_. * * * * * chap. xiii. _of the luxation of the thigh._ the luxation which most commonly happens in this part, is the internal; so that a protuberance appears on the hole of the _os pubis_; the indispos'd leg is longer than the other, and the knee and foot turn outward; neither can the thigh be any longer bended, nor drawn near the other. if the luxation be external, the leg becomes shorter than the other, the knee and foot turning inward, and the heel to the outside. when the luxation is on the fore-part, a tumour ariseth in the groin, so that the patient cannot draw this thigh toward the other, nor bend the leg; his body resting only upon the heel. {311} if the luxation be posterior, a tumour is felt in the buttocks with great pain, and the legg is shorter than it ought to be: there also appears a sinking in the groin, the leg is lifted off from the ground, and the hurt person is apt to fall backward. to reduce the internal luxation, the patient is to be laid with his back upon a table, to which is fixt a thick wooden pin, about a foot long, which is to be set between his thighs, to detain his body when his legs are drawn down; then a strap is to be pass'd above the joynt of the thigh, to draw the _ischion_ upward; and the thigh is to be drawn down with another strap fasten'd above the knee: in the mean while the surgeon thrusts the thigh upward, to cause it to re-enter its cavity, the straps being somewhat loosen'd in the time of the reduction to facilitate the operation. to reduce the external luxation, the patient is to be laid upon his belly; and the drawing to be perform'd after the same manner as we have even now shewn, whilst the thigh is thrust from the outside inward, to cause the bone to re-enter its cavity. in reducing the anterior luxation, the hurt person is to be laid upon the side opposite to the luxation, and extensions are to be made, by drawing both upward and down-ward, as before: then the head of the bone is to be forc'd, by the means of a ball thrust strongly with the knee, in drawing the luxated leg toward the other. {312} the posterior luxation is thus reduc'd; the patient being laid upon his belly, the double extension is to be made, and his knee drawn outward, to set the bone in its place. after the operation hath been perform'd, a bolster is to be apply'd, steept in spirituous medicaments; and the bandage call'd _spica_, of which we have given an account in treating of the luxation of the shoulder. * * * * * chap. xiv. _of the luxation of the knee._ when the _tibia_ is luxated behind, its prominences are in the cavity of the ham, and the leg flies off, or is bended. if the same _tibia_ be dislocated on the side, a kind of tumour appears in the luxated side, and a sinking in the opposite. but if the _condylus_ of the _tibia_ remains in the inside, the leg turns outward; and if it be in the outside, it turns inward. the posterior luxation is reduc'd by obliging the patient to lie upon his belly, whilst the surgeon during the extensions bends the leg, in drawing the heel toward the top of the thigh. if the _tibia_ be luxated on the side, the usual extensions are to be made, and the bone is to be push'd with the knee. {313} if the luxation were in the fore-part, it wou'd be requisite to lay the patient upon his back, to make the extensions, by drawing the thigh and leg; and to press the protuberant parts. _the bandage_ is prepar'd with a band three ells long, and two fingers broad, roll'd with two balls: a circumvolution being at first made above the knee, the figure ky is form'd underneath, and a circumvolution above it; then the band is carry'd up again over the knee, in making rollers and ky's underneath, till the knee be entirely cover'd. * * * * * chap. xv. _of the luxation of the _patella_ or knee-pan._ the knee-pan is luxated by starting upward; and to reduce it, the patient's leg is to be held streight, whilst it is thrust back into its place with the hands. then he must be oblig'd to keep his bed; and the same bandage is to be apply'd with that which hath been describ'd for the luxation of the knee. if the _perone_ or _fibula_ be remov'd from the _tibia_, the sides of the foot are to be press'd, to draw it back again; and it may be kept close {314} with the bandage which is appropriated to the fractures of the _tarsus_. the _astragalus_ may be also luxated in the fore-part; so that the operator ought to thrust it back into its place, and to make use of the bandage which we have prepar'd for the fracture of the foot. the _calcaneum_ sometimes flies off from the _astragalus_ both in the inside and without; and the bones of the _tarsus_, _metatarsus_, and toes are likewise apt to be luxated. but a little circumspection is only requisite to reduce all these dislocations. * * * * * {315} a treatise of _medicinal compositions_ necessary for a surgeon. * * * * * chap. i. _of balsams._ * * * * * _the balsam of _arcæus_._ take two pounds of the suet of a he-goat, _venice_ turpentine and gum _elemi_, a pound and a half of each; and of hogs-lard one pound. after the gum _elemi_, being cut into small pieces, hath been melted over a very gentle fire, add to it the turpentine, goats-suet, and {316} swines-grease; and when all these ingredients are well dissolv'd, strain the liquor thro' a new linnen-cloth, to separate the scum and dregs from it; then let the whole mass cool, and the balsam is made. this balsam serves to incarnate and consolidate all sorts of wounds and ulcers: it is likewise us'd in fractures and dislocations of the bones; as also to cure the contusions and wounds of the nerves. _the balsam of _spain_._ take pure wheat, the roots of valerian and _carduus benedictus_, of each one ounce, and beat 'em well in a mortar with a pint of white-wine; strain the whole composition into an earthen vessel leaded, having a narrow mouth; stop up the vessel, and set it upon hot embers during twenty four hours: then add six ounces, of st. _john_'s wort; set the whole mass in _balneo mariæ_, till the wine be consum'd and let it be strain'd and squeez'd. afterward add two ounces of frankincense well pulveriz'd, with eight ounces of _venice_ turpentine, mixing 'em together over a gentle fire, and the balsam will be made. this is the balsam which was always us'd by _hieronymus fabritius ab aguapendente_, a noted _italian_ surgeon, and is excellent for all kinds of wounds, even for the nervous, which (as it is avouch'd by some persons) may be cur'd by it within the space of twenty four hours. but the wound must be at first wash'd with good white-wine cold, and afterward anointed {317} with this balsam well heated. if the wound be deep, it may be syringed with the same balsam very hot, and the sides of it anointed when drawn together. then a bolster steep'd in the balsam is to be apply'd to the part, and upon that another bolster soakt in the lees of wine; as also over this last another drie bolster. _the green balsam._ take linseed-oil and that of olives, of each one pint; one ounce of oil of bays; two ounces of _venice_ turpentine, half an ounce of the destill'd oil of juniper-berries, three drams of verdegrease, two drams of sucotrin aloes, two drams and a half of white vitriol, and one of the oil of cloves. having made choice of the best olive and linseed-oil well purify'd and mingl'd together in a skillet or pan over a very gentle fire, let the turpentine and oil of bays be incorporated in it; then having taken off the pan from the fire, and left the liquor to be well cool'd, let it be intermixt by little and little with the verdegrease, the white vitriol, and the sucotrin aloes beaten to fine powder: afterward the destill'd oils of cloves and juniper-berries being added, and the whole composition well mingl'd together, the balsam will be entirely compounded according to art. this is the balsam that hath been so much talkt of at _paris_, and which many quack-salvers, pretending to the art of physick and surgery, keep as a great secret. indeed it is very good for all sorts of wounds, whether they {318} be made by the sword, or other iron weapons, or by gun-shot. but it wou'd be requisite at first to wash the wound with warm wine, then to anoint it with this balsam very hot, and to apply bolsters that have been steept in it, as also a large bolster over the other, dipt in some styptick liquor. this balsam mundifies, incarnates, and cicatrizes wounds; being likewise good against the bitings of venomous beasts, and fistulous and malignant ulcers. __samaritan_ balsam._ take an equal quantity of common oil and good wine; boil 'em together in a glaz'd earthen vessel, till the wine be wholly consum'd, and the balsam will be made. i have produc'd this balsam in particular, by reason of its simplicity, and in regard that it may be readily prepar'd at all times. it serves to mundifie and consolidate simple wounds more especially those that are recent. * * * * * {319} chap. ii. _of ointments._ * * * * * __unguentum althææ_._ take of the roots of _althæa_ or marsh-mallows, six ounces, the seeds of line, and fenugreek, and squills, of each four ounces; of yellow wax one pound; colophony and rosin, of each one pound; _venice_ turpentine, _galbanum_, and gum _hederæ_ pulveriz'd, two ounces of each. the marsh-mallow-roots being newly gather'd, are to be well wash'd and slic'd, as well as the squills. after they have been put into a copper-pan or skillet, tinn'd over on the inside, together with the seeds of line and fenugreek, and a gallon of fair water pour'd upon 'em, the whole mass is to be macerated during twenty four hours, over a very gentle fire, stirring the ingredients from time to time with a wooden _spatula_: thus they are to be boil'd slowly, often reiterating the stirring, till the mucilages are sufficiently thicken'd; then, after having well squeez'd and strain'd 'em thro' a strong and very close cloth, and mingl'd 'em with the prepar'd oil, they are to be boil'd together again over a very gentle fire, till the superfluous moisture of the mucilages be wholly {320} consum'd: afterward having strain'd the oil again, the yellow wax, colophony, and rosin cut into small pieces, are to be melted in it; and if any dregs appear at the bottom of the pan, when the whole mass is dissolv'd, it is to be strain'd a-new, or at least the pure liquor must be separated from the gross or impure by inclination, whilst it is as yet very hot: the ointment is to be stirr'd about with a wooden pestle; and when it begins to grow thick, you may add the turpentine, the _galbanum_ purify'd and thicken'd, and the gum _hederæ_ beaten to fine powder, all which ingredients were before incorporated together. then the ointment is to be continually stirr'd, till it be altogether grown cold. this ointment serves to moisten, mollifie, and heat gently; it also allayes the pains of the side, and softens tumours, particularly the _parotides_. it may be us'd either alone, or with other ointments or oils. _the mundificative ointment of smallage._ take three handfuls of smallage-leaves; with ground-ivy, great wormwood, great centory, germander, sage, st. _john_'s-wort, plantain, milfoil or yarrow, perewinkle, the greater comfrey, the lesser comfrey, betony, honey-suckle, fluellin, vervein, knot-grass, adders-tongue, and burnet, of every one of these plants two handfuls; a gallon of common oil, white pitch, mutton-suet, yellow wax, and turpentine, of each two pounds. {321} bruise all these herbs in a marble-mortar; let the wax, white pitch, and mutton-suet cut into pieces, as also the turpentine be melted in the oil, in a copper-pan lin'd with tin, over a moderate fire; put the bruis'd herbs in it, and cause the whole mass to simmer together very slowly, stirring it about from time to time with a wooden _spatula_. as soon as it shall be perceiv'd that the oil of the herbs is almost quite consum'd, the whole composition is to be strain'd, and strongly squeez'd. then after having let the ointment cool, to draw off all the dregs and moisture, it is to be dissolv'd over a very gentle fire; and after having left it a little while to cool again and thicken, you may add thereto myrrh, aloes, _florence_ orris, and round birth-wort pulveriz'd very fine. when all these ingredients are by this means well incorporated, the ointment will be brought to perfection. this ointment is of singular use to cleanse ulcers; as also to mundifie, cicatrize, and consolidate all sorts of wounds. _the black or suppurative ointment._ take a quart of common oil, white and yellow wax, mutton-suet that lies near the kidneys, pure rosin, ship-pitch, _venice_ turpentine, of each half a pound; and of mastick beaten to fine powder, two ounces; let all that is capable of being dissolv'd, be liquify'd in the oil; and add the powder of mastick to make an ointment. {322} this ointment searches and opens all sorts of impostumes, as well as carbuncles, and pestilential and venereal bubo's. the use of the same ointment is also to be continu'd after the opening of the abcesses, till their perfect cure be compleated. __unguentum rosatum_._ take bore's-grease well purify'd, and often wash'd, and red roses newly pickt, of each four pounds, with the like quantity of white roses. the thin membrane or skin which lies upon the bores-grease, being taken away, it is to be cut into small pieces, well wash'd in fair water, and melted in a glaz'd earthen-pot over a very gentle fire; the first grease that is dissolv'd is to be strain'd thro' a cloth, well wash'd, and mixt with the same quantity of thick rose-buds well bruis'd. then the whole mass is to be put into a glaz'd earthen-pot with a narrow mouth; the pot is to be well stopt, and set during six hours in water, which is between luke-warm and boiling hot. afterward it is to be boil'd an hour, strain'd and strongly squeez'd. in the mean while four pounds of white roses newly blown are to be taken, well bruis'd, and mingl'd with the former composition, the pot being cover'd, which is likewise set for the space of six hours in water, between luke-warm and boiling hot: then the liquor is to be strain'd and strongly squeez'd. lastly, after the ointment hath been cool'd, and separated from its _fæces_ or dregs, it may be kept for use. {323} if it be desir'd to give a rose-colour to this ointment, it wou'd be requisite a quarter of an hour before it be strain'd the last time, to throw into it two or three ounces of _orcanet_, which is to be stirr'd into the ointment. if it be thought fit to retain the white colour, and to produce the smell of roses, it may be done with damask-roses without _orcanet_. if you are desirous to give it the consistence of a liniment, you may add oil of sweet almonds to the quantity of a sixth part of its weight. this ointment is a very good remedy against all manner of external inflammations, particularly against _phlegmons_, _erysipelas's_, and tetters; as also against the head-ach and hæmorrhoids or piles. __unguentum album, aut de cerussa_._ take three pints of oil of roses, nine ounces of white wax, one pound of _venice_ ceruse or white lead, and a dram and a half of camphire. the ceruse being pulveriz'd by rubbing the pieces upon the cloath of a hair-sieve turn'd upside-down; the powder is to be receiv'd on a sheet of paper laid underneath, and to be often wash'd with water in a great earthen-pan, stirring it about with a wooden _spatula_, and pouring off the water by inclination as soon as the powder is sunk to the bottom. when the water of these washings grows insipid, the last lotion is to be made with rose-water, leaving it for the space of five or six hours, which being expir'd, it is to be pour'd off by inclination, and {324} the ceruse must be dry'd in the shade, cover'd with paper. then the broken wax and prepar'd oil is to put into a glaz'd earthen-pot, and the pot into the boiling bath. as soon as the wax is melted, the pot may be taken out of the bath, and the dissolv'd liquor stirr'd with a wooden pestle till it begins to grow thick. afterward the pulveriz'd ceruse is to be infus'd, and the ointment stirr'd about till it be almost cold. if you shall think fit to add camphire, let it be dissolv'd in a little oil, and incorporated with the ointment when it is cold. the whites of eggs may be also well mixt with the ointment, by stirring it about, to make an exact union of the several ingredients. this ointment is good for burns, _erysipelas's_, the itch, and many distempers of the skin; it allayes the itchings and intemperature of ulcers; it dissipates the chafings and redness that happen in the bodies of infants; it is of great efficacy in the healing of contusions, and it serves to consolidate and cool light wounds. __unguentum ægyptiacum_._ take eleven ounces of verdegrease, fourteen ounces of strong vinegar, and twenty eight ounces of good honey. let the verdegrease be put into a copper-pan or skillet over a very gentle fire; then bruise it with a wooden pestle; work it well in the vinegar, and strain the whole thro' a hair-sieve. if a little verdegrease remains on the sieve, it is to be put again into the {325} skillet bruis'd and beaten small therein, as before, with a portion of the same vinegar, straining it thro' the sieve, till the unprofitable drossy parts of the copper be only left. afterward this liquor is to be boil'd over a gentle fire, with the honey, stirring it about from time to time till it hath acquir'd the consistence of a softish ointment, and a very red colour. this ointment consumes putrify'd flesh, and the superfluities of ulcers and wounds. __unguentum basilicon_, or royal ointment_. take yellow wax, mutton-suet, rosin, ship-pitch, and _venice_ turpentine, one pound of each; with five pints of common oil. cut the suet, rosin, and black pitch into small pieces, and let 'em be melted together, with the oil, in a copper-pan over a very moderate fire; then after having strain'd the liquor thro' a thick cloth, let it be incorporated with the turpentine, and the ointment will be made. it promotes suppuration, and cicatrizes wounds when the purulent matter is drawn forth. it is often laid alone upon the bolsters, and sometimes mixt with the yolks of eggs, turpentine, and other ointments, or with oils and plaisters. {326} _a cooling cerate._ take a pint of oil of roses, and three ounces of white wax. let the whole composition be put into a glaz'd earthen-pot, and the pot set in _balneo mariæ_, till the wax be well dissolv'd in the oil: then take the vessel out of the bath, and stir the ointment with a wooden pestle till it be cool'd; add two ounces of water, and stir it about with the pestle till it be imbib'd by the cerate; let as much more water be infus'd, and again the same quantity, till the cerate becomes very white, and hath been well soakt with fresh water. afterward all the water is to be pour'd off by inclination, and separated as much as is possible from the cerate, which may then be kept for use; but some surgeons cause an ounce of vinegar to be mingl'd with it. this cerate is usually laid outwardly upon all parts that stand in need of cooling, and asswages the pains of the hæmorrhoids or piles. it is also good for chaps, sore nipples, and other ill accidents that happen in the breast; and is us'd for burns either alone, or mixt with other ointments. whensoever it is necessary to apply desiccatives and astringents to any part, this cerate may be mingl'd with _unguentum de cerussa_. {327} _an ointment for burns._ take a pound of bores-grease, two pints of white-wine, the leaves of the greater sage, groundand wall-ivy, sweet marjoram, or the greater house-leek, of each two handfuls. let the whole mass be boil'd over a gentle fire, and having afterward strain'd and squeez'd it, let the ointment so made be kept for use. * * * * * chap. iii. _of plaisters._ * * * * * _the plaister of _diapalma_._ take three pounds of prepar'd litharge of gold, three pints of common oil, two pounds of hogs-lard, a quart of the decoction of palm-tree or oak-tops; four ounces of vitriol calcin'd till it become red, and steept in the said decoction. having bruis'd or cut very small two handfuls of palm-tree or oak-tops, let 'em be boil'd slowly in three quarts of water till about half be consum'd; and after the whole mass hath been well squeez'd, the strain'd decoction is to be preserv'd. in the mean time the litharge is to be {328} pounded in a great brass mortar, and diluted with two or three quarts of clear water; but it will be requisite readily to pour out into another vessel the muddy water which is impregnated with the more subtil part of the litharge, whilst the thicker remains at the bottom of the mortar; whereupon this part of the litharge will sink to the bottom of the water, and the litharge remaining in the mortar is to be pounded again. then having diluted it in the water of the first lotion, or in some other fresh water, the muddy liquor is to be pour'd by inclination upon the subtil litharge that remain'd in the bottom of the vessel: afterward you may continue to pound the litharge, to bruise it in the water, to pour it off by inclination, and to let the powder settle, till there be left only at the bottom a certain impure part of the litharge, capable of being pulveriz'd, and rais'd amidst the water. as soon as the lotions are well settl'd, and care hath been taken to separate by inclination the water which swims over the powder of litharge; this powder is to be dry'd, and having weigh'd out the appointed quantity, it is to be put as yet cold into a copper-pan lin'd with tin, and stirr'd about to mingle it with the oil, lard, and decoction of palm-tree-tops. when these ingredients have been well incorporated together, a good charcoal fire must be kindl'd in a furnace, over which they are to be boil'd, stirring 'em continually with a great wooden _spatula_, and constantly maintaining an equal degree of heat during the whole time of their boiling. at last you may add {329} the rubify'd vitriol dissolv'd in a portion of the liquor that hath been reserv'd, if you wou'd have the plaister tinctur'd with a red colour; or else white vitriol melted in the same decoction, if it shall be thought fit to retain the whiteness of the plaister, which may be form'd into rolls, and wrapt up with paper. this plaister is us'd for the cure of wounds, ulcers, tumours, burns, contusions, fractures, and chilblains, and is also laid upon the cauteries. if you mingle with it the third or fourth part of its weight of some convenient oil, it will attain to the consistence of a cerate; and this is that which is call'd _dissolved diapalma_ or _cerate of diapalma_. _the plaister of simple _diachylum_._ take of marsh-mallow-roots peel'd, three drams; the seeds of line and fenugreek, of each four ounces; three quarts of spring-water; two quarts of common oil, and two pounds of litharge of gold. let the mucilages of marsh-mallow-roots, and of the seeds of line and fenugreek be taken, as hath been shewn in the making of _unguentum althææ_, and let the litharge be prepar'd after the same manner as for the plaister of _diapalma_. having at first well mixt the oil with the litharge in a large copper-vessel or pan, tinn'd on the inside, being wide at the top, and tapering like a cone toward the bottom, as also having afterward added and well incorporated the mucilages, a moderate {330} charcoal fire is to be kindl'd in a furnace, upon which the vessel is to be set, and the whole mass is to be stirr'd about incessantly with a wooden _spatula_; and as fast as is possible. a gentle fire is to be maintain'd, and the boiling and agitation to be continu'd, till it be perceiv'd that the plaister begins to sink in the pan; then the heat of the fire must be diminish'd one half at the least; and it will be requisite only to cause an evaporation by little and little, of the superfluous moisture that might remain in the plaister, which being consum'd, it will be sufficiently boil'd, having attain'd to its due consistence and whiteness. this plaister softens and dissolves hard swellings, and even the scirrhous tumours of the liver and bowels; such are the scrophulous or king's-evil tumours, the old remains of abcesses, _&c._ _the plaister of _andreas crucius_._ take two ounces of rosin; four ounces of gum _elemi_, _venice_ turpentine and oil of bays, of each two ounces. after having beat in pieces the rosin and gum _elemi_, they are to be melted together over a very gentle fire, and then may be added the turpentine and oil of bays. when the whole mass hath been by this means well incorporated, it must be strain'd thro' a cloth, to separate it from the dregs. the plaister being afterward cool'd, is to be made up in rolls, and kept for use. {331} this plaister is proper for wounds of the breast: it also mundifies and consolidates all sorts of wounds and ulcers, dissipates contusions, strengthens the parts in fractures and dislocations, and causeth the serous humours to pass away by transpiration. __emplastrum divinum_._ take of litharge of gold prepar'd, one pound and an half; three pints of common oil; one quart of spring-water; six ounces of prepar'd load-stone; gum _ammoniack_, _galbanum_, _opoponax_, and _bdellium_, of each three ounces; myrrh, _olibanum_, mastick, verdegrease, and round birth-wort, of every one of these an ounce and an half; eight ounces of yellow wax, and four ounces of turpentine. let the gum _ammoniack_, _galbanum_, _bdellium_, and _opopanax_ be dissolv'd in vinegar, in a little earthen pipkin; strain 'em thro' a course cloth, and let 'em be thicken'd by evaporation, according to the method before observ'd in other plaisters: then prepare the load-stone upon a porphyry or marble-stone, and take care to bruise separately, the _olibanum_, the mastick, the myrrh, the round birth-wort, and the verdegrease, which is to be kept to be added at last. in the mean while, having incorporated cold the oil with the litharge, and mingl'd the water with 'em, they are to be boil'd together over a very good fire, stirring 'em incessantly, till the whole composition hath aquir'd the consistence of a somewhat solid {332} plaister, in which is to be dissolv'd the yellow wax cut into small pieces. afterward having taken off the pan from the fire, and left the ingredients to be half cool'd, intermix the gums, which have been already thicken'd and incorporated with the turpentine; then the load-stone mingl'd with the birth-wort, myrrh, mastick, and _olibanum_; and last of all the verdegrease. thus when all these ingredients are well stirr'd and mixt together, the plaister will be entirely compounded; so that it may be made up into rolls, and preserv'd to be us'd upon necessary occasions. this plaister is efficacious in curing of all kinds of wounds, ulcers, tumours, and contusions; for it mollifies, digestes, and brings to suppuration such matter as ought to be carry'd off this way. it also mundifies, cicatrizes, and entirely consolidates wounds, _&c._ * * * * * chap. iv. _of cataplasms or pultisses._ cataplasms are usually prepar'd to asswage pain; as also to dissolve and dissipate recent tumours, and are made thus: take four ounces and a half of white bread, one pint of new milk, three yolks of eggs, one ounce of oil of roses, one dram of saffron, and two drams of the extract of _opium_. {333} the crum is to be taken out of the inside of a white loaf newly drawn out of the oven, and to be boil'd with the milk in a skillet over a little fire, stirring it from time to time with a _spatula_, till it be reduc'd to a thick pap. after having taken the vessel off from the fire, the three yolks of eggs beaten are to be put into it, and the dram of saffron pulveriz'd; to these ingredients may be added two drams of the extract of _opium_ somewhat liquid, if the pain be great. _here is another cataplasm proper to mollifie and to bring to suppuration when it is necessary._ take white-lilly-roots, and marsh-mallow-roots, of each four ounces; the leaves of common mallows, marsh-mallows, groundsel, violet-plants, brank-ursin, of every one of these herbs one handful; the meal of line, fenugreek, and oil of lillies, of each three ounces. the roots when wash'd and slic'd, are to be boil'd in water, and the leaves being added some time after, the boiling is to be continu'd till the whole mass becomes perfectly tender and soft; at which time having strain'd the decoction, beat the remaining gross substance in a stone-mortar, with a wooden pestle, and pass the pulp thro' a hair-sieve turn'd upside-down: then let the decoction and pulp so strain'd be put into a skillet, and having intermixt the meal of line, fenugreek, {334} and oil of lillies; let 'em be boil'd together over a gentle fire, stirring about the ingredients from time to time, till they be all sufficiently thicken'd. these two cataplasms may serve as a model for the making of many others. * * * * * chap. v. _of oils._ oils are made either by infusion or expression. _simple oil of roses made by infusion._ take two pounds of roses newly gather'd, and bruis'd in a mortar; half a pint of the juice of roses, and five pints of common oil: let the whole composition be put into a earthen-vessel, leaded and well stopt, and then let it be expos'd to the sun during forty days. afterward let it be boil'd in _balneo mariæ_; and having strain'd and squeez'd the roses, let the oil be kept for use. _compound oil of roses made by infusion._ take a pound of red roses newly gather'd, and pound 'em in a mortar; as also four ounces of the juice of red roses, and two quarts of common oil. let the whole composition be put into an earthen-vessel leaded, the mouth {335} of which is narrow, and well stopt; and then having expos'd it to the sun during four days, let it be set in _balneo mariæ_ for an hour, and then strain'd and squeez'd. afterward let this liquor be put into the same vessel, adding to it the juice of roses, and roses themselves, in the same quantity as before: let the vessel be stopt; let the maceration, boiling, straining, and expression be made in like manner as before; and let the same operation be once more re-iterated: then let your oil be depurated, and preserv'd for use. these oils qualifie and disperse defluctions of humours, suppress inflammations, mitigate the head-ach and _deliriums_, and provoke to sleep. they must be warm'd before the parts are anointed with 'em, and they may be given inwardly against the bloody-flux and worms, the dose being from half an ounce to a whole ounce. the parts are also anointed with 'em in fractures and dislocations of the bones, and _oxyrodins_ are made of 'em with an equal quantity of vinegar of roses. _oil of sweet almonds made by expression._ take new almonds that are fat and very dry, without their shells, and having shaken 'em in a somewhat thick sieve, to cause the dust to fall off; let 'em be put into hot water till their skins become tender, so that they may be separated by squeezing 'em with the fingers: afterward having taken off the skin, they must be wip'd with a white linnen-cloth, and spread upon it to be dry'd: then they are {336} to be put into a stone-mortar, and pounded with a wooden-pestle, till the paste grows very thin, and begins to give oil: this paste is to be put into a little linnen-bag, new and strong, the mouth of which hath been well ty'd; and the bag is to be plac'd between two platines of tin, or of wood lin'd on the inside with a leaf of tin, squeezing the whole mass gently at first; but afterward very strongly, and leaving it for a long while in the press, that the oil may have time to run out. this oil mitigates the nephritick colicks, remedies the retention of urine, facilitates child-birth, allayes the after-pains in women after their delivery, and the gripes in young infants: it is taken inwardly fasting from half an ounce to two ounces; and it is us'd in liniments to asswage and mollifie. the oils of common wall-nuts and small-nuts, may be also prepar'd after the same manner as that of sweet-almonds. _the oil of bayes._ take as much as you please of laurel or bay-berries, well cleans'd, perfectly ripe, and soundly bruis'd; let 'em be put into a kettle, and boil'd with a sufficient quantity of water during half an hour; then strain and squeeze 'em strongly; let the liquor cool, and scum off the fat that swims upon the water: afterward pound the remaining substance in a mortar, and cause it to be boil'd again for half an hour, with some of the first water which was left, adding a little fresh; then strain and squeez it, {337} as before, and take off the oil that swims on the top. but the first oil is better than the second, and therefore ought to be kept separately. the oils of berries of mastick, myrtle, and other oleaginous plants, may be extracted after the same manner. the oil of bayes mollifies, attenuates, and is opening and discussive: it is very good against the palsie, and the shiverings or cold fits of a feaver or ague in anointing the back; as also against scabs, tetters, _&c._ _the oil of eggs by expression._ take newly laid eggs, and let 'em be harden'd in water; then separate the yolks, and put 'em into a frying-pan over a gentle coal-fire, stirring 'em about from time to time, and at last without discontinuing, till they grow reddish, and begin to yield their oil: then they are to be sprinkl'd with spirit of wine, and pour'd very hot into a little linnen-bag, which is to be ty'd, and set in a press between two heated platines; so that the oil may be squeez'd out as readily as is possible. this oil mitigates the pains of the ears and hæmorrhoids, cures scabs and ring-worms or tetters; as also chaps and clefts in the breast, hands, feet, and fundament; and is made use of in burns, _&c._ * * * * * {338} chap. vi. _of _collyrium_'s._ _collyrium's_ are medicines prepar'd for the diseases of the eyes: the following is that of _lanfrancus_. take a pint of white-wine, three pints of plantain-water, three pounds of roses, two drams of _orpiment_, one dram of verdegrease; myrrh and aloes, of each two scruples. the _orpiment_, verdegrease, myrrh, and aloes are to be beaten to a fine powder before they are intermixt with the liquors. this _collyrium_ is not only good for the eyes, but is also of use to make injections into the privy-parts of men and women; but before the injections are made, it ought to be sweeten'd with three or four times the quantity in weight of rose, plantain, or morel-water. _a dry _collyrium_._ take two drams of sugar-candy; prepar'd tutty, lizard's-dung, of each one dram; white vitriol, sucotrin aloes, and _sal saturni_, of each half a dram. let the whole composition be reduc'd to a very fine powder, and mixt together: two or three grains of this powder may be blown at {339} once into the eye with a small quill, pipe of straw, or reed, as long as it is necessary; and the same powder may also be steept in ophthalmick waters, to make a liquid _collyrium_. _a blue _collyrium_._ take a pint of water in which unslackt lime has been quench'd, and a dram of _sal ammoniack_ pulveriz'd; mingle these ingredients together in a brass-bason, and let 'em be infus'd during a whole night; then filtrate the liquor and keep it for use. this _collyrium_ is one of the best medicines that can be prepar'd for all manner of diseases of the eyes. * * * * * chap. vii. _of powders._ * * * * * _a powder against madness or frenzy._ take the leaves of rue, vervein, the lesser sage, plantain, polypody, common wormwood, mint, mother-wort, balm, betony, st. _john_'s-wort, and the lesser centory; of every one an equal quantity. these plants must be gather'd in the month of _june_, during the clear and serene weather, {340} and ty'd up in nose-gays, or little bundles; which are to be wrap'd up in paper, and hung in the air to be dry'd in the shade. afterward they are to be pounded in a great brass-mortar, and the powder is to be sifted thro' a silk-sieve. the dose of this powder is from two to three drams, mingl'd with half a dram of the powder of vipers, in half a glass of good white-wine every morning fasting, for fifty one days successively. it has an admirable effect, provided the wounded person be not bit in the head nor face, and that the wound has not been wash'd with water. * * * * * chap. viii. _styptick-water._ take _colcothar_ or red vitriol that remains in the retort after the spirit has been drawn off, burnt allom, and sugar-candy, of each thirty grains; the urine of a young person, and rose-water, of each half an ounce; and two ounces of plantain-water: let the whole mixture be stirr'd about for a long time, and then put into a vial. but the liquor must be pour'd off by inclination when there shall be occasion to take any for use. {341} if a bolster steept in this water be laid upon an open artery, and held close with the hand, it will soon stop the blood; a small tent may be also soakt in it, and put up into the nose for the same purpose. if it be taken inwardly, it stops the spitting of blood, and the dysentery or bloody-flux; as also the hæmorrhoidal and menstruous fluxes; the dose being from half a dram to two drams, in knot-grass-water. * * * * * _finis._ * * * * * a table of the chapters and of the principal matters which are contain'd in every _chapter_. * * * * * chap. i. _of the qualifications of a surgeon, and the art of surgery,_ page 1 _of _synthesis_, _diæresis_, _exæresis_, and _prosthesis__ 2 _what ought to be observ'd before the undertaking of an operation_ 3 chap. ii. _of chirurgical instruments, portable and not portable_ 5 chap. iii. _of anatomy in general, and in particular of all the parts of which the human body is compos'd_ 7 chap. iv. _of the general division of a human body_ 10 chap. v. _of the skeleton_ 12 _of the different kinds of articulations,_ 14 _of the number of the bones of the human skeleton_ 16 chap. vi. _of myology, or the description and anatomy of the muscles of the human body_ 19 chap. vii. _of the myology or anatomy of the muscles of the head_ 21 chap. viii. _of the myology or anatomy of the muscles of the chest, or of the breast, belly, and back_ 31 chap. ix. _of the myology or anatomy of the muscles of the lower belly_ 34 _of the muscles of the parts that serve for generation in both sexes_ 36 chap. x. _of the muscles of the shoulder-blades, arms and hands._ 37 chap. xi. _of the muscles of the thighs, legs, and feet,_ 48 _a list of all the muscles of the humane body,_ 57 chap. xii. _of the anatomy of the nerves, arteries, and veins in general_ 58 _of the structure of the four tunicks of the arteries_ 61 _of the structure of the four tunicks of the veins_ 63 _of the beginning and origine of all the veins_ 64 _of the distribution of the ascending _vena cava__ ibid. chap. xiii. _of the anatomy of the _abdomen_ or lower belly,_ 66 _of the opening of a dead body at a publick dissection_ 67 _of the _peristaltick_ motion of the guts_ 71 _of the parts appointed for generation in men_ 74 _of the parts appropriated to generation in women_ 75 chap. xiv. _of the anatomy of the breast, or middle _venter_,_ 77 _the manner of opening the breast in order to dissect it_ ibid. chap. xv. _of the anatomy of the head or upper _venter_,_ 80 _an exact historical account of the holes of the skull, and the vessels that pass thro' 'em_ 83 _the manner of opening the head, and anatomizing the brain_ 91 chap. xvi. _of straps, swathing-bands, bandages, bolsters, and tents_ 93 a treatise of chirurgical diseases. chap. i. _of tumours in general, impostumes or abcesses, breakings out, pustules, and tubercles_ 97 chap. ii. _of the general method to be observ'd in the curing of tumours_ 100 _how many several ways may all curable tumours be terminated_ 101 _what are the best means of curing impostumes, whether to dissolve, or to bring 'em to suppuration_ ibid. _of the circumstances, to be observ'd by a surgeon in the opening of tumours_ 102 _of the general causes of tumours_ 103 chap. iii. _of natural tumours, and first of the _phlegmon_, and its dependances_ 104 _of remedies proper for the _phlegmon__ 105 _remedies for the curing of _aneurisms_ and _varices__ 108 _remedies for _echymoses_, contusions, or bruises_ 109 _of tumours, and their remedies_ 110 _of a gangrene_ 111 _remedies for a gangrene_ 113 _of kibes and chilblains, and their remedies_ 114 _of the _panaritium_ and its remedies_ ibid. _of a burn and its remedies_ 115 _of the _erysipelas_ and its dependences_ 116 _remedies for the _erysipelas__ ibid. _of _erysipelatous_ tumours or impostumes, and their remedies_ 118 _of the _oedema_, and its proper remedies,_ 119 _of _oedomatous_ tumours and impostumes_ 120 _of a _scirrhus_ and its remedies_ 123 _of _scirrhous_ tumours_ 124 _remedies for the _polypus__ 125 _of cancers_ 126 _remedies for cancers_ ibid. _and_ 127 chap. iv. _of bastard or _encysted_ tumours_ 128 _of the remedies for _encysted_ tumours_ 129 chap. v. _of critical, malignant, pestilential, and venereal tumours and impostumes_ 131 chap. vi. _of the scurvy,_ 133 a treatise of wounds, ulcers, and sutures, chap. i. _of sutures or stitches,_ 138 chap. ii. _of wounds in general_ 141 _of remedies proper to stop the hæmorrhage of a wound_ 143 _what is to be done when a convulsion happens in a wound, by reason of a wounded nerve or tendon_ 144 _what course is to be taken to draw extraneous bodies out of a wound_ 145 _of vulnerary decoctions to be taken inwardly_ 148 chap. iii. _of the particular wounds of the head_ 149 chap. iv. _of the particular wounds of the breast_ 151 chap. v. _of the particular wounds of the lower belly_ 153 chap. vi. _of wounds made by guns or fire-arms_ 154 _of the prognostick of wounds by gun-shot_ 155 _of the cure of wounds by gun-shot_ ibid. _of a burn made by gun-powder_ 159 chap. vii. _of ulcers in general_ 164 chap. viii. _of venereal diseases_ 168 _of the _chaude-pisse_ or _gonorrhæa__ ibid. _of shankers_ 170 _of bubo's_ ibid. _of the pox_ 171 _the manner of making the _mercurial panacæa__ 175, &c. a treatise of the diseases of the bones. chap. i. _of the dislocation of bones_ 181 chap. ii. _of the fractures of bones_ 187 chap. iii. _of the particular fractures of the skull_ 192 chap. iv. _of the _caries_, _exostoses_, and _nodus_ of the bones_ 197 chap. v. _of cauteries, vesicatories, setons, cupping-glasses, and leeches_ 199 _of the compounding of potential cauteries_ 201 chap. vi. _of phlebotomy_ 204 a treatise of chirurgical operations. chap. i. _of the operation of the _trepan__ 209 _of the bandage of the _trepan__ 213 chap. ii. _of the operation of the _fistula lachrymalis__ 214 _the dressing and bandage of the _fistula lachrymalis__ 215 chap. iii. _of the operation of the cataract_ 216 _the dressing and bandage of the operation of the cataract_ 217 _of purulent matter gather'd under the corneous tunicle of the eye_ 218 _of a tumour that ariseth in the eye,_ ibid. _of the eye-lids glu'd together_ ibid. _of the hairs of the eye-brows that offend the eye_ 219 _of the hard and transparent tumours on the eye-lids_ ibid. chap. iv. _of the operation of the _polypus__ ibid. chap. v. _of the operation of the hare-lip_ 220 _the dressing and bandage for the hare-lip_ 221 chap. vi. _of the operation of _bronchotomy__ 222 chap. vii. _of the operation of the _uvula__ 223 chap. viii. _of the operation of a cancer in the breast_ ibid. _the dressing and bandage of the breast_ 225 chap. ix. _the operation of the _empyema__ 227 _the dressing and bandage for the operation of the _empyema__ 228 chap. x. _of the operation of the _paracentesis_ of the lower belly_ 229 _the dressing and bandage for that _paracentesis__ 230 _the operation of the _parcentesis_ of the _scrotum__ ibid. chap. xi. _of the operation of _gastroraphy__ 231 chap. xii. _of the operation of _exomphalus__ 234 chap. xiii. _of the operation of the _bubonocele_, and of the compleat rupture_ 236 _the dressing and bandage_ 237 _of the compleat rupture_ ibid. chap. xiv. _of the operation of _castration__ 238 _of the dressing and bandage for the _castration__ 239 chap. xv. _of the operation of the stone in the _ureter__ 240 chap. xvi. _of the operation of _lithotomy__ 241 _the dressing and bandage for the operation of _lithotomy__ 243 _of the operation of _lithotomy_ in women by the lesser preparative_ 244 chap. xvii. _of the operation of the puncture of the _perinæum__ 245 chap. xviii. _of the operation of the _fistula in ano__ ibid. chap. xix. _of the suture of stitching of a tendon_ 247 chap. xx. _of the _cæsarian_ operation_ 248 chap. xxi. _of the operation of _amputation_; with its proper dressings and bandages_ 249 and 251 chap. xxii. _of the operation of the _aneurism__ 253 _the bandage for the _aneurism__ 255 chap. xxiii. _of the operation of _phlebotomy__ ibid. _the bandage in _phlebotomy__ 256 chap. xxiv. _of the operation of _encysted_ tumours_ 257 _of _ganglions__ 258 chap. xxv. _of the operation of _hydrocephalus__ ibid. chap. xxvi. _of the operation of cutting the tongue-string_ 259 chap. xxvii. _of the operation of opening stopt _ductus_'s_ 260 _of an incision made to open the _vagina uteri__ ibid. _the manner of separating the lips of the _pudendum_ when conglutinated_ ibid. _the manner of opening the _vagina_ when stopt with a fleshy substance_ ibid. _the method of opening the urinary _ductus_ as well in boys as in young virgins_ ibid. _the method of opening the _ductus_ of the ear, when stopt with a membrane or a carnous substance_ 261 chap. xxviii. _of the operation of the _phimosis_ and _paraphimosis__ ibid. chap. xxix. _of the operation of the _varix__ 262 chap. xxx. _of the operation of the _panaritium__ 263 _the dressing and bandage for this operation_ ibid. chap. xxxi. _of the reduction of the falling of the _anus__ 264 chap. xxxii. _of the reducing of the falling of the _matrix__ 265 chap. xxxiii. _of the application of the cautery and its bandage_ ibid. chap. xxxiv. _of the application of leeches, and the dressing_ 267 chap. xxxv. _of the application of the _seton__ 268 chap. xxxvi. _of scarifications_ 269 chap. xxxvii. _of the application of _vesicatories__ ibid. chap. xxxviii. _of the application of cupping-glasses_ 270 chap. xxxix. _of the opening of abscesses or impostumes_ 271 a treatise of the operations of fractures. chap. i. _of the fracture of the nose_ 272 _the dressing and bandage for the fracture of the nose_ 273 chap. ii. _of the fracture of the lower jaw_ 274 _the dressing and bandage_ ibid. chap. iii. _of the fracture of the _clavicle__ 276 _the dressing and bandage_ ibid. chap. iv. _of the fracture of the _omoplata_ or shoulder-blade_ 278 _the dressing_ ibid. chap. v. _of the fracture of the ribs_ 279 _the dressing and bandage_ 280 chap. vi. _of the fracture of the _sternum_ or breast-bone_ ibid. _the dressing and bandage_ 281 chap. vii. _of the fracture of the _vertebra's__ ibid. chap. viii. _of the fracture of the _os sacrum__ 283 chap. ix. _of the fracture of the _coccyx_ or rump-bone_ ibid. _the dressing and bandage for that fracture_ 284 chap. x. _of the fracture of the _humerus_ or arm-bone_ ibid. _its proper dressing and bandage_ 285 chap. xi. _of the fracture of the bone of the elbow_ 286 _the dressing and bandage_ ibid. chap. xii. _of the fracture of the _carpus_ or wrist-bone_ 287 _the dressing and bandage_ ibid. chap. xiii. _of the fracture of the bone of the _metacarpium_ or back of the hand_ 288 _the dressing and bandage_ ibid. chap. xiv. _of the fracture of the bones of the fingers_ 289 chap. xv. _of the fracture of the thigh-bone_ ibid. _the dressing and bandage_ 290 chap. xvi. _of the fracture of the _patella_ or knee-pan_ 291 _the dressing and bandage_ ibid. chap. xvii. _of the fracture of the leg-bone_ 292 _its proper dressing and bandage_ 293 _the dressing for complicated fractures_ 294 chap. xviii. _of the fracture of the bones of the foot_ 295 _the dressing and bandage_ 296 a treatise of the operations which are perform'd in luxations. chap. i. _of the luxation of the bone of the nose_ 297 _the dressing and bandage proper for such a luxation_ 298 chap. ii. _of the luxation of the lower jaw-bone_ ibid. _the dressing and bandage_ 299 chap. iii. _of the luxation of the _clavicle__ ibid. chap. iv. _of the luxation of the _vertebra_'s_ 300 _the dressing and bandage_ 301 chap. v. _of the luxation of the _coccyx_ or rump-bone_ 302 chap. vi. _of the bunch_ ibid. chap. vii. _of the luxation of the ribs_ 303 _the dressing and bandage_ ibid. chap. viii. _of the sinking of the _xiphoides_ or sword-like cartilage_ 304 chap. ix. _of the luxation of the _humerus_ or arm-bone,_ ibid. _the dressing and bandage_ 306 chap. x. _of the luxation of the bone of the elbow_ ibid. _the bandage for the same luxation_ 307 chap. xi. _of the luxation of the _carpus_ or wrist-bone_ 308 _the bandage_ 309 chap. xii. _of the luxation of the bones of the fingers_ ibid. _the bandage for that luxation_ ibid. chap. xiii. _of the luxation of the thigh_ 310 _its proper dressing and bandage_ 312 chap. xiv. _of the luxation of the knee_ ibid. _the bandage_ 313 chap. xv. _of the luxation of the _patella_, knee-pan, or whirl-bone of the knee_ ibid. _of the separation of the _perone_ from the_ tibia ibid. _of the luxation of the _astragalus__ 314 _of the separation of the _calcaneum_ from the _astragalus__ ibid. a treatise of medicinal compositions necessary for a surgeon. chap. i. _of balsams_ 315 _the balsam of _arcæus__ ibid. _the balsam of _spain__ 316 _the green balsam_ 317 _the _samaritan_ balsam_ 318 chap. ii. _of ointments_ 319 __unguentum althææ__ ibid. _the mundificative ointment of smallage_ 320 _the black or suppurative ointment_ 321 __unguentum rosatum__ 322 __unguentum album, aut de cerussa__ 323 __unguentum ægyptiacum__ 324 __unguentum basilicon_, or the royal ointment_ 325 _a cooling cerate_ 326 _an ointment for burns_ 327 chap. iii. _of plaisters_ 328 _of plaister of _diapalma__ ibid. _the plaister of simple _diachylum__ 329 _the plaister of _andreas crucius__ 330 __emplastrum divinum__ 331 chap. iv. _of the cataplasms or pultisses_ 332 chap. v. _of oils_ 334 _simple oil of roses made by infusion_ ibid. _compound oil of roses made by infusion_ ibid. _oil of sweet almonds made by expression_ 335 _oil of bayes_ 336 _oil of eggs made by expression_ 337 chap. vi. _of _collyriums__ 338 _a dry _collyrium__ ibid. _a blue _collyrium__ 339 chap. vii. _of powders_ ibid. _a powder against madness or frenzy_ ibid. chap. viii. _a styptick water_ 340 the end of the table. * * * * * transcriber's note: changes made to the printed copy. page 20. "causeth the antagonist to swell": 'anatgonist' in original. page 29. "which arising from the fore-part on the inside": 'ari-rising' on line break in original. page 30. "the scalenus or triangularis": 'scalenu' in original. page 36. "round ligament of the matrix": 'liga-' appears only as the catch-word in original. page 113. "the mortify'd and corrupt parts": 'morrify'd' in original. page 117. "and often renew'd": 'ond often renew'd' in original. page 118. "tumours or impostumes that partake": 'parrake' in original. page 130. "reiterated purgations": 'reirerated' in original. page 146. "oyl of hemp-seed": 'hmp-seed' in original. page 160. "which may be laid altogether": 'be be' in original. page 180. "all sorts of venereal diseases": 'venenereal' in original. page 202. "in what parts is the seton to be apply'd?": 'to seton be' in original. page 216. "taking a steel-needle": 'a a' on line break in original. page 229. "this dressing is to be kept close": 'kepc' in original. page 237. "to make a good cicatrice or scar.": 'to to' on line break in original. page 249-50. "the periosteum is to be scrap'd": 'be' catch-word only, not in text in original. page 252. "round about the stump": 'the about the' in original. page 269. "with a warm cloth": 'wram' in original. page 288. "the shape of the part": 'skape' in original. page 299. "but remains somewhat open": 're-remains' on line break in original. page 302. "requisite to keep emollients": 'lo keep' in original. toc. "of the muscles of the parts that serve for generation": 'geration' in original. the harvard classics volume 38 scientific papers (physiology, medicine, surgery, geology) contents the oath of hippocrates the law of hippocrates journeys in diverse places ... ambroise pare translated by stephen paget on the motion of the heart and blood in animals william harvey. . . translated by robert willis the three original publications on vaccination against smallpox . ... .. edward jenner the contagiousness of puerperal fever o. w. holmes on the antiseptic principle of the practice of surgery lord lister the physiological theory of fermentation louis pasteur translated by f. faulkner and d. c. robb (revised) the germ theory and its applications to medicine and surgery (revised) . ... .. louis pasteur translated by h. c. ernst on the extension of the germ theory to the etiology of certain common diseases (revised) louis pasteur translated by h. c. ernst prejudices which have retarded the progress of geology. ... . ... .. sir charles lyell uniformity in the series of past changes in the animate and inanimate world sir charles lyell introductory note hippocrates, the celebrated greek physician, was a contemporary of the historian herodotus. he was born in the island of cos between 470 and 460 b. c., and belonged to the family that claimed descent from the mythical aesculapius, son of apollo. there was already a long medical tradition in greece before his day, and this he is supposed to have inherited chiefly through his predecessor herodicus; and he enlarged his education by extensive travel. he is said, though the evidence is unsatisfactory, to have taken part in the efforts to check the great plague which devastated athens at the beginning of the peloponnesian war. he died at larissa between 380 and 360 b. c. the works attributed to hippocrates are the earliest extant greek medical writings, but very many of them are certainly not his. some five or six, however, are generally granted to be genuine, and among these is the famous "oath." this interesting document shows that in his time physicians were already organized into a corporation or guild, with regulations for the training of disciples, and with an esprit de corps and a professional ideal which, with slight exceptions, can hardly yet be regarded as out of date. one saying occurring in the words of hippocrates has achieved universal currency, though few who quote it to-day are aware that it originally referred to the art of the physician. it is the first of his "aphorisms": "life is short, and the art long; the occasion fleeting; experience fallacious, and judgment difficult. the physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate." the oath of hippocrates i swear by apollo the physician and aesculapius, and health, and all-heal, and all the gods and goddesses, that, according to my ability and judgment, i will keep this oath and this stipulation --to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, i will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. i will follow that system of regimen which, according to my ability and judgment, i consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. i will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner i will not give to a woman a pessary to produce abortion. with purity and with holiness i will pass my life and practice my art. i will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. into whatever houses i enter, i will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. whatever, in connection with my professional practice, or not in connection with it, i see or hear, in the life of men, which ought not to be spoken of abroad, i will not divulge, as reckoning that all such should be kept secret. while i continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. but should i trespass and violate this oath, may the reverse be my lot. the law of hippocrates medicine is of all the arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts. their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medicine (and with it alone) except disgrace, and that does not hurt those who are familiar with it. such persons are like the figures which are introduced in tragedies, for as they have the shape, and dress, and personal appearance of an actor, but are not actors, so also physicians are many in title but very few in reality. 2. whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advantages: a natural disposition; instruction; a favorable position for the study; early tuition; love of labour; leisure. first of all, a natural talent is required; for, when nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming an early pupil in a place well adapted for instruction. he must also bring to the task a love of labour and perseverance, so that the instruction taking root may bring forth proper and abundant fruits. 3. instruction in medicine is like the culture of the productions of the earth. for our natural disposition, is, as it were, the soil; the tenets of our teacher are, as it were, the seed; instruction in youth is like the planting of the seed in the ground at the proper season; the place where the instruction is communicated is like the food imparted to vegetables by the atmosphere; diligent study is like the cultivation of the fields; and it is time which imparts strength to all things and brings them to maturity. 4. having brought all these requisites to the study of medicine, and having acquired a true knowledge of it, we shall thus, in travelling through the cities, be esteemed physicians not only in name but in reality. but inexperience is a bad treasure, and a bad fund to those who possess it, whether in opinion or reality, being devoid of self-reliance and contentedness, and the nurse both of timidity and audacity. for timidity betrays a want of powers, and audacity a lack of skill. they are, indeed, two things, knowledge and opinion, of which the one makes its possessor really to know, the other to be ignorant. 5. those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated in the mysteries of the science. journeys in diverse places by ambroise pare translated by stephen paget ambroise pare was born in the village of bourg-hersent, near laval, in maine, france, about 1510. he was trained as a barbersurgeon at a time when a barber-surgeon was inferior to a surgeon and the professions of surgeon and physician were kept apart by the law of the church that forbade a physician to shed blood. under whom he served his apprenticeship is unknown, but by 1533 he was in paris, where he received an appointment as house surgeon at the hotel dieu. after three or four years of valuable experience in this hospital, he set up in private practise in paris, but for the next thirty years he was there only in the intervals of peace; the rest of the time he followed the army. he became a master barber-surgeon in 1541. in pare's time the armies of europe were not regularly equipped with a medical service. the great nobles were accompanied by their private physicians; the common soldiers doctored themselves, or used the services of barber-surgeons and quacks who accompanied the army as adventurers. "when pare joined the army" says paget, "he went simply as a follower of colonel montejan, having neither rank, recognition, nor regular payment. his fees make up in romance for their irregularity: a cask of wine, fifty double ducats and a horse, a diamond, a collection of crowns and half-crowns from the ranks, other honorable presents and of great value'; from the king himself, three hundred crowns, and a promise he would never let him be in want; another diamond, this time from the finger of a duchess: and a soldier once offered a bag of gold to him." when pare was a man of seventy, the dean of the faculty of medicine in paris made an attack on him on account of his use of the ligature instead of cauterizing after amputation. in answer, pare appealed to his successful experience, and narrated the "journeys in diverse places" here printed. this entertaining volume gives a vivid picture, not merely of the condition of surgery in the sixteenth century, but of the military life of the time; and reveals incidentally a personality of remarkable vigor and charm. pare's own achievements are recorded with modest satisfaction: "i dressed him, and god healed him," is the refrain. pare died in paris in december, 1590. journeys in diverse places [footnote: the present translation is taken from mr. stephen paget's "ambroise pare and his times" by arrangement with messrs. g. p. putnam's sons.] 1537-1569 the journey to turin. 1537 i will here shew my readers the towns and places where i found a way to learn the art of surgery: for the better instruction of the young surgeon. and first, in the year 1536, the great king francis sent a large army to turin, to recover the towns and castles that had been taken by the marquis du guast, lieutenant-general of the emperor. m. the constable, then grand master, was lieutenant-general of the army, and m. de montejan was colonel-general of the infantry, whose surgeon i was at this time. a great part of the army being come to the pass of suze, we found the enemy occupying it; and they had made forts and trenches, so that we had to fight to dislodge them and drive them out. and there were many killed and wounded on both sides,--but the enemy were forced to give way and retreat into the castle, which was captured, part of it, by captain le rat, who was posted on a little hill with some of his soldiers, whence they fired straight on the enemy. he received an arquebus-shot in his right ankle, and fell to the ground at once, and then said, "now they have got the rat." i dressed him, and god healed him. we entered pell-mell into the city, and passed over the dead bodies, and some not yet dead, hearing them cry under our horses' feet; and they made my heart ache to hear them. and truly i repented i had left paris to see such a pitiful spectacle. being come into the city, i entered into a stable, thinking to lodge my own and my man's horse, and found four dead soldiers, and three propped against the wall, their features all changed, and they neither saw, heard, nor spake, and their clothes were still smouldering where the gunpowder had burned them. as i was looking at them with pity, there came an old soldier who asked me if there were any way to cure them; i said no. and then he went up to them and cut their throats, gently, and without ill will toward them. seeing this great cruelty, i told him he was a villain: he answered he prayed god, when he should be in such a plight, he might find someone to do the same for him; that he should not linger in misery. to come back to my story, the enemy were called on to surrender, which they did, and left the city with only their lives saved, and the white stick in their hands; and most of them went off to the chateau de villane, where about two hundred spaniards were stationed. m. the constable would not leave these behind him, wishing to clear the road for our own men. the castle is seated on a small hill; which gave great confidence to those within, that we could not bring our artillery to bear upon them. they were summoned to surrender, or they would be cut in pieces: they answered that they would not, saying they were as good and faithful servants of the emperor, as m. the constable could be of the king his master. thereupon our men by night hoisted up two great cannons, with the help of the swiss soldiers and the lansquenets; but as ill luck would have it, when the cannons were in position, a gunner stupidly set fire to a bag full of gunpowder, whereby he was burned, with ten or twelve soldiers; and the flame of the powder discovered our artillery, so that all night long those within the castle fired their arquebuses at the place where they had caught sight of the cannons, and many of our men were killed and wounded. next day, early in the morning, the attack was begun, and we soon made a breach in their wall. then they demanded a parley; but it was too late, for meanwhile our french infantry, seeing them taken by surprise, mounted the breach, and cut them all in pieces, save one very fair young girl of piedmont, whom a great seigneur would have. ... the captain and the ensign were taken alive, but soon afterward hanged and strangled on the battlements of the gate of the city, to give example and fear to the emperor's soldiers, not to be so rash and mad as to wish to hold such places against so great an army. the soldiers within the castle, seeing our men come on them with great fury, did all they could to defend themselves, and killed and wounded many of our soldiers with pikes, arquebuses, and stones, whereby the surgeons had all their work cut out for them. now i was at this time a fresh-water soldier; i had not yet seen wounds made by gunshot at the first dressing. it is true i had read in john de vigo, first book, of wounds in general, eighth chapter, that wounds made by firearms partake of venenosity, by reason of the powder; and for their cure he bids you cauterise them with oil of elders scalding hot, mixed with a little treacle. and to make no mistake, before i would use the said oil, knowing this was to bring great pain to the patient, i asked first before i applied it, what the other surgeons did for the first dressing; which was to put the said oil, boiling well, into the wounds, with tents and setons; wherefore i took courage to do as they did. at last my oil ran short, and i was forced instead thereof to apply a digestive made of the yolks of eggs, oil of roses, and turpentine. in the night i could not sleep in quiet, fearing some default in not cauterising, that i should find the wounded to whom i had not used the said oil dead from the poison of their wounds; which made me rise very early to visit them, where beyond my expectation i found that those to whom i had applied my digestive medicament had but little pain, and their wounds without inflammation or swelling, having rested fairly well that night; the others, to whom the boiling oil was used, i found feverish, with great pain and swelling about the edges of their wounds. then i resolved never more to burn thus cruelly poor men with gunshot wounds. while i was at turin, i found a surgeon famed above all others for his treatment of gunshot wounds; into whose favour i found means to insinuate myself, to have the recipe of his balm, as he called it, wherewith he dressed gunshot wounds. and he made me pay my court to him for two years, before i could possibly draw the recipe from him. in the end, thanks to my gifts and presents, he gave it to me; which was to boil, in oil of lilies, young whelps just born, and earth-worms prepared with venetian turpentine. then i was joyful, and my heart made glad, that i had understood his remedy, which was like that which i had obtained by chance. see how i learned to treat gunshot wounds; not by books. my lord marshal montejan remained lieutenant-general for the king in piedmont, having ten or twelve thousand men in garrison in the different cities and castles, who were often fighting among themselves with swords and other weapons, even with arquebuses. and if there were four wounded, i always had three of them; and if there were question of cutting off an arm or a leg, or of trepanning, or of reducing a fracture or a dislocation, i accomplished it all. the lord marshal sent me now hire now there to dress the soldiers committed to me who were wounded in other cities beside turin, so that i was always in the country, one way or the other. m. the marshal sent to milan, to a physician of no less reputation than the late m. le grand for his success in practice, to treat him for an hepatic flux, whereof in the end he died. this physician was some while at turin to treat him, and was often called to visit the wounded, where always he found me; and i was used to consult with him, and with some other surgeons; and when we had resolved to do any serious work of surgery, it was ambroise pare that put his hand thereto, which i would do promptly and skilfully, and with great assurance, insomuch that the physician wondered at me, to be so ready in the operations of surgery, and i so young. one day, discoursing with the lord marshal, he said to him: "signor, tu hai un chirurgico giovane di anni, ma egli e vecchio di sapere e di esperientia: guardato bene, perche egli ti fara servicio et honore." that is to say, "thou hast a surgeon young in age, but he is old in knowledge and experience: take good care, of him, for he will do thee service and honour." but the good man did not know i had lived three years at the hotel dieu in paris, with the patients there. in the end, m. the marshal died of his hepatic flux. he being dead, the king sent m. the marshal d'annebaut to be in his place: who did me the honour to ask me to live with him, and he would treat me as well or better than m. the marshal de montejan. which i would not do, for grief at the loss of my master, who loved me dearly; so i returned to paris. the journey to marolle and low brittany. 1543 i went to the camp of marolle, with the late m. de rohan, as surgeon of his company; where was the king himself. m. d'estampes, governor of brittany, had told the king how the english had hoist sail to land in low brittany; and had prayed him to send, to help him, mm. de rohan and de laval, because they were the seigneurs of that country, and by their help the country people would beat back the enemy, and keep them from landing. having heard this, the king sent these seigneurs to go in haste to the help of their country; and to each was given as much power as to the governor, so that they were all three the king's lieutenants. they willingly took this charge upon them, and went off posting with good speed, and took me with them as far as landreneau. there we found every one in arms, the tocsin sounding on every side, for a good five or six leagues round the harbours, brent, couquet, crozon, le fou, doulac, laudanec; each well furnished with artillery, as cannons, demi-cannons, culverins, muskets, falcons, arquebuses; in brief, all who came together were well equipped with all sorts and kinds of artillery, and with many soldiers, both breton and french, to hinder the english from landing as they had resolved at their parting from england. the enemy's army came right under our cannons: and when we perceived them desiring to land, we saluted them with cannonshot, and unmasked our forces and our artillery. they fled to sea again. i was right glad to see their ships set sail, which were in good number and good order, and seemed to be a forest moving upon the sea. i saw a thing also whereat i marvelled much, which was, that the balls of the great cannons made long rebounds, and grazed over the water as they do over the earth. now to make the matter short, our english did us no harm, and returned safe and sound into england. and they leaving us in peace, we stayed in that country in garrison until we were assured that their army was dispersed. now our soldiers used often to exercise themselves with running at the ring, or with fencing, so that there was always some one in trouble, and i had always something to employ me. m. d'estampes, to make pastime and pleasure for the seigneurs de rohan and de laval, and other gentlemen, got a number of village girls to come to the sports, to sing songs in the tongue of low brittany: wherein their harmony was like the croaking of frogs when they are in love. moreover, he made them dance the brittany triori, without moving feet or hips: he made the gentlemen see and hear many good things. at other tunes they made the wrestlers of the towns and villages come, where there was a prize for the best: and the sport was not ended but that one or other had a leg or arm broken, or the shoulder or hip dislocated. there was a little man of low brittany, of a square body and well set, who long held the credit of the field, and by his skill and strength threw five or six to the ground. there came against him a big man, one dativo, a pedagogue, who was said to be one of the best wrestlers in all brittany: he entered into the lists, having thrown off his long jacket, in hose and doublet: when he was near the little man, it looked as though the little man had been tied to his girdle. nevertheless, when they gripped each other round the neck, they were a long time without doing anything, and we thought they would remain equal in force and skill: but the little man suddenly leaped beneath this big dativo, and took him on his shoulder, and threw him to earth on his back all spread out like a frog; and all the company laughed at the skill and strength of the little fellow. the great dativo was furious to have been thus thrown to earth by so small a man: he rose again in a rage, and would have his revenge. they took hold again round the neck, and were again a good while at their hold without falling to the ground: but at last the big man let himself fall upon the little, and in falling put his elbow upon the pit of his stomach, and burst his heart, and killed him stark dead. and knowing he had given him his death's blow, took again his long cassock, and went away with his tail between his legs, and eclipsed himself. seeing the little man came not again to himself, either for wine, vinegar, or any other thing presented to him, i drew near to him and felt his pulse, which did not beat at all: then i said he was dead. then the bretons, who were assisting at the wrestling, said aloud in their jargon, "andraze meuraquet enes rac un bloa so abeuduex henelep e barz an gouremon enel ma hoa engoustun." that is to say, "that is not in the sport." and someone said that this great dativo was accustomed to do so, and but a year past he had done the same at a wrestling. i must needs open the body to know the cause of this sudden death. i found much blood in the thorax. ... i tried to find some internal opening whence it might have come, which i could not, for all the diligence that i could use. ... the poor little wrestler was buried. i took leave of mm. de rohan, de laval, and d'estampes. m. de rohan made me a present of fifty double ducats and a horse, m. de laval gave me a nag for my man, and m. d'estampes gave me a diamond worth thirty crowns: and i returned to my house in paris. the journey to perpignan. 1543 some while after, m. de rohan took me with him posting to the camp at perpignan. while we were there, the enemy sallied out, and surrounded three pieces of our artillery before they were beaten back to the gates of the city. which was not done without many killed and wounded, among the others m. de brissac, who was then grand master of the artillery, with an arquebus-shot in the shoulder. when he retired to his tent, all the wounded followed him, hoping to be dressed by the surgeons who were to dress him. being come to his tent and laid on his bed, the bullet was searched for by three or four of the best surgeons in the army, who could not find it, but said it had entered into his body. at last he called for me, to see if i could be more skilful than they, because he had known me in piedmont. then i made him rise from his bed, and told him to put himself in the same posture that he had when he was wounded, which he did, taking a javelin in his hand just as he had held his pike to fight. i put my hand around the wound, and found the bullet. ... having found it, i showed them the place where it was, and it was taken out by m. nicole lavernot, surgeon of m. the dauphin, who was the king's lieutenant in that army; all the same, the honour of finding it belonged to me. i saw one very strange thing, which was this: a soldier in my presence gave one of his fellows a blow on the head with a halbard, penetrating to the left ventricle of the brain; yet the man did not fall to the ground. he that struck him said he heard that he had cheated at dice, and he had drawn a large sum of money from him, and was accustomed to cheat. they called me to dress him; which i did, as it were for the last time, knowing that he would die soon. when i had dressed him, he returned all alone to his quarters, which were at the least two hundred paces away. i bade one of his companions send for a priest to dispose the affairs of his soul; he got one for him, who stayed with him to his last breath. the next day, the patient sent for me by his girl, dressed in boy's apparel, to come and dress him; which i would not, fearing he would die under my hands; and to be rid of the matter i told her the dressing must not be removed before the third day. but in truth he was sure to die, though he were never touched again. the third day, he came staggering to find me in my tent, and the girl with him, and prayed me most affectionately to dress him, and showed me a purse wherein might be an hundred or sixscore pieces of gold, and said he would give me my heart's desire; nevertheless, for all that, i put off the removal of the dressing, fearing lest he should die then and there. certain gentlemen desired me to go and dress him; which i did at their request; but in dressing him he died under my hands in a convulsion. the priest stayed with him till death, and seized his purse, for fear another man should take it, saying he would say masses for his poor soul. also he took his clothes, and everything else. i have told this case for the wonder of it, that the soldier, having received this great blow, did not fall down, and kept his reason to the end. not long afterward, the camp was broken up from diverse causes: one, because we were told that four companies of spaniards were entered into perpignan: the other, that the plague was spreading through the camp. moreover, the country folk warned us there would soon be a great overflowing of the sea, which might drown us all. and the presage which they had, was a very great wind from sea, which rose so high that there remained not a single tent but was broken and thrown down, for all the care and diligence we could give; and the kitchens being all uncovered, the wind raised the dust and sand, which salted and powdered our meats in such fashion that we could not eat them; and we had to cook them in pots and other covered vessels. nor was the camp so quickly moved but that many carts and carters, mules and mule drivers, were drowned in the sea, with great loss of baggage. when the camp was moved i returned to paris. the journey to landresy. 1544 the king raised a great army to victual landresy. against him the emperor had no fewer men, but many more, to wit, eighteen thousand germans, ten thousand spaniards, six thousand walloons, ten thousand english, and from thirteen to fourteen thousand horse. i saw the two armies near each other, within cannon-shot; and we thought they could not withdraw without giving battle. there were some foolish gentlemen who must needs approach the enemy's camp; the enemy fired on them with light field pieces; some died then and there, others had their arms or legs carried away. the king having done what he wished, which was to victual landresy, withdrew his army to guise, which was the day after all saints, 1544; and from there i returned to paris. a little while after, we went to boulogne; where the english, seeing our army, left the forts which they were holding, moulanabert, le petit paradis, monplaisir, the fort of chastillon, le portet, the fort of dardelot. one day, as i was going through the camp to dress my wounded men, the enemy who were in the tour d' ordre fired a cannon against us, thinking to kill two men-at-arms who had stopped to talk together. it happened that the ball passed quite close to one of them, which threw him to the ground, and it was thought the ball had touched him, which it did not; but only the wind of the ball full against his corselet, with such force that all the outer part of his thigh became livid and black, and he could hardly stand. i dressed him, and made diverse scarifications to let out the bruised blood made by the wind of the ball; and by the rebounds that it made on the ground it killed four soldiers, who remained dead where they fell. i was not far from this shot, so that i could just feel the moved air, without its doing me any harm save a fright, which made me duck my head low enough; but the ball was already far away. the soldiers laughed at me, to be afraid of a ball which had already passed. mon petit maistre, i think if you had been there, i should not have been afraid all alone, and you would have had your share of it. monseigneur the due de guise, francois de lorraine, was wounded before boulogne with a thrust of a lance, which entered above the right eye, toward the nose, and passed out on the other side between the ear and the back of the neck, with so great violence that the head of the lance, with a piece of the wood, was broken and remained fast; so that it could not be drawn but save with extreme force, with smith's pincers. yet notwithstanding the great violence of the blow, which was not without fracture of bones, nerves, veins, and arteries, and other parts torn and broken, my lord, by the grace of god, was healed. he was used to go into battle always with his vizard raised: that is why the lance passed right out on the other side. the journey to germany. 1552 i went to germany, in the year 1552, with m. de rohan, captain of fifty men-at-arms, where i was surgeon of his company, as i have said before. on this expedition, m. the constable was general of the army; m. de chastillon, afterward the admiral, was chief colonel of the infantry, with four regiments of lansquenets under captains recrod and ringrave, two under each; and every regiment was of ten ensigns, and every ensign of five hundred men. and beside these were captain chartel, who led the troops that the protestant princes had sent to the king (this infantry was very fine, and was accompanied by fifteen hundred men-at-arms, with a following of two archers apiece, which would make four thousand five hundred horse); and two thousand light horse, and as many mounted arquebusiers, of whom m. d'aumalle was general; and a great number of the nobility, who were come there for their pleasure. moreover, the king was accompanied by two hundred gentlemen of his household, under the command of the seigneurs de boisy and de canappe, and by many other princes. for his following, to escort him, there were the french and scotch and swiss guards, amounting to six hundred foot soldiers; and the companies of mm. the dauphin, de 'guise, d'aumalle, and marshal saint andre, amounting to four hundred lances; which was a marvellous thing, to see such a multitude; and with this equipage the king entered into toul and metz. i must not omit to say that the companies of mm. de rohan, the comte de sancerre, and de jarnac, which were each of them of fifty horse, went upon the wings of the camp. and god knows how scarce we were of victuals, and i protest before him that at three diverse times i thought to die of hunger; and it was not for want of money, for i had enough of it; but we could not get victuals save by force, because the country people collected them all into the towns and castles. one of the servants of the captain-ensign of the company of m. de rohan went with others to enter a church where the peasants were retreated, thinking to get victuals by love or by forces; but he got the worst of it, as they all did, and came back with seven sword wounds on the head, the least of which penetrated to the inner table of the skull; and he had four other wounds upon the arms, and one on the right shoulder, which cut more than half of the bladebone. he was brought back to his master's lodging, who seeing him so mutilated, and not hoping he could be cured, made him a grave, and would have cast him therein, saying that else the peasants would massacre and kill him: i in pity told him the man might still be cured if he were well dressed. diverse gentlemen of the company prayed he would take him along with the baggage, since i was willing to dress him; to which he agreed, and after i had got the man ready, he was put in a cart, on a bed well covered and well arranged, drawn by a horse. i did him the office of physician, apothecary, surgeon, and cook. i dressed him to the end of his case, and god healed him; insomuch that all the three companies marvelled at this cure; the men-at-arms of the company of m. de rohan, the first muster that was made, gave me each a crown, and the archers half a crown, the journey to danvilliers. 1552 on his return from the expedition against the german camp, king henry besieged danvilliers, and those within would not surrender. they got the worst of it, but our powder failed us; so they had a good shot at our men. there was a culverin-shot passed through the tent of h. de rohan, which hit a gentleman leg who was of his household. i had to finish the cutting off of it, which i did without applying the hot irons. the king sent for powder to sedan, and when it came we began the attack mere vigorously than before, so that a breach was made. mm. de guise and the constable, being in the king's chamber, told him, and they agreed that next day they would assault the town, and were confident they would enter into it; and it must be kept secret, for fear the enemy should come to hear of it; and each promised not to speak of it to any man. now there was a groom of the king's chamber, who being laid under the king's camp-bed to sleep, heard they were resolved to attack the town next day. so he told the secret to a certain captain, saying that they would make the attack next day for certain, and he had heard it from the king, and prayed the said captain to speak of it to no man, which he promised; but his promise did not hold, and forthwith he disclosed it to a captain, and this captain to a captain, and the captains to some of the soldiers, saying always, "say nothing." and it was just so much hid, that next day early in the morning there was seen the greater part of the soldiers with their boots and breeches cut loose at the knee for the better mounting of the breach. the king was told of this rumour that ran through the camp, that the attack was to be made; whereat he was astonished, seeing there were but three in that advice, who had promised each other to tell it to no man. the king sent for m. de guise, to know if he had spoken of this attack; he swore and affirmed to him he had not told it to anybody; and m. the constable said the same, and told the king they must know for certain who had declared this secret counsel, seeing they were but three. inquiry was made from captain to captain. in the end they found the truth; for one said, "it was such an one told me," and another said the same, till it came to the first of all, who declared he had heard it from the groom of the king's chamber, called guyard, a native of blois, son of a barber of the late king francis. the king sent for him into his tent, in the presence of mm. de guise and the constable, to hear from him whence he had his knowledge, and who had told him the attack was to be made; and said if he did not speak the truth he would have him hanged. then he declared he lay down under the king's bed thinking to sleep, and so having heard the plan he revealed it to a captain who was a friend of his, to the end he might prepare himself with his soldiers to be the first at the attack. then the king knew the truth, and told him he should never serve him again, and that he deserved to be hanged, and forbade him ever to come again to the court. the groom of the chamber went away with this to swallow, and slept that night with a surgeon-in-ordinary of the king, master louis of saint andre; and in the night he gave himself six stabs with a knife, and cut his throat nor did the surgeon perceive it till the morning, when he found his bed all bloody, and the dead body by him. he marvelled at this sight on his awaking, and feared they would say he was the cause of the murder; but he was soon relieved, seeing the reason, which was despair at the loss of the good friendship of the king. so guyard was buried. and those of danvilliers, when they saw the breach large enough for us to enter, and our soldiers ready to assault them, surrendered themselves to the mercy of the king. their leaders were taken prisoners, and their soldiers were sent away without arms. the camp being dispersed, i returned to paris with my gentleman whose leg i had cut off; i dressed him, and god healed him. i sent him to his house merry with a wooden leg; and he was content saying he had got off cheap, not to have been miserably burned to stop the blood, as you write in your book, won petit matetre, the journey to chateau le comte. 1552 some time after. king henry raised an army of thirty thousand men, to go and lay waste the country about hesdin. the king of navarre, who was then called m. de vendosme, was chief of the army, and the king's lieutenant. being at st. denis, in france, waiting while the companies passed by, he sent to paris for me to speak with him. when i came he begged me (and his request was a command) to follow him on this journey; and i, wishing to make my excuses, saying my wife was sick in bed, he made answer there were physicians in pairs to cure her, and he, too, had left his wife, who was of as good a house as mine, and he said he would use me well, and forthwith ordered i should be attached to his household. seeing this great desire he had to take me with him, i dared not refuse him. i went after him to chateau le comte, within three or four leagues of hesdin. the emperor's soldiers were in garrison there, with a number of peasants from the country road. m. de vendosme called on them to surrender; they made answer that he should never take them, unless it were piecemeal; let him do his worst, and they would do their best to defend themselves. they trusted in their moats, which were full of water; but in two hours, with plenty of faggots and casks, we made a way for our infantry to pass over, when they had to advance to the assault; and the place was attacked with five cannons, and a breach was made large enough for our men to enter; where those within received the attack very valiantly, and killed and wounded a great number of our men with arquebuses, pikes, and stones. in the end, when they saw themselves overpowered, they set fire to their powder and ammunition, whereby many of our men were burned, and some of their own. and they were almost all put to the sword; but some of our soldiers had taken twenty or thirty, hoping to have ransom for them: and so soon as this was known, orders were given to proclaim by trumpet through the camp, that all soldiers who had spaniards for prisoners must kill them, on pain of being themselves hanged and strangled: which was done in cold blood. thence we went and burned several villages; and the barns were all full of grain, to my very great regret. we came as far as tournahan, where there was a large tower, whither the enemy withdrew, but we found the place empty: our men sacked it, and blew up the tower with a mine of gunpowder, which turned it upside down. after that, the camp was dispersed, and i returned to paris. and the day after chateau le comte was taken, m. de vendosme sent a gentleman under orders to the king, to report to him all that had happened, and among other things he told the king i had done very good work dressing the wounded, and had showed him eighteen bullets that i had taken out of their bodies, and there were many more that i had not been able to find or take out; and he spoke more good of me than there was by half. then the king said he would take me into his service, and commanded m. de goguier, his first physician, to write me down in the king's service as one of his surgeons-in-ordinary, and i was to meet him at rheims within ten or twelve days: which i did. and the king did me the honour to command me to live near him, and he would be a good friend to me. then i thanked him most humbly for the honour he was pleased to do me, in appointing me to serve him. the journey to metz. 1552 the emperor having besieged metz with more than an hundred and twenty thousand men, and in the hardest time of winter,--it is still fresh in the minds of all--and there were five or six thousand men in the town, and among them seven princes; mm. le duc de guise, the king's lieutenant, d'enghien, de conde, de la montpensier, de la roche-sur-yon, de nemours, and many other gentlemen, with a number of veteran captains and officers: who often sallied out against the enemy (as i shall tell hereafter), not without heavy loss on both sides. our wounded died almost all, and it was thought the drugs wherewith they were dressed had been poisoned. wherefore m. de guise, and mm. the princes, went so far as to beg the king that if it were possible i should be sent to them with a supply of drugs, and they believed their drugs were poisoned, seeing that few of their wounded escaped. my belief is that there was no poison; but the severe cutlass and arquebus wounds, and the extreme cold, were the cause why so many died. the king wrote to m. the marshal de saint andre, who was his lieutenant at verdun, to find means to get me into metz, whatever way was possible. mm. the marshal de saint andre, and the marshal de vielleville, won over an italian captain, who promised to get me into the place, which he did (and for this he had fifteen hundred crowns). the king having heard the promise that the italian captain had made, sent for me, and commanded me to take of his apothecary, named daigne, so many and such drugs as i should think necessary for the wounded within the town; which i did, as much as a post-horse could carry. the king gave me messages to m. de guise, and to the princes and the captains that were in metz. when i came to verdun, some days after, m. the marshal de saint andre got horses for me and for my man, and for the italian captain, who spoke excellent german, spanish, and walloon, beside his own mother-tongue. when we were within eight or ten leagues of metz, we began to go by night only; and when we came near the enemy's camp i saw, more than a league and a half off, fires lighted all round the town, as if the whole earth were burning; and i believed we could never pass through these fires without being discovered, and therefore hanged and strangled, or cut in pieces, or made to pay a great ransom. to speak truth, i could well and gladly have wished myself back in paris, for the great danger that i foresaw. god guided our business so well, that we entered into the town at midnight, thanks to a signal the captain had with another captain of the company of m. de guise; to whom i went, and found him in bed, and he received me with high favour, being right glad at my coming. i gave him my message as the king had commanded me, and told him i had a little letter for him, and the next day i would not fail to deliver it. then he ordered me a good lodging, and that i should be well treated, and said i must not fail next morning to be upon the breach, where i should find all the princes and seigneurs, and many captains. which i did, and they received me with great joy, and did me the honour to embrace me, and tell me i was welcome; adding they would no more be afraid of dying, if they should happen to be wounded. m. le prince de la roche-sur-yon was the first who entertained me, and inquired what they were saying at the court concerning the town of metz. i told him all that i chose to tell. forthwith he begged me to go and see one of his gentlemen named m. de magnane, now chevalier of the order of the king, and lieutenant of his majesty's guards, who had his leg broken by a cannon-shot. i found him in bed, his leg bent and crooked, without any dressing on it, because a gentleman promised to cure him, having his name and his girdle, with certain words (and the poor patient was weeping and crying out with pain, not sleeping day or night for four days past). then i laughed at such cheating and false promises; and i reduced and dressed his leg so skilfully that he was without pain, and slept all the night, and afterward, thanks be to god, he was healed, and is still living now, in the king's service. the prince de la roche-sur-yon sent me a cask of wine, bigger than a pipe of anjou, to my lodging, and told me when it was drunk, he would send me another; that was how he treated me, most generously. after this, m, de guise gave me a list of certain captains and seigneurs, and bade me tell them what the king had charged me to say; which i did, and this was to commend him to them, and give them his thanks for the duty they had done and were doing in holding his town of metz, and that he would remember it. i was more than eight days acquitting myself of this charge, because they were many. first, to all the princes; then to others, as the duke horace, the count de martigues, and his brother m. de bauge, the seigneurs de montmorency and d'anville, now marshal of france, m. de la chapelle aux ursins, bonnivet, carouge, now governor of rouen, the vidasme de chartres, the count de lude, m. de biron, now marshal of france, m. de randan, la rochefoucaut, bordaille, d' estres the younger, m. de saint jehan en pauphine, and many others whom it would take too long to name; and also to many captains, who had all done their duty well for the defence of their lives and of the town. afterward i asked m. de guise what it pleased him i should do with the drugs i had brought with me; he bade me distribute them to the surgeons and apothecaries, and principally to the poor wounded soldiers, who were in great numbers in the hospital. which i did, and can truly say i could not so much as go and see all the wounded, who kept sending for me to visit and dress them. all the seigneurs within the town asked me to give special care, above all the rest; to m. de pienne, who had been wounded, while on the breach, by a stone shot from a cannon, on the temple, with fracture and depression of the bone. they told me that so soon as he received the blow, he fell to the ground as dead, and cast forth blood by the mouth, nose, and ears, with great vomiting, and was fourteen days without being able to speak or reason; also he had tremors of a spasmodic nature, and all his face was swelled and livid, he was trepanned at the side of the temporal muscle, over the frontal bone. i dressed him, with other surgeons, and god healed him; and to-day he is still living, thank god. the emperor attacked the town with forty double cannons, and the powder was not spared day or night. so soon as m. de guise saw the artillery set and pointed to make a breach, he had the nearest houses pulled down and made into ramparts, and the beams and joists were put end to end, and between them faggots, earth, beds, and wool-packs; then they put above them other beams and joists as before. and there was plenty of wood from the houses in the suburbs; which had been razed to the ground, for fear the enemy should get under cover of them, and make use of the wood; it did very well for repairing the breach. everybody was hard at work carrying earth to repair it, day and night; mm. the princes, the seigneurs, and captains, lieutenants, ensigns, were all carrying the basket, to set an example to the soldiers and citizens to do the like, which they did; even the ladies and girls, and those who had not baskets, made use of cauldrons, panniers, sacks, sheets, and all such things to carry the earth; so that the enemy had no sooner broken down the wall than they found behind it a yet stronger rampart. the wall having fallen, our men cried out at those outside, "fox, fox, fox," and they vented a thousand insults against one another. m. de guise forbade any man on pain of death to speak with those outside, for fear there should be some traitor who would betray what was being done within the town. after this order, our men tied live cats to the ends of their pikes, and put them over the wall and cried with the cats, "miaut, miaut." truly the imperials were much enraged, having been so long making a breach, at great loss, which was eighty paces wide, that fifty men of their front rank should enter in, only to find a rampart stronger than the wall. they threw themselves upon the poor cats, and shot them with arquebuses as men shoot at the popinjay. our men often ran out upon them, by order of m. de guise; a few days ago, our men had all made haste to enrol themselves in sallying-parties, chiefly the young nobility, led by experienced captains; and indeed it was doing them a great favour to let them issue from the town and run upon the enemy. they went forth always an hundred or six score men, well armed with cutlasses, arquebuses, pistols, pikes, partisans, and halbards; and advanced as far as the trenches, to take the enemy unawares. then an alarum would be sounded all through the enemy's camp, and their drums would beat plan, plan, ta ti ta, ta ta ti ta, tou touf touf. likewise their trumpets and clarions rang and sounded, to saddle, to saddle, to saddle, to horse, to horse, to horse, to saddle, to horse, to horse. and all their soldiers cried, "arm, arm arm! to arms, to arms, to arms! arm, to arms, arm, to arms, arm":--like the hue-and-cry after wolves; and all diverse tongues, according to their nations; and you saw them come out of their tents and little lodgings, as thick as little ants when you uncover the ant-hills, to bring help to their comrades, who were having their throats cut like sheep. their cavalry also came from all sides at full gallop, patati, patata, patati, patata, pa, ta, ta, patata pata, ta, eager to be in the thick of the fighting, to give and take their share of the blows. and when our men saw themselves hard pressed, they would turn back into the town, fighting all the way; and those pursuing them were driven back with cannon-shots, and the cannons were loaded with flint-stones and with big pieces of iron, square or three-sided. and our men on the wall fired a volley, and rained bullets on them as thick as hail, to send them back to their beds; whereas many remained dead on the field: and our men also did not all come back with whole skins, and there were always some left behind (as it were a tax levied on us) who were joyful to die on the bed of honour. and if there was a horse wounded, it was skinned and eaten by the soldiers, instead of beef and bacon; and if a man was wounded, i must run and dress him. some days afterward there were other sallies, which infuriated the enemy, that we would not let him sleep a little in safety. m. de guise played a trick upon them: he sent a peasant, who was none of the wisest, with two letters to the king, and gave him ten crowns, and promised the king would give him an hundred if he got the letters to him. in the one letter m. de guise told the king that the enemy shewed no of retreating, and had put forth all their strength made a great breach, which he hoped to defend, even at the cost of his own life and of all who were in the town; and that the enemy had planted their artillery so well in a certain place (which he named) that it was with great difficulty he could keep them from entering the town, seeing it was the weakest place in the town; but soon he hoped to rebuild it well, so that they should not be able to enter. this letter was sewed in the lining of the man's doublet, and he was told to be very careful not to speak of it to any person. and the other letter was given to him, wherein m. de guise told the king that he and all those besieged with him hoped to guard the town well; and other matters which i leave untold here. he sent out the man at night, and he was taken by the enemy's guard and brought to the duke of alva, that the duke might hear what was doing in the town; and the peasant was asked if he had any letters. he said "yes," and gave them the one; and they having seen it asked him if he had not another. he said "no." then he was searched, and they found on him that which was sewed in his doubtlet; and the poor messenger was handed and strangled. the letters were taken to the emperor, who called his council, where it was resolved, since they had been unable to do anything at the first breach, the artillery should forthwith be set against the place which they thought weakest, where they put forth all their strength to make a fresh breach; and they sapped and mined the wall, and tried hard to make a way into the hell tower, but dared not assault it openly. the duke of alva represented to the emperor that every day their soldiers were dying, to the number of more than two hundred, and there was so little hope of entering the town, seeing the time of year and the great number of our soldiers who were in it. the emperor asked what men they were who were dying, and whether they were gentlemen and men of mark; answer was made to him "they were all poor soldiers." then said he, "it was no great loss if they died," comparing them to caterpillars, grasshoppers, and cockchafers, which eat up the buds and other good things of the earth; and if they were men of any worth they would not be in his camp at six livres the month, and therefore it was no great harm if they died. moreover, he said he would never depart from the town till he had taken it by force or by famine, though he should lose all his army; because of the great number of princes who were shut up in it, with the greater part of the nobility of france, who he hoped would pay his expenses four times over; and he would go yet again to paris, to see the parisians, and to make himself king of all the kingdom of france. m. de guise, with the princes, captains, and soldiers, and in general all the citizens of the town, having heard the emperor's resolve to exterminate us all, forbade the soldiers and citizens, and even the princes and seigneurs, to eat fresh fish or venison, or partridges, woodcocks, larks, francolines, plovers, or other game, for fear these had acquired any pestilential air which could bring infection among us. so they had to content themselves with the fare of the army; biscuit, beef, salt cow-beef, bacon, cervelas, and mayence hams; also fish, as haddock, salmon, shad, tunny, whale, anchovy, sardines, herrings; also peas, beans, rice, garlic, onions, prunes, cheeses, butter, oil, and salt; pepper, ginger, nutmegs and other spices to put in our pies, mostly of horses, which without the spice had a very bad taste. many citizens, having gardens in the town, had planted them with fine radishes, turnips, carrots, and leeks, which they kept flourishing and very dear, for the extreme necessity of the famine. now all these stores were distributed by weight, measure, and justice, according to the quality of the persons, because we knew not how long the siege would last. for after we heard the emperors words, how he would not depart from before metz, till he had taken it by force or by famine, the victuals were cut down; and what they used to distribute to three soldiers was given to four; and it was forbidden to them to sell the remains which might be left after their meals; but they might give them to the rabble. and they always rose from table with an appetite, for fear they should be subject to take physick. and before we surrendered to the mercy of the enemy, we had determined to eat the asses, mules, and horses, dogs, cats, and rats, even our boots and collars, and other skins that we could have softened and stewed. and, in a word, all the besieged were resolved to defend themselves valiantly with all instruments of war; to set the artillery at the entry of the breach, and load with balls, stones, cart-nails, bars and chains of iron; also all sorts and kinds of artificial fires, as barricadoes, grenades, stink-pots, torches, squibs, fire-traps, burning faggots; with boiling water, melted lead, and lime, to put out the enemy's eyes. also, they were to make holes right through their houses, and put arquebusiers in them, to take the enemy in flank and hasten his going, or else give him stop then and there. also they were to order the women to pull up the streets, and throw from their windows billets, tables, trestles, benches, and stools, to dash out the enemy's brains. moreover, a little within the breach, there was a great stronghold full of carts and palisades, tuns and casks; and barricades of earth to serve as gabions, interlaid with falconets, falcons, field-pieces, crooked arquebuses, pistols, arquebuses, and wildfires, to break their legs and thighs, so that they would be taken from above and on the flank and from behind; and if they had carried this stronghold, there were others where the streets crossed, every hundred paces, which would have been as bad friends to them as the first, or worse, and would have made many widows and orphans. and if fortune had been so hard on us that they had stormed and broken up our strongholds, there would yet have been seven great companies, drawn up in square and in triangle, to fight them all at once, each led by one of the princes, for the better encouragement of our men to fight and die all together, even to the last breath of their souls. and all were resolved to bring their treasures, rings, and jewels, and their best and richest and most beautiful household stuffs, and burn them to ashes in the great square, lest the enemy should take them and make trophies of them. also there were men charged to set fire to all the stores and burn them, and to stave in all the wine-casks; others to set fire to every single house, to burn the enemy and us together. the citizens thus were all of one mind, rather than see the bloody knife at their throats, and their wives and daughters ravished and taken by the cruel savage spaniards. now we had certain prisoners, who had been made secretly to understand our last determination and desperation; these prisoners m. de guise sent away on parole, who being come to their camp, lost no time in saying what we had told them; which restrained the great and vehement desire of the enemy, so that they were no longer eager to enter the town to cut our throats and enrich themselves with the spoils. the emperor, having heard the decision of this great warrior, m. de guise, put water in his wine, and restrained his fury; saying that he could not enter the town save with vast butchery and carnage, and shedding of much blood, both of those defending and of those attacking, and they would be all dead together, and in the end he would get nothing but ashes; and afterward men might say it was a like destruction to that of the town of jerusalem, made of old time by titus and vespasian. the emperor thus having heard our last resolve, and seeing how little he had gained by his attack, sappings, and mines, and the great plague that was through all his camp, and the adverse time of the year, and the want of victuals and of money, and how his soldiers were disbanding themselves and going off in great companies, decided at last to raise the siege and go away, with the cavalry of his vanguard, and the greater part of the artillery and engines of war. the marquis of brandebourg was the last to budge from his place; he had with him some troops of spaniards and bohemians, and his german regiments, and there he stopped for a day and a half, to the great regret of m. de guise, who brought four pieces of artillery out of the town, which he fired on him this side and that, to hurry him off: and off he went, sure enough, and all his men with him. when he was a quarter of a league from metz, he was seized with a panic lest our cavalry should fall upon his tail; so he set fire to his store of powder, and left behind him some pieces of artillery, and a quantity of baggage, which he could not take along with him, because their vanguard and their great cannons had broken and torn tip the roads. our cavalry were longing with all their hearts to issue from the town and attack him behind; but m. de guise never let them, saying on the contrary we had better make their way smooth for them, and build them gold and silver bridges to let them go; like the good pastor and shepherd, who will not lose one of his sheep. that is how our dear and well-beloved imperials went away from metz, which was the day after christmas day, to the great content of those within the walls, and the praise of the princes, seigneurs, captains, and soldiers, who had endured the travail of this siege for more than two months. nevertheless, they did not all go: there wanted more than twenty thousand of them, who were dead, from our artillery and the fighting, or from plague, cold, and starvation (and from spite and rage that they could not get into the town to cut our throats and plunder us): and many of their horses also died, the greater part whereof they had eaten instead of beef and bacon. we went where their camp had been, where we found many dead bodies not yet buried, and the earth all worked up, as one sees in the cemetery of the holy innocents during some time of many deaths. in their tents, pavilions, and lodgings were many sick people. also cannon-shot, weapons, carts, waggons, and other baggage, with a great quantity of soldier's bread, spoiled and rotted by the snows and rains (yet the soldiers had it but by weight and measure). also they left a good store of wood, all that remained of the houses they had demolished and broken down in the villages for two or three leagues around; also many other pleasure-houses, that had belonged to our citizens, with gardens and fine orchards full of diverse fruit-trees. and without all this, they would have been benumbed and dead of the cold, and forced to raise the siege sooner than they did. m. de guise had their dead buried, and their sick people treated. also the enemy left behind them in the abbey of saint arnoul many of their wounded soldiers, whom they could not possibly take with them. m. de guise sent them all victuals enough, and ordered me and the other surgeons to go dress and physick them, which we did with good will; and i think they would not have done the like for our men. for the spaniard is very cruel, treacherous, and inhuman, and so far enemy of all nations: which is proved by lopez the spaniard, and benzo of milan, and others who have written the history of america and the west indies: who have had to confess that the cruelty, avarice, blasphemies, and wickedness of the spaniards have utterly estranged the poor indians from the religion that these spaniards professed. and all write that they are of less worth than the idolatrous indians, for their cruel treatment of these indians. and some days later m. de guise sent a trumpet to thionville to the enemy, that they could send for their wounded in safety: which they did with carts and waggons, but not enough. m. de guise gave them carts and carters, to help to take them to thionville. our carters, when they returned, told us the roads were all paved with dead bodies, and they never got half the men there, for they died in their carts: and the spaniards seeing them at the point of death, before they had breathed their last, threw them out of the carts and buried them in the mud and mire, saying they had no orders to bring back dead men. moreover, our carters said they had found on the roads many carts stuck in the mud, full of baggage, for which the enemy dared not send back, lest we who were within metz should run out upon them. i would return to the reason why so many of them died; which was mostly starvation, the plague, and cold. for the snow was more than two feet deep upon the ground, and they were lodged in pits below the ground, covered only with a little thatch. nevertheless, each soldier had his camp-bed, and a coverlet all strewed with stars, glittering and shining brighter than fine gold, and every day they had white sheets, and lodged at the sign of the moon, and enjoyed themselves if only they had been able, and paid their host so well over night that in the morning they went off quits, shaking their ears; and they had no need of a comb to get the down and feathers out of their beards and hair, and they always found a white table-cloth, and would have enjoyed good meals but for want of food. also the greater part of them had neither boots, half-boots, slippers, hose, nor shoes: and most of them would rather have none than any, because they were always in the mire up to mid-leg. and because they went barefoot, we called them the emperor's apostles. after the camp was wholly dispersed, i distributed my patients into the hands of the surgeons of the town, to finish dressing them: then i took leave of m. de guise, and returned to the king, who received me with great favour, and asked me how i had been able to make my way into metz. i told him fully all that i had done. he gave me two hundred crowns, and an hundred which i had when i set out: and said he would never leave me poor. then i thanked him very humbly for the good and the honour he was pleased to do me. the journey to hesdin. 1553 the emperor charles laid siege to the town of therouenne; and m. le due de savoie was general of his whole army. it was taken by assault: and there was a great number of our men killed and taken prisoners. the king, wishing to prevent the enemy from besieging the town and castle of hesdin also, sent thither mm. le duc de bouillon, le duc horace, le marquis de villars, and a number of captains, and about eighteen hundred soldiers: and during the siege of therouenne, these seigneurs fortified the castle of hesdin, so that it seemed to be impregnable. the king sent me to the seigneurs, to help them with my art, if they should come to have need of it. soon after the capture of therouenne, we were besieged in hesdin. there was a clear stream of running water within shot of our cannon, and about it were fourscore or an hundred of the enemy's rabble, drawing water. i was on a rampart watching the enemy pitch their camp; and, seeing the crowd of idlers round the stream, i asked m. du pont, commissary of the artillery, to send one cannon-shot among this canaille: he gave me a flat refusal, saying that all this sort of people was not worth the powder would be wasted on them. again i begged him to level the cannon, telling him, "the more dead, the fewer enemies;" which he did for my sake: and the shot killed fifteen or sixteen, and wounded many. our men made sorties against the enemy, wherein many were killed and wounded on both sides, with gunshot or with fighting hand to hand; and our men often sallied out before their trenches were made; so that i had my work cut out for me, and had no rest either day or night for dressing the wounded. and here i would note that we had put many of them in a great tower, laying them on a little straw: and their pillows were stones, their coverlets were cloaks, those who had any. when the attack was made, so often as the enemy's cannons were fired, our wounded said they felt pain in their wounds, as if you had struck them with a stick: one was crying out on his head, the other on his arm, and so with the other parts of the body: and many had their wounds bleed again, even more profusely than at the time they were wounded, and then i had to run to staunch them. mon petit maistre, if you had been there, you would have been much hindered with your hot irons; you would have wanted a lot of charcoal to heat them red, and sure you would have been killed like a calf for your cruelty. many died of the diabolical storm of the echo of these engines of artillery, and the vehement agitation and severe shock of the air acting on their wounds; others because they got no rest for the shouting and crying that were made day and night, and for want of good food, and other things needful for their treatment. mon petit maistre, if you had been there, no doubt you could have given them jelly, restoratives, gravies, pressed meats, broth, barley-water, almond-milk, blanc-mange, prunes, plums, and other food proper for the sick; but your diet would have been only on paper, and in fact they had nothing but beef of old shrunk cows, seized round hesdin for our provision, salted and half-cooked, so that he who would eat it must drag at it with his teeth, as birds of prey tear their food. nor must i forget the linen for dressing their wounds, which was only washed daily and dried at the fire, till it was as hard as parchment: i leave you to think how their wounds could do well. there were four big fat rascally women who had charge to whiten the linen, and were kept at it with the stick; and yet they had not water enough to do it, much less soap. that is how the poor patients died, for want of food and other necessary things. one day the enemy feigned a general attack, to draw our soldiers into the breach, that they might see what we were like: every man ran thither. we had made a great store of artificial fires to defend the breach; a priest of m. le duc de bouillon took a grenade, thinking to throw it at the enemy, and lighted it before he ought: it burst, and set fire to all our store, which was in a house near the breach. this was a terrible disaster for us, because it burned many poor soldiers; it even caught the house, and we had all been burned, but for help given to put it out; there was only one well in the castle with any water in it, and this was almost dry, and we took beer to put it out instead of water; afterward we were in great want of water, and to drink what was left we must strain it through napkins. the enemy, seeing the explosion and violence of the fires, which made a wonderful flame and thundering, thought we had lit them on purpose to defend the breach, and that we had many more of them. this made them change their minds, to have us some other way than by attack: they dug mines, and sapped the greater part of our walls, till they came near turning our castle altogether upside down; and when the sappers had finished their work, and their artillery was fired, all the castle shook under our feet like an earthquake, to our great astonishment. moreover, they had levelled five pieces of artillery, which they had placed on a little hillock, so as to have us from behind when we were gone to defend the breach. m. le duc horace had a cannonshot on the elbow, which carried off his arm one way and his body the other, before he could say a single word; his death was a great disaster to us, for the high rank that he held in the town. also m. de martigues had a gunshot wound which pierced his lungs: i dressed him, as i shall tell hereafter. then we asked leave to speak with the enemy; and a trumpet was sent to the prince of piedmont, to know what terms he would give us. he answered that all the leaders, such as gentlemen, captains, lieutenants, and ensigns, would be taken prisoners for ransom, and the soldiers would leave the town without their arms; and if we refused this fair and honest offer, we might rest assured they would take us next day, by attack or otherwise. a council was held, to which i was called, to know if i would sign the surrender of the town; with many captains, gentlemen, and others. i answered it was not possible to hold the town, and i would sign the surrender with my own blood, for the little hope i had we could resist the enemy's forces, and for the great longing i had to be out of this hell and utter torture; for i slept neither night nor day for the great number of the wounded, who were about two hundred. the dead were advanced in putrefaction, piled one upon the other like faggots, and not covered with earth, because we had none. and if i went into a soldier's lodging, there were soldiers waiting for me at the door when i came out, for me to dress others; it was who should have me, and they carried me like the body of a saint, with my feet off the ground, fighting for me. i could not satisfy this great number of wounded: nor had i got what i wanted for their treatment. for it is not enough that the surgeon do his duty toward his patients, but the patient also must do his; and the assistants, and external things, must work together for him: see hippocrates, aphorism the first. having heard that we were to surrender the place, i knew our business was not prospering; and for fear of being known, i gave a velvet coat, a satin doublet, and a cloak of fine cloth trimmed with velvet, to a soldier; who gave me a bad doublet all torn and ragged with wear, and a frayed leather collar, and a bad hat, and a short cloak; i dirtied the neck of my shirt with water mixed with a little soot, i rubbed my hose with a stone at the knees and over the heels, as though they had been long worn, i did the same to my shoes, till one would have taken me for a chimneysweep rather than a king's surgeon. i went in this gear to m. de martigues, and prayed him to arrange i should stop with him to dress him; which he granted very willingly, and was as glad i should be near him as i was myself. soon afterward, the commissioners who were to select the prisoners entered the castle, the seventeenth day of july, 1553. they took prisoners mm. le due de bouillon, le marquis de villars, de roze, le baron de culan, m. du pont, commissary of the artillery, and m. de martigues; and me with him, because he asked them; and all the gentlemen who they knew could pay ransom, and most of the soldiers and the leaders of companies; so many and such prisoners as they wished. and then the spanish soldiers entered by the breach, unresisted; our men thought they would keep their faith and agreement that all lives should be spared. they entered the town in a fury to kill, plunder, and ravage everything: they took a few men, hoping to have ransom for them. ... if they saw they could not get it, they cruelly put them to death in cold blood. ... and they killed them all with daggers, and cut their throats. such was their great cruelty and treachery; let him trust them who will. to return to my story: when i was taken from the castle into the town, with m. de martigues, there was one of m. de savoie's gentlemen, who asked me if m. de martigues's wound could be cured. i told him no, that it was incurable: and off he went to tell m. le due de savoie. i bethought myself they would send physicians and surgeons to dress m. de martigues; and i argued within myself if i ought to play the simpleton, and not let myself be known for a surgeon, lest they should keep me to dress their wounded, and in the end i should be found to be the king's surgeon, and they would make me pay a big ransom. on the other hand, i feared, if i did not show i was a surgeon and had dressed m. de martigues skilfully, they would cut my throat. forthwith i made up my mind to show them he would not die for want of having been well dressed and nursed. soon after, sure enough, there came many gentlemen, with the emperor's physician, and his surgeon, and those belonging to m. de savoie, and six other surgeons of his army, to see m. de martigues's wound, and to know of me how i had dressed and treated it. the emperor's physician bade me declare the essential nature of the wound, and what i had done for it. and all his assistants kept their ears wide open, to know if the wound were or were not mortal. i commenced my discourse to them, how m. martigues, looking over the wall to mark those who were sapping it, was shot with an arquebus through the body, and i was called of a sudden to dress him. i found blood coming from his mouth and from his wounds. moreover, he bad a great difficulty of breathing in and out, and air came whistling from the wounds, so that it would have put out a candle; and he said he had a very great stabbing pain where the bullet had entered. ... i withdrew some scales of bone, and put in each wound a tent with a large head, fastened with a thread, lest on inspiration it should be drawn into the cavity of the chest; which has happened with surgeons, to the detriment of the poor wounded; for being fallen in, you cannot get them out; and then they beget corruption, being foreign bodies. the tents were anointed with a preparation of yolk of egg, venice turpentine, and a little oil of roses. ... i put over the wounds a great plaster of diachylum, wherewith i had mixed oil of roses, and vinegar, to avoid inflammation. then i applied great compresses steeped in oxycrate, and bandaged him, not too tight, that he might breathe easily. next, i drew five basons of blood from his right arm, considering his youth and his sanguine temperament. ... fever took him, soon after he was wounded, with feebleness of the heart. ... his diet was barleywater, prunes with sugar, at other times broth: his drink was a ptisane. he could lie only on his back. ... what more shall i say? but that my lord de martigues never had an hour's rest after he was wounded. ... these things considered, gentlemen, no other prognosis is possible, save that he will die in a few days, to my great grief. having finished my discourse, i dressed him as i was accustomed. when i displayed his wounds, the physicians and surgeons, and other assistants present, knew the truth of what i had said. the physicians, having felt his pulse and seen that the vital forces were depressed and spent, agreed with me that in a few days he would die. then they all went to the duc de savoie, and told him m. de martigues would die in a short time. he answered them, "possibly, if he had been well dressed, he might have escaped death." then they all with one voice said he had been very well dressed and cared for altogether, and it could not be better, and it was impossible to cure him, and his wound was of necessity mortal. then m. de savoie was very angry with them, and cried, and asked them again if for certain they all held his case hopeless: they answered, yes. then a spanish impostor came forward, who promised on his life to cure him; and if he did not, they should cut him in an hundred pieces; but he would have no physicians, nor surgeons nor apothecaries with him: and m. le duc de savoie forthwith bade the physicians and surgeons not go near m. de martigues; and sent a gentleman to bid me, under pain of death, not so much as to touch him. which i promised, and was very glad, for now he would not die under my hands; and the impostor was told to dress him, and to have with him no other physicians or surgeons, but only himself. by and bye he came, and said to m. de martigues, "senor cavallero, m. de savoie has bid me come and dress your wound. i swear to god, before eight days i will set you on horseback, lance in hand, provided none touch you but i alone. you shall eat and drink whatever you like. i will be dieted instead of you; and you may trust me to perform what i promise. i have cured many who had worse wounds than yours." and the seigneurs answered him, "god give you his grace for it." he asked for a shirt of m. de martigues, and tore it in little strips, which he laid cross-wise, muttering and murmuring certain words over the wounds: having done this much for him, he let him eat and drink all he would, saying he himself would be dieted in his stead; which he did, eating but six prunes and six morsels of bread for dinner, and drinking only beer. nevertheless, two days later, m. de martigues died: and my friend the spaniard, seeing him at the point of death, eclipsed himself, and got away without good-bye to any man. and i believe if he had been caught he would have been hanged and strangled, for the false promise he made to m. le due de savoie and many other gentlemen. m. de martigues died about ten o'clock in the morning; and after dinner m. de savoie sent the physicians and surgeons, and his apothecary, with a store of drugs to embalm him. they came with many gentlemen and captains of his army. the emperor's surgeon came to me, and asked me in a very friendly way to make, the embalmment; which i refused, saying that i was not worthy to carry his instrument-box after him. he begged me again to do it to please him, and that he would be very glad of it...seeing his kindness, and fearing to displease him, i then decided to show them the anatomist that i was, expounding to them many things, which would here be too long to recite... our discourse finished, i embalmed the body; and it was placed in a coffin. then the emperor's surgeon drew me aside, and told me, if i would stop with him, he would treat me well, and give me a new suit of clothes, and set me on horseback. i gave him many thanks, and said i had no wish to serve any country but my own. then he told me i was a fool, and if he were a prisoner as i was, he would serve a devil to get his freedom. in the end i told him flat i would not stop with him. the emperor's physician then went back to m. de savoie, and explained to him the causes of m. de martigues' death, and that it was impossible for all the men in the world to have cured him; and assured him again i had done all that was to be done, and besought him to take me into his service; saying much more good of me than there was. he having been persuaded to do this, sent to me one of his stewards, m. du bouchet, to tell me, if i would serve him, he would use me well; i sent back my very humble thanks, and that i had decided not to take service under any foreigner. when he heard my answer he was very angry, and said i ought to be sent to the galleys. m. de vaudeville, governor of graveline, and colonel of seventeen ensigns of infantry, asked him to send me to him, to dress an old ulcer on his leg, that he had had for six or seven years. m. de savoie said he was willing, so far as i was concerned; and if i used the cautery to his leg, it would serve him right. m. de vaudeville answered, if he saw me trying it, he would have my throat cut. soon after, he sent for me four german halberdiers of his guard; and i was terrified, for i did not know where they were taking me: they spoke no more french than i german. when i was come to his lodging, he bade me welcome, and said, now i belonged to him; and so soon as i had healed him, he would let me go without ransom. i told him i had no means to pay any ransom. he called his physician and his surgeon-in-ordinary, to show me his leg; and when we had examined it, we withdrew into a room, where i began my discourse to them. ... then the physician left me with the surgeon, and went back to m. de vaudeville, and said he was sure i could cure him, and told him all i had decided to do; which pleased him vastly. he sent for me, and asked if i thought i could cure him; i said yes, if he were obedient to what was necessary. he promised to do only what i wished and ordered; and so soon as he was healed, he would let me go home without ransom. then i asked him to make better terms with me, saying it was too long to wait for my liberty: in fifteen days i hoped his ulcer would be less than half its present size, and give no pain; then his own surgeon and physician could finish the cure. he granted this to me. then i took a piece of paper to measure the size of the ulcer, and gave it to him, and kept another by me; i asked him to keep his promise, when i had done my work; he swore by the faith of a gentleman he would. then i set myself to dress him properly, after the manner of galen. ... he wished to know if it were true, what i said of galen, and bade his physician look to it, for he would know it for himself; he had the book put on the table, and found that what i said was true; so the physician was ashamed, and i was glad. within the fifteen days, it was almost all healed; and i began to feel happy about the compact made between us. he had me to eat and drink at his table, when there were no more great persons than he and i only. he gave me a big red scarf which i must wear; which made me feel something like a dog when they give him a clog, to stop him eating the grapes in the vineyards. his physician and surgeon took me through the camp to visit their wounded; and i took care to observe what our enemy was doing. i found they had no more great cannons, but only twenty-five or thirty field-pieces. m. de vaudeville held prisoner m. de bauge, brother of m. de martigues who died at hesdin. m. de bauge was prisoner at chateau de la motte au bois, belonging to the emperor; he had been captured at therouenne by two spanish soldiers; and m. de vaudeville, when he saw him there, concluded he must be some gentleman of good family: he made him pull off his stockings, and seeing his clean legs and feet, and his fine white stockings, knew he was one to pay a good ransom. he told the soldiers he would give them thirty crowns down for their prisoner: they agreed gladly, for they had no place to keep him, nor food for him, nor did they know his value: so they gave their man into his hands, and he sent him off at once, guarded by four of his own soldiers, to chateau de la motte au bois, with others of our gentlemen who were prisoners. m. de bauge would not tell who he was; and endured much hardship, living on bread and water, with a little straw for his bed. when hesdin was taken, m. de vaudeville sent the news of it to him and to the other prisoners, and the list of the killed, and among them m. de martigues: and when m. de bauge heard with his own ears his brother was dead, he fell to crying, weeping, and lamentation. his guards asked him why he was so miserable: he told them, for love of m. de martigues, his brother. when he heard this, the captain of the castle sent straight to tell m. de vaudeville he had a good prisoner: who was delighted at this, and sent me next day with four soldiers, and his own physician, to the castle, to say that if m. de bauge would pay him fifteen thousand crowns ransom, he would send him home free: and he asked only the security of two antwerp merchants that he should name. m. de vaudeville persuaded me i should commend this offer to his prisoner: that is why he sent me to the castle. he told the captain to treat him well and put him in a room with hangings, and strengthen his guard: and from that time onward they made a great deal of him, at the expense of m. de vaudeville. m. de bauge answered that he could not pay his ransom himself: it depended on m. d' estampes his uncle, and mlle. de bressure his aunt: he had no means to pay such a ransom. i went back with my guards, and gave this answer to m. de vaudeville; who said, "possibly he will not get away so cheap": which was true, for they knew who he was. then the queen of hungary and m. le duc de savoie sent word to m. de vaudeville that this mouthful was too big for him, and he must send his prisoner to them (which he did), and he had other prisoners enough without him. the ransom paid was forty thousand crowns, without other expenses. on my way back to m. de vaudeville, i passed by saint omer, where i saw their great cannons, most of which were fouled and broken. also i passed by therouenne, where i saw not one stone left on another, save a vestige of the great church: for the emperor ordered the country people for five or six leagues round to clear and take away the stones; so that now you may drive a cart over the town: and the same at hesdin, and no trace of castle and fortress. such is the evil that wars bring with them. to return to my story; m. de vaudeville soon got the better of his ulcer, and was nearly healed: so he let me go, and sent me by a trumpet, with passport, as far as abbeville. i posted from here, and went to find my master, king henry, at aufimon, who received me gladly and with good favour. he sent mm. de guise, the constable, and d' estres, to hear from me the capture of hesdin; and i made them a true report, and assured them i had seen the great cannons they had taken to saint omer: and the king was glad, for he had feared the enemy would come further into france. he gave me two hundred crowns to take me home: and i was thankful to be free, out of this great torment and thunder of the diabolical artillery, and away from the soldiers, blasphemers and deniers of god. i must add that after hesdin was taken, the king was told i was not killed but taken prisoner. he made m. goguier, his chief physician, write to my wife that i was living, and she was not to be unhappy, and he would pay my ransom. battle of saint quentin. 1557 after the battle of saint quentin, the king sent me to la fere en tartenois, to m. le marechal de bourdillon, for a passport to m. le duc de savoie, that i might go and dress the constable, who had been badly wounded in the back with a pistol-shot, whereof he was like to die, and remained prisoner in the enemy's hands. but never would m. le duc de savoie let me go to him, saying he would not die for want of a surgeon; that he much doubted i would go there only to dress him, and not rather to take some secret information to him; and that he knew i was privy to other things besides surgery, and remembered i had been his prisoner at hesdin. m. le marechal told the king of this refusal: who wrote to m. le marechal, that if mme. the constable's lady would send some quick-witted man of her household i would give him a letter, and had also something to say to him by word of mouth, entrusted to me by the king and by m. le cardinal de lorraine. two days later there came one of the constable's gentlemen of the bedchamber, with his shirts and other linen, to whom m. le marechal gave a passport to go to the constable. i was very glad, and gave him my letter, and instructed him what his master must do now he was prisoner. i thought, having finished my mission, to return to the king; but m. le marechal begged me to stop at la fere with him, to dress a very great number of wounded who had retreated there after the battle, and he would write to the king to explain why i stopped; which i did. their wounds were very putrid, and full of worms, with gangrene, and corruption; and i had to make free play with the knife to cut off what was corrupt, which was not done without amputation of arms and legs, and also sundry trepannings. they found no store of drugs at la fere, because the surgeons of the camp had taken them all away; but i found the waggons of the artillery there, and these had not been touched. i asked m. le marechal to let me have some of the drugs which were in them, which he did; and i was given the half only at one time, and five or six days later i had to take the rest; and yet it was not half enough to dress the great number of wounded. and to correct and stop the corruption, and kill the worms in their wounds, i washed them with aegyptiacum dissolved in wine and eau-de-vie, and did all i could for them; but in spite of all my care many of them died. there were at la fere some gentlemen charged to find the dead body of m. de bois-dauphin the elder, who had been killed in the battle; they asked me to go with them to the camp, to pick him out, if we could, among the dead; but it was not possible to recognize him, the bodies being all far gone in corruption, and their faces changed. we saw more than half a league round us the earth all covered with the dead; and hardly stopped there, because of the stench of the dead men and their horses; and so many blue and green flies rose from them, bred of the moisture of the bodies and the heat of the sun, that when they were up in the air they hid the sun. it was wonderful to hear them buzzing; and where they settled, there they infected the air, and brought the plague with them. mon petit maistre, i wish you had been there with me, to experience the smells, and make report thereof to them that were not there. i was very weary of the place; i prayed m. le marechal to let me leave it, and feared i should be ill there; for the wounded men stank past all bearing, and they died nearly all, in spite of everything we did. he got surgeons to finish the treatment of them, and sent me away with his good favour. he wrote to the king of the diligence i had shown toward the poor wounded. then i returned to paris, where i found many more gentlemen, who had been wounded and gone thither after the battle. the journey to the camp at amiens. 1558 the king sent me to dourlan, under conduct of captain gouast; with fifty men-at-arms, for fear i should be taken by the enemy; and seeing we were always in alarms on the way, i made my man let down, and made him the master; for i got on his horse, which carried my valise, and could go well if we had to make our escape, and i took his cloak and hat and gave him my mount, which was a good little mare; he being in front, you would have taken him for the master and me for the servant the garrison inside dourlan, when they saw us, thought we were the enemy, and fired their cannon at us. captain gouast, my conductor, made signs to them with his hat that we were not the enemy; at last they ceased firing, and we entered dourlan, to our great relief. five or six days before this, a sortie had been made from dourlan; wherein many captains and brave soldiers had been killed or wounded: and among the wounded was captain saint aubin, vaillant comme l' espce, a great friend of m. de guise: for whose sake chiefly the king had sent me there. who, being attacked with a quartan fever, yet left his bed to command the greater part of his company. a spaniard, seeing him in command, perceived he was a captain, and shot him through the neck with an arquebus. captain saint aubin thought himself killed; and by this fright i protest to god he lost his quartan fever, and was forever free of it. i dressed him, with antoine portail, surgeon-in-ordinary of the king; and many other soldiers. some died, others got off with the loss of an arm or a leg or an eye, and said they had got off cheap, to be alive at all. then, the enemy having broken up their camp, i returned to paris. i say nothing here of mon petit maistre, who was more comfortable in his house than i at the wars. the journey to bourges. 1562 the king with his camp was but a short time at bourges, till those within the walls should surrender; and they came out with their goods saved. i know nothing worth remembering, but that a boy of the king's kitchen, having come near the walls of the town before the agreement had been signed, cried with a loud voice, "huguenot, huguenot, shoot here, shoot here," having his arm thrown up and his hand spread out; a soldier shot his hand right through with a bullet. when he was thus shot, he came to find me to dress him. and the constable seeing the boy in tears, with his hand all bloody, asked who had wounded him: then a gentleman who had seen him shot said it served him right, because he kept calling "huguenot, hit here, aim here." and then the constable said, this huguenot was a good shot and a good fellow, for most likely if he had chosen to fire at the boy's head, he would have hit it even more easily than his hand. i dressed the kitchen boy, who was very ill. he recovered, but with no power in his hand: and from that time his comrades called him "huguenot": he is still living now. the journey to rouen. 1562 now, as for the capture of rouen, they killed many of our men both before and at the attack: and the very next day after we had entered the town, i trepanned eight or nine of our men, who had been wounded with stones as they were on the breach. the air was so malignant, that many died, even of quite small wounds, so that some thought the bullets had been poisoned; and those within the town said the like of us; for though they had within the town all that was needful, yet all the same they died like those outside. the king of navarre was wounded, some days before the attack, with a bullet in the shoulder. i visited him, and helped to dress him, with one of his own surgeons, master gilbert, one of the chief men of montpellier, and others. they could not find the bullet. i searched for it very accurately, and found reason to believe it had entered at the top of the arm, by the head of the bone, and had passed into the hollow part of the bone, which was why they could not find it; and most of them said it had entered his body and was lost in it. m. le prince de la roche-sur-yon, who dearly loved the king of navarre, drew me aside and asked if the wound were mortal. i told him yes, because all wounds of great joints, and especially contused wounds, were mortal, according to all those who have written about them. he asked the others what they thought of it, and chiefly master gilbert, who told him he had great hope his lord the king would recover; which made the prince very glad. four days later, the king, and the queen-mother, and m. le cardinal de bourbon, his brother, and m. le prince de la rochesur-yon, and m. de guise, and other great persons, after we had dressed the king of navarre, wished us to hold a consultation in their presence, all the physicians and surgeons together. each of them said what he thought, and there was not one but had good hope, they said, that he would recover. i persisted always in the contrary. m. le prince, who loved me, drew me aside, and said i was alone against the opinion of all the others, and prayed me not to be obstinate against so many good men. i answered, when i shall see good signs of recovery, i will change my mind. many consultations were held, and i never changed what i said, and the prognosis i had made at the first dressing, and said always the arm would fall into a gangrene: which it did, for all the care they could give to it; and he rendered his spirit to god the eighteenth day after his wound. m. le prince, having heard of it, sent to me his surgeon, and his physician, one lefevre, now physician-in-ordinary to the king and queen-mother, to say he wished to have the bullet, and we were to look for it, to see where it was. then i was very glad, and assured them i should quickly find it; which i did in their presence, with many other gentlemen: it was just in the very middle of the bone. m. le prince took and showed it to the king and to the queen, who all said that my prognosis had come true. the body was laid to rest at chateau gaillard: and i returned to paris, where i found many patients, who had been wounded on the breach at rouen, and chiefly italians, who were very eager i should dress them: which i did willingly. many of them recovered: the rest died. mon petit maistre, i think you were called to dress some, for the great number there was of them. the battle of dreux. 1562 the day after the battle of dreux, the king bade me go and dress m. le comte d'eu, who had been wounded in the right thigh, near the hip-joint, with a pistol-shot: which had smashed and broken the thigh-bone into many pieces: whereon many accidents supervened, and at last death, to my great grief. the day after i came, i would go to the camp where the battle had been, to see the dead bodies. i saw, for a long league round, the earth all covered: they estimated it at twenty-five thousand men or more; and it was all done in less than two hours. i wish, mon petit maistre, for the love i bear you, you had been there, to tell it to your scholars and your children. now while i was at dreux, i visited and dressed a great number of gentlemen, and poor soldiers, and among the rest many of the swiss captains. i dressed fourteen all in one room, all wounded with pistol-shots and other diabolical firearms, and not one of the fourteen died. m. le comte d'eu being dead, i made no long stay at dreux. surgeons came from paris, who fulfilled their duty to the wounded, as pigray, cointeret, hubert, and others; and i returned to paris, where i found many wounded gentlemen who had retreated thither after the battle, to have their wounds dressed; and i was not there without seeing many of them. the journey to havre de grace. 1563 and i will not omit to tell of the camp at havre de grace. when our artillery came before the walls of the town, the english within the walls killed some of our men, and several pioneers who were making gabions. and seeing they were so wounded that there was no hope of curing them, their comrades stripped them, and put them still living inside the gabions, which served to fill them up. when the english saw that they could not withstand our attack, because they were hard hit by sickness, and especially by the plague, they surrendered. the king gave them ships to return to england, very glad to be out of this plague-stricken place. the greater part of them died, and they took the plague to england, and they have not got rid of it since. captain sarlabous, master of the camp, was left in garrison, with six ensigns of infantry, who had no fear of the plague; and they were very glad to get into the town, hoping to enjoy themselves there, mon petit maistre, if you had been there, you would have done as they did. the journey to bayonne. 1564 i went with the king on that journey to bayonne, when we were two years and more making the tour of well-nigh all this kingdom. and in many towns and villages i was called in consultation over sundry diseases, with the late m. chapelain, chief physician to the king, and m. castellan, chief physician to the queen-mother; honorable men and very learned in medicine and surgery. during this journey, i always inquired of the surgeons if they had noted anything rare in their practices, so that i might learn something new. while i was at bayonne, two things happened worthy of remark by young surgeons. the first is, i dressed a spanish gentleman, who had a great and enormous swelling of the throat. he had lately been touched by the deceased king charles for the king's evil. i opened his swelling. ... i left him in the hands of a surgeon of the town, to finish his cure. m. de fontaine, knight of the order of the king, had a severe continued pestilent fever, accompanied with many inflammatory swellings in sundry parts of the body. he had bleeding at the nose for two days, without ceasing, nor could we staunch it: and after this haemorrhage the fever ceased, with much sweating, and by and bye the swellings suppurated, and he was dressed by me, and healed by the grace of god. battle of saint denis, 1567 as for the battle of saint denis, there were many killed on both sides. our wounded withdrew to paris to be dressed, with the prisoners they had taken, and i dressed many of them. the king ordered me, at the request of mme. the constable's lady, to go to her house to dress the constable; who had a pistol-shot in the middle of the spine of his back, whereby at once he lost all feeling and movement in his thighs and legs ... because the spinal cord, whence arise the nerves to give feeling and movement to the parts below, was crushed, broken, and torn by the force of the bullet. also he lost understanding and reason, and in a few days he died. the surgeons of paris were hard put to it for many days to treat all the wounded. i think, mon petit maistre, you saw some of them. i beseech the great god of victories, that we be never more employed in such misfortune and disaster. voyage of the battle of moncontour. 1569 during the battle of moncontour, king charles was at plessis-lestours, where he heard the news of the victory. a great number of gentlemen and soldiers retreated into the town and suburbs of tours, wounded, to be dressed and treated; and the king and the queen-mother bade me do my duty by them, with other surgeons who were then on duty, as pigray, du bois, portail, and one siret, a surgeon of tours, a man well versed in surgery, who was at this time surgeon to the king's brother. and for the multitude of bad cases we had scarce any rest, nor the physicians either. m. le comte de mansfeld, governor of the duchy of luxembourg, knight of the order of the king, was severely wounded in the battle, in the left arm, with a pistol-shot which broke a great part of his elbow; and he withdrew to borgueil near tours. then he sent a gentleman to the king, to beg him to send one of his surgeons, to help him of his wound. so they debated which surgeon they should send. m. le marechal de montmorency told the king and the queen that they ought to send him their chief surgeon; and urged that m. de mansfeld had done much toward the victory. the king said flat, he would not have me go, and wished me to stop with himself. then the queen-mother told him i would but go and come back, and he must remember it was a foreign lord, who had come, at the command of the king of spain, to help him. then he let me go, provided i came back very soon. so he sent for me, and the queen-mother with him, and bade me go and find the lord de mansfeld, wherever he should be, to do all i could for him to heal his wound. i went to him, with a letter from their majesties. when he saw it, he received me with good-will, and forthwith dismissed three or four surgeons who were dressing him; which was to my very great regret, because his wound seemed to me incurable. now many gentlemen had retreated to borgueil, having been wounded: for they knew that m. de guise was there, who also had been badly wounded with a pistol-shot through the leg, and they were sure that he would have good surgeons to dress him, and would help them, as he is kindly and very generous, and would relieve their wants. this he did with a will, both for their eating and drinking, and for what else they needed: and for my part, they had the comfort and help of my art: some died, others recovered, according to their wounds. m. le comte ringrave died, who was shot in the shoulder, like the king of navarre before rouen. m. de bassompierre, colonel of twelve hundred horse, was wounded by a similar shot, in the same place, as m. de mansfeld: whom i dressed, and god healed. god blessed my work so well, that in three weeks i sent them back to paris: where i had still to make incisions in m. de mansfeld's arm, to remove some pieces of the bones, which were badly splintered, broken, and carious. he was healed by the grace of god, and made me a handsome present, so i was well content with him, and he with me; as he has shown me since. he wrote a letter to m. le duc d' ascot, how he was healed of his wound, and also m. de bassompierre of his, and many others whom i had dressed after the battle of moncontour; and advised him to ask the king of france to let me visit m. le marquis d' auret, his brother: which he did. the journey to flanders. 1569 m. le duc d' ascot did not fail to send a gentleman to the king, with a letter humbly asking he would do him so much kindness and honour as to permit and command his chief surgeon to visit m. le marquis d' auret, his brother, who had received a gunshot wound near the knee, with fracture of the bone, about seven months ago, and the physicians and surgeons all this time had not been able to heal him. the king sent for me and bade me go and see m. d' auret, and give him all the help i could, to heal him of his wound. i told him i would employ all the little knowledge it had pleased god to give me. i went off, escorted by two gentlemen, to the chateau d' auret, which is a league and a half from mons in hainault, where m. le marquis was lying. so soon as i had come, i visited him, and told him the king had commanded me to come and see him and dress his wound. he said he was very glad i had come, and was much beholden to the king, who had done him so much honour as to send me to him. i found him in a high fever, his eyes deep sunken, with a moribund and yellowish face, his tongue dry and parched, and the whole body much wasted and lean, the voice low as of a man very near death: and i found his thigh much inflamed, suppurating, and ulcerated, discharging a greenish and very offensive sanies. i probed it with a silver probe, wherewith i found a large cavity in the middle of the thigh, and others round the knee, sanious and cuniculate: also several scales of bone, some loose, others not. the leg was greatly swelled, and imbued with a pituitous humor ... and bent and drawn back. there was a large bedsore; he could rest neither day nor night; and had no appetite to eat, but very thirsty. i was told he often fell into a faintness of the heart, and sometimes as in epilepsy: and often he felt sick, with such trembling he could not carry his hands to his mouth. seeing and considering all these great complications, and the vital powers thus broken down, truly i was very sorry i had come to him, because it seemed to me there was little hope he would escape death. all the same, to give him courage and good hope, i told him i would soon set him on his legs, by the grace of god, and the help of his physicians and surgeons. having seen him, i went a walk in a garden, and prayed god he would show me this grace, that he should recover; and that he would bless our hands and our medicaments, to fight such a complication of diseases. i discussed in my mind the means i must take to do this. they called me to dinner. i came into the kitchen, and there i saw, taken out of a great pot, half a sheep, a quarter of veal, three great pieces of beef, two fowls, and a very big piece of bacon, with abundance of good herbs: then i said to myself that the broth of the pot would be full of juices, and very nourishing. after dinner, we began our consultation, all the physicians and surgeons together, in the presence of m. le duc d' ascot and some gentlemen who were with him. i began to say to the surgeons that i was astonished they had not made incisions in m. le marquis' thigh, seeing that it was all suppurating, and the thick matter in it very foetid and offensive, showing it had long been pent up there; and that i had found with the probe caries of the bone, and scales of bone, which were already loose. they answered me: "never would he consent to it"; indeed, it was near two months since they had been able to get leave to put clean sheets on his bed; and one scarce dared touch the coverlet, so great was his pain. then i said, "to heal him, we must touch something else than the coverlet of his bed." each said what he thought of the malady of the patient, and in conclusion they all held it hopeless. i told them there was still some hope, because he was young, and god and nature sometimes do things which seem to physicians and surgeons impossible. to restore the warmth and nourishment of the body, general frictions must be made with hot cloths, above, below, to right, to left, and around, to draw the blood and the vital spirits from within outward. ... for the bedsore, he must be put in a fresh, soft bed, with clean shirt and sheets... having discoursed of the causes and complications of his malady, i said we must cure them by their contraries; and must first ease the pain, making openings in the thigh to let out the matter. ... secondly, having regard to the great swelling and coldness of the limb, we must apply hot bricks round it, and sprinkle them with a decoction of nerval herbs in wine and vinegar, and wrap them in napkins; and to his feet, an earthenware bottle filled with the decoction, corked, and wrapped in cloths. then the thigh, and the whole of the leg, must be fomented with a decoction made of sage, rosemary, thyme, lavender, flowers of chamomile and melilot, red roses boiled in white wine, with a drying powder made of oak-ashes and a little vinegar and half a handful of salt. ... thirdly, we must apply to the bedsore a large plaster made of the desiccative red ointment and of unguentum comitissoe, equal parts, mixed together, to ease his pain and dry the ulcer; and he must have a little pillow of down, to keep all pressure off it. ... and for the strengthening of his heart, we must apply over it a refrigerant of oil of waterlilies, ointment of roses, and a little saffron, dissolved in rose-vinegar and treacle, spread on a piece of red cloth. for the syncope, from exhaustion of the natural forces, troubling the brain, he must have good nourishment full of juices, as raw eggs, plums stewed in wine and sugar, broth of the meat of the great pot, whereof i have already spoken; the white meat of fowls, partridges' wings minced small, and other roast meats easy to digest, as veal, kid, pigeons, partridges, thrushes, and the like, with sauce of orange, verjuice, sorrel, sharp pomegranates; or he may have them boiled with good herbs, as lettuce, purslain, chicory, bugloss, marigold, and the like. at night he can take barley-water, with juice of sorrel and of waterlilies, of each two ounces, with four or five grains of opium, and the four cold seeds crushed, of each half an ounce; which is a good nourishing remedy and will make him sleep. his bread to be farmhouse bread, neither too stale nor too fresh. for the great pain in his head, his hair must be cut, and his head rubbed with rose-vinegar just warm, and a double cloth steeped in it and put there; also a forehead-cloth, of oil of roses and water-lilies and poppies, and a little opium and rose-vinegar, with a little camphor, and changed from time to time. moreover, we must allow him to smell flowers of henbane and water-lilies, bruised with vinegar and rose-water, with a little camphor, all wrapped in a handkerchief, to be held some time to his nose. ... and we must make artificial rain, pouring water from some high place into a cauldron, that he may hear the sound of it; by which means sleep shall be provoked on him. as for the contraction of his leg, there is hope of righting it when we have let out the pus and other humors pent up in the thigh, and have rubbed the whole knee with ointment of mallows, and oil of lilies, and a little eau-de-vie, and wrapped it in black wool with the grease left in it; and if we put under the knee a feather pillow doubled, little by little we shall straighten the leg. this my discourse was well approved by the physicians and surgeons. the consultation ended, we went back to the patient, and i made three openings in his thigh. ... two or three hours later, i got a bed made near his old one, with fair white sheets on it; then a strong man put him in it, and he was thankful to be taken out of his foul stinking bed. soon after, he asked to sleep; which he did for near four hours; and everybody in the house began to feel happy, and especially m. le duc d' ascot, his brother. the following days, i made injections, into the depth and cavities of the ulcers, of aegyptiacum dissolved sometimes in eau-de-vie, other times in wine, i applied compresses to the bottom of the sinuous tracks, to cleanse and dry the soft spongy flesh, and hollow leaden tents, that the sanies might always have a way out; and above them a large plaster of diacalcitheos dissolved in wine. and i bandaged him so skilfully that he had no pain; and when the pain was gone, the fever began at once to abate. then i gave him wine to drink moderately tempered with water, knowing it would restore and quicken the vital forces. and all that we agreed in consultation was done in due time and order; and so soon as his pains and fever ceased, he began steadily to amend. he dismissed two of his surgeons, and one of his physicians, so that we were but three with him. now i stopped there about two months, not without seeing many patients, both rich and poor, who came to me from three or four leagues round. he gave food and drink to the needy, and commended them all to me, asking me to help them for his sake. i protest i refused not one, and did for them all i could, to his great pleasure. then, when i saw him beginning to be well, i told him we must have viols and violins, and a buffoon to make him laugh: which he did. in one month, we got him into a chair, and he had himself carried about in his garden and at the door of his chateau, to see everybody passing by. the villagers of two or three leagues round, now they could have sight of him, came on holidays to sing and dance, men and women, pell-mell for a frolic, rejoiced at his good convalescence, all glad to see him, not without plenty of laughter and plenty to drink. he always gave them a hogshead of beer; and they all drank merrily to his health. and the citizens of mons in hainault, and other gentlemen, his neighbours, came to see him for the wonder of it, as a man come out of the grave; and from the time he was well, he was never without company. when one went out, another came in to visit him; his table was always well covered. he was dearly loved both by the nobility and by the common people; as for his generosity, so for his handsome face and his courtesy: with a kind look and a gracious word for everybody, so that all who saw him had perforce to love him. the chief citizens of mons came one saturday, to beg him let me go to mons, where they wished to entertain me with a banquet, for their love of him. he told them he would urge me to go, which he did; but i said such great honour was not for me, moreover they could not feast me better than he did. again he urged me, with much affection, to go there, to please him; and i agreed. the next day, they came to fetch me with two carriages: and when we got to mons, we found the dinner ready, and the chief men of the town, with their ladies, who attended me with great devotion. we sat down to dinner, and they put me at the top of the table, and all drank to me, and to the health of m. le marquis d'auret: saying he was happy, and they with him, to have had me to put him on his legs again; and truly the whole company were full of honour and love for him. after dinner, they brought me back to the chateau d'auret, where m. le marquis was awaiting me; who affectionately welcomed me, and would hear what we had done at our banquet; and i told him all the company had drunk many times to his health. in six weeks he began to stand a little on crutches, and to put on fat and get a good natural colour. he would go to beaumont, his brother's place; and was taken there in a carrying-chair, by eight men at a time. and the peasants in the villages through which we passed, knowing it was m. le marquis, fought who should carry him, and would have us drink with them; but it was only beer. yet i believe if they had possessed wine, even hippocras, they would have given it to us with a will. and all were right glad to see him, and all prayed god for him. when we came to beaumont, everybody came out to meet us and pay their respects to him, and prayed god bless him and keep him in good health. we came to the chateau, and found there more than fifty gentlemen whom m. le duc d'ascot had invited to come and be happy with his brother; and he kept open house three whole days. after dinner, the gentlemen used to tilt at the ring and play with the foils, and were full of joy at the sight of m. d'auret, for they had heard he would never leave his bed or be healed of his wound. i was always at the upper end of the table, and everybody drank to him and to me, thinking to make me drunk, which they could not; for i drank only as i always do. a few days later, we went back; and i took my leave of mdme. la duchesse d'ascot, who drew a diamond from her finger, and gave it me in gratitude for my good care of her brother: and the diamond was worth more than fifty crowns. m. d'auret was ever getting better, and was walking all alone on crutches round his garden. many times i asked him to let me go back to paris, telling him his physician and his surgeon could do all that was now wanted for his wound: and to make a beginning to get away from him, i asked him to let me go and see the town of antwerp. to this he agreed at once, and told his steward to escort me there, with two pages. we passed through malines and brussels, where the chief citizens of the town begged us to let them know of it when we returned; for they too wished, like those of mons, to have a festival for me. i gave them very humble thanks, saying i did not deserve such honour. i was two days and a half seeing the town of antwerp, where certain merchants, knowing the steward, prayed he would let them have the honour of giving us a dinner or a supper: it was who should have us, and they were all truly glad to hear how well m. d' auret was doing, and made more of me than i asked. on my return, i found m. le marquis enjoying himself: and five or six days later i asked his leave to go, which he gave, said he, with great regret. and he made me a handsome present of great value, and sent me back, with the steward, and two pages, to my house in paris. i forgot to say that the spaniards have since ruined and demolished his chateau d' auret, sacked, pillaged, and burned all the houses and villages belonging to him: because he would not be of their wicked party in their assassinations and ruin of the netherlands. i have published this apologia, that all men may know on what footing i have always gone: and sure there is no man so touchy not to take in good part what i have said. for i have but told the truth; and the purport of my discourse is plain for all men to see, and the facts themselves are my guarantee against all calumnies. on the motion of the heart and blood in animals by william harvey translated by robert willis and revised by alexander bowie introductory note william harvey, whose epoch-making treatise announcing and demonstrating the ejaculation of the blood is here printed, was born at folkestone, kent, england, april 1, 1578. he was educated at the king's school, canterbury, and at gonville and caius college, cambridge; and studied medicine on the continent, receiving the degree of m.d. from the university of padua. he took the same degree later at both the english universities. after his return to england he became fellow of the college of physicians, physician to st. bartholomew's hospital, and lumleian lecturer at the college of physicians. it was in this last capacity that he delivered, in 1616, the lectures in which he first gave public notice of his theories on the circulation of the blood. the notes of these lectures are still preserved in the british museum. in 1618 harvey was appointed physician extraordinary to james i, and he remained in close professional relations to the royal family until the close of the civil war, being present at the battle of edgehill. by mandate of charles i, he was, for a short time, warden of merton college, oxford (1645-6), and, when he was too infirm to undertake the duties, he was offered the presidency of the college of physicians. he died on june 3, 1657. harvey's famous "exercitatio anatomica de motu cordis et sanguinis in animalibus" was published in latin at frankfort in 1628. the discovery was received with great interest, and in his own country was accepted at once; on the continent it won favor more slowly. before his death, however, the soundness of his views was acknowledged by the medical profession throughout europe, and "it remains to this day the greatest of the discoveries of physiology, and its whole honor belongs to harvey." dedication to his very dear friend, doctor argent, the excellent and accomplished president of the royal college of physicians, and to other learned physicians, his most esteemed colleagues. i have already and repeatedly presented you, my learned friends, with my new views of the motion and function of the heart, in my anatomical lectures; but having now for more than nine years confirmed these views by multiplied demonstrations in your presence, illustrated them by arguments, and freed them from the objections of the most learned and skilful anatomists, i at length yield to the requests, i might say entreaties, of many, and here present them for general consideration in this treatise. were not the work indeed presented through you, my learned friends, i should scarce hope that it could come out scatheless and complete; for you have in general been the faithful witnesses of almost all the instances from which i have either collected the truth or confuted error. you have seen my dissections, and at my demonstrations of all that i maintain to be objects of sense, you have been accustomed to stand by and bear me out with your testimony. and as this book alone declares the blood to course and revolve by a new route, very different from the ancient and beaten pathway trodden for so many ages, and illustrated by such a host of learned and distinguished men, i was greatly afraid lest i might be charged with presumption did i lay my work before the public at home, or send it beyond seas for impression, unless i had first proposed the subject to you, had confirmed its conclusions by ocular demonstrations in your presence, had replied to your doubts and objections, and secured the assent and support of our distinguished president. for i was most intimately persuaded, that if i could make good my proposition before you and our college, illustrious by its numerous body of learned individuals, i had less to fear from others. i even ventured to hope that i should have the comfort of finding all that you granted me in your sheer love of truth, conceded by others who were philosophers like yourselves. true philosophers, who are only eager for truth and knowledge, never regard themselves as already so thoroughly informed, but that they welcome further information from whomsoever and from wheresoever it may come; nor are they so narrow-minded as to imagine any of the arts or sciences transmitted to us by the ancients, in such a state of forwardness or completeness, that nothing is left for the ingenuity and industry of others. on the contrary, very many maintain that all we know is still infinitely less than all that still remains unknown; nor do philosophers pin their faith to others' precepts in such wise that they lose their liberty, and cease to give credence to the conclusions of their proper senses. neither do they swear such fealty to their mistress antiquity, that they openly, and in sight of all, deny and desert their friend truth. but even as they see that the credulous and vain are disposed at the first blush to accept and believe everything that is proposed to them, so do they observe that the dull and unintellectual are indisposed to see what lies before their eyes, and even deny the light of the noonday sun. they teach us in our course of philosophy to sedulously avoid the fables of the poets and the fancies of the vulgar, as the false conclusions of the sceptics. and then the studious and good and true, never suffer their minds to be warped by the passions of hatred and envy, which unfit men duly to weigh the arguments that are advanced in behalf of truth, or to appreciate the proposition that is even fairly demonstrated. neither do they think it unworthy of them to change their opinion if truth and undoubted demonstration require them to do so. they do not esteem it discreditable to desert error, though sanctioned by the highest antiquity, for they know full well that to err, to be deceived, is human; that many things are discovered by accident and that many may be learned indifferently from any quarter, by an old man from a youth, by a person of understanding from one of inferior capacity. my dear colleagues, i had no purpose to swell this treatise into a large volume by quoting the names and writings of anatomists, or to make a parade of the strength of my memory, the extent of my reading, and the amount of my pains; because i profess both to learn and to teach anatomy, not from books but from dissections; not from the positions of philosophers but from the fabric of nature; and then because i do not think it right or proper to strive to take from the ancients any honor that is their due, nor yet to dispute with the moderns, and enter into controversy with those who have excelled in anatomy and been my teachers. i would not charge with wilful falsehood any one who was sincerely anxious for truth, nor lay it to any one's door as a crime that he had fallen into error. i avow myself the partisan of truth alone; and i can indeed say that i have used all my endeavours, bestowed all my pains on an attempt to produce something that should be agreeable to the good, profitable to the learned, and useful to letters. farewell, most worthy doctors, and think kindly of your anatomist, william harvey. introduction as we are about to discuss the motion, action, and use of the heart and arteries, it is imperative on us first to state what has been thought of these things by others in their writings, and what has been held by the vulgar and by tradition, in order that what is true may be confirmed, and what is false set right by dissection, multiplied experience, and accurate observation. almost all anatomists, physicians, and philosophers up to the present time have supposed, with galen, that the object of the pulse was the same as that of respiration, and only differed in one particular, this being conceived to depend on the animal, the respiration on the vital faculty; the two, in all other respects, whether with reference to purpose or to motion, comporting themselves alike. whence it is affirmed, as by hieronymus fabricius of aquapendente, in his book on "respiration," which has lately appeared, that as the pulsation of the heart and arteries does not suffice for the ventilation and refrigeration of the blood, therefore were the lungs fashioned to surround the heart. from this it appears that whatever has hitherto been said upon the systole and diastole, or on the motion of the heart and arteries, has been said with especial reference to the lungs. but as the structure and movements of the heart differ from those of the lungs, and the motions of the arteries from those of the chest, so it seems likely that other ends and offices will thence arise, and that the pulsations and uses of the heart, likewise of the arteries, will differ in many respects from the heavings and uses of the chest and lungs. for did the arterial pulse and the respiration serve the same ends; did the arteries in their diastole take air into their cavities, as commonly stated, and in their systole emit fuliginous vapours by the same pores of the flesh and skin; and further, did they, in the time intermediate between the diastole and the systole, contain air, and at all times either air or spirits, or fuliginous vapours, what should then be said to galen, who wrote a book on purpose to show that by nature the arteries contained blood, and nothing but blood, and consequently neither spirits nor air, as may readily be gathered from the experiments and reasonings contained in the same book? now, if the arteries are filled in the diastole with air then taken into them (a larger quantity of air penetrating when the pulse is large and full), it must come to pass that if you plunge into a bath of water or of oil when the pulse is strong and full, it ought forthwith to become either smaller or much slower, since the circumambient bath will render it either difficult or impossible for the air to penetrate. in like manner, as all the arteries, those that are deep-seated as well as those that are superficial, are dilated at the same instant and with the same rapidity, how is it possible that air should penetrate to the deeper parts as freely and quickly through the skin, flesh, and other structures, as through the cuticle alone? and how should the arteries of the foetus draw air into their cavities through the abdomen of the mother and the body of the womb? and how should seals, whales, dolphins, and other cetaceans, and fishes of every description, living in the depths of the sea, take in and emit air by the diastole and systole of their arteries through the infinite mass of water? for to say that they absorb the air that is present in the water, and emit their fumes into this medium, were to utter something like a figment. and if the arteries in their systole expel fuliginous vapours from their cavities through the pores of the flesh and skin, why not the spirits, which are said to be contained in those vessels, at the same time, since spirits are much more subtile than fuliginous vapours or smoke? and if the arteries take in and cast out air in the systole and diastole, like the lungs in the process of respiration, why do they not do the same thing when a wound is made in one of them, as in the operation of arteriotomy? when the windpipe is divided, it is sufficiently obvious that the air enters and returns through the wound by two opposite movements; but when an artery is divided, it is equally manifest that blood escapes in one continuous stream, and that no air either enters or issues. if the pulsations of the arteries fan and refrigerate the several parts of the body as the lungs do the heart, how comes it, as is commonly said, that the arteries carry the vital blood into the different parts, abundantly charged with vital spirits, which cherish the heat of these parts, sustain them when asleep, and recruit them when exhausted? how should it happen that, if you tie the arteries, immediately the parts not only become torpid, and frigid, and look pale, but at length cease even to be nourished? this, according to galen, is because they are deprived of the heat which flowed through all parts from the heart, as its source; whence it would appear that the arteries rather carry warmth to the parts than serve for any fanning or refrigeration. besides, how can their diastole draw spirits from the heart to warm the body and its parts, and means of cooling them from without? still further, although some affirm that the lungs, arteries, and heart have all the same offices, they yet maintain that the heart is the workshop of the spirits, and that the arteries contain and transmit them; denying, however, in opposition to the opinion of columbus, that the lungs can either make or contain spirits. they then assert, with galen, against erasistratus, that it is the blood, not spirits, which is contained in the arteries. these opinions are seen to be so incongruous and mutually subversive, that every one of them is justly brought under suspicion. that it is blood and blood alone which is contained in the arteries is made manifest by the experiment of galen, by arteriotomy, and by wounds; for from a single divided artery, as galen himself affirms in more than one place, the whole of the blood may be withdrawn in the course of half an hour or less. the experiment of galen alluded to is this: "if you include a portion of an artery between two ligatures, and slit it open lengthwise you will find nothing but blood"; and thus he proves that the arteries contain only blood. and we too may be permitted to proceed by a like train of reasoning: if we find the same blood in the arteries as in the veins, after having tied them in the same way, as i have myself repeatedly ascertained, both in the dead body and in living animals, we may fairly conclude that the arteries contain the same blood as the veins, and nothing but the same blood. some, whilst they attempt to lessen the difficulty, affirm that the blood is spirituous and arterious, and virtually concede that the office of the arteries is to carry blood from the heart into the whole of the body, and that they are therefore filled with blood; for spirituous blood is not the less blood on that account. and no one denies the blood as such, even the portion of it which flows in the veins, is imbued with spirits. but if that portion of it which is contained in the arteries be richer in spirits, it is still to be believed that these spirits are inseparable from the blood, like those in the veins; that the blood and spirits constitute one body (like whey and butter in milk, or heat in hot water), with which the arteries are charged, and for the distribution of which from the heart they are provided. this body is nothing else than blood. but if this blood be said to be drawn from the heart into the arteries by the diastole of these vessels, it is then assumed that the arteries by their distension are filled with blood, and not with the surrounding air, as heretofore; for if they be said also to become filled with air from the ambient atmosphere, how and when, i ask, can they receive blood from the heart? if it be answered: during the systole, i take it to be impossible: the arteries would then have to fill while they contracted, to fill, and yet not become distended. but if it be said: during diastole, they would then, and for two opposite purposes, be receiving both blood and air, and heat and cold, which is improbable. further when it is affirmed that the diastole of the heart and arteries is simultaneous, and the systole of the two is also concurrent, there is another incongruity. for how can two bodies mutually connected, which are simultaneously distended, attract or draw anything from one another? or being simultaneously contracted, receive anything from each other? and then it seems impossible that one body can thus attract another body into itself, so as to become distended, seeing that to be distended is to be passive, unless, in the manner of a sponge, which has been previously compressed by an external force, it is returning to its natural state. but it is difficult to conceive that there can be anything of this kind in the arteries. the arteries dilate, because they are filled like bladders or leathern bottles; they are not filled because they expand like bellows. this i think easy of demonstration, and indeed conceive that i have already proved it. nevertheless, in that book of galen headed "quod sanguis continetur in arterus," he quotes an experiment to prove the contrary. an artery having been exposed, is opened longitudinally, and a reed or other pervious tube is inserted into the vessel through the opening, by which the blood is prevented from being lost, and the wound is closed. "so long," he says, "as things are thus arranged, the whole artery will pulsate; but if you now throw a ligature about the vessel and tightly compress its wall over the tube, you will no longer see the artery beating beyond the ligature." i have never performed this experiment of galen's nor do i think that it could very well be performed in the living body, on account of the profuse flow of blood that would take place from the vessel that was operated on; neither would the tube effectually close the wound in the vessel without a ligature; and i cannot doubt but that the blood would be found to flow out between the tube and the vessel. still galen appears by this experiment to prove both that the pulsative property extends from the heart by the walls of the arteries, and that the arteries, whilst they dilate, are filled by that pulsific force, because they expand like bellows, and do not dilate as if they are filled like skins, but the contrary is obvious in arteriotomy and in wounds; for the blood spurting from the arteries escapes with force, now farther, now not so far, alternately, or in jets; and the jet always takes place with the diastole of the artery, never with the systole. by which it clearly appears that the artery is dilated with the impulse of the blood; for of itself it would not throw the blood to such a distance and whilst it was dilating; it ought rather to draw air into its cavity through the wound, were those things true that are commonly stated concerning the uses of the arteries. do not let the thickness of the arterial tunics impose upon us, and lead us to conclude that the pulsative property proceeds along them from the heart for in several animals the arteries do not apparently differ from the veins; and in extreme parts of the body where the arteries are minutely subdivided, as in the brain, the hand, etc., no one could distinguish the arteries from the veins by the dissimilar characters of their coats: the tunics of both are identical. and then, in the aneurism proceeding from a wounded or eroded artery, the pulsation is precisely the same as in the other arteries, and yet it has no proper arterial covering. to this the learned riolanus testifies along with me, in his seventh book. nor let any one imagine that the uses of the pulse and the respiration are the same, because, under the influences of the same causes, such as running, anger, the warm bath, or any other heating thing, as galen says, they become more frequent and forcible together. for not only is experience in opposition to this idea, though galen endeavours to explain it away, when we see that with excessive repletion the pulse beats more forcibly, whilst the respiration is diminished in amount;, but in young persons the pulse is quick, whilst respiration is slow. so it is also in alarm, and amidst care, and under anxiety of mind; sometimes, too, in fevers, the pulse is rapid, but the respiration is slower than usual. these and other objections of the same kind may be urged against the opinions mentioned. nor are the views that are entertained of the offices and pulse of the heart, perhaps, less bound up with great and most inextricable difficulties. the heart, it is vulgarly said, is the fountain and workshop of the vital spirits, the centre from which life is dispensed to the several parts of the body. yet it is denied that the right ventricle makes spirits, which is rather held to supply nourishment to the lungs. for these reasons it is maintained that fishes are without any right ventricle (and indeed every animal wants a right ventricle which is unfurnished with lungs), and that the right ventricle is present solely for the sake of the lungs. 1. why, i ask, when we see that the structure of both ventricles is almost identical, there being the same apparatus of fibres, and braces, and valves, and vessels, and auricles, and both in the same way in our dissections are found to be filled up with blood similarly black in colour, and coagulated--why, i say, should their uses be imagined to be different, when the action, motion, and pulse of both are the same? if the three tricuspid valves placed at the entrance into the right ventricle prove obstacles to the reflux of the blood into the vena cava, and if the three semilunar valves which are situated at the commencement of the pulmonary artery be there, that they may prevent the return of the blood into the ventricle; why, when we find similar structures in connexion with the left ventricle, should we deny that they are there for the same end, of preventing here the egress, there the regurgitation, of the blood? 2. and, when we have these structures, in points of size, form, and situation, almost in every respect the same in the left as in the right ventricle, why should it be said that things are arranged in the former for the egress and regress of spirits, and in the latter or right ventricle, for the blood? the same arrangement cannot be held fitted to favour or impede the motion of the blood and of spirits indifferently. 3. and when we observe that the passages and vessels are severally in relation to one another in point of size, viz., the pulmonary artery to the pulmonary veins; why should the one be destined to a private purpose, that of furnishing the lungs, the other to a public function? 4. and as realdus columbus says, is it probable that such a quantity of blood should be required for the nutrition of the lungs; the vessel that leads to them, the vena arteriosa or pulmonary artery being of greater capacity than both the iliac veins? 5. and i ask, as the lungs are so close at hand, and in continual motion, and the vessel that supplies them is of such dimensions, what is the use or meaning of this pulse of the right ventricle? and why was nature reduced to the necessity of adding another ventricle for the sole purpose of nourishing the lungs? when it is said that the left ventricle draws materials for the formation of spirits, air and blood, from the lungs and right sinuses of the heart, and in like manner sends spirituous blood into the aorta, drawing fuliginous vapours from there, and sending them by the pulmonary vein into the lungs, whence spirits are at the same time obtained for transmission into the aorta, i ask how, and by what means is the separation effected? and how comes it that spirits and fuliginous vapours can pass hither and thither without admixture or confusion? if the mitral cuspidate valves do not prevent the egress of fuliginous vapours to the lungs, how should they oppose the escape of air? and how should the semiluftars hinder the regress of spirits from the aorta upon each supervening diastole of the heart? above all, how can they say that the spirituous blood is sent from the pulmonary veins by the left ventricle into the lungs without any obstacle to its passage from the mitral valves, when they have previously asserted that the air entered by the same vessel from the lungs into the left ventricle, and have brought forward these same mitral valves as obstacles to its retrogression? good god! how should the mitral valves prevent the regurgitation of air and not of blood? moreover, when they appoint the pulmonary artery, a vessel of great size, with the coverings of an artery, to none but a kind of private and single purpose, that, namely, of nourishing the lungs, why should the pulmonary vein, which is scarcely so large, which has the coats of a vein, and is soft and lax, be presumed to be made for many--three or four different--uses? for they will have it that air passes through this vessel from the lungs into the left ventricle; that fuliginous vapours escape by it from the heart into the lungs; and that a portion of the spirituous blood is distributed to the lungs for their refreshment. if they will have it that fumes and air--fumes flowing from, air proceeding towards the heart--are transmitted by the same conduit, i reply, that nature is not wont to construct but one vessel, to contrive but one way for such contrary motions and purposes, nor is anything of the kind seen elsewhere. if fumes or fuliginous vapours and air permeate this vessel, as they do the pulmonary bronchia, wherefore do we find neither air nor fuliginous vapours when we divide the pulmonary vein? why do we always find this vessel full of sluggish blood, never of air, whilst in the lungs we find abundance of air remaining? if any one will perform galen's experiment of dividing the trachea of a living dog, forcibly distending the lungs with a pair of bellows, and then tying the trachea securely, he will find, when he has laid open the thorax, abundance of air in the lungs, even to their extreme investing tunic, but none in either the pulmonary veins or the left ventricle of the heart. but did the heart either attract air from the lungs, or did the lungs transmit any air to the heart, in the living dog, much more ought this to be the case in the experiment just referred to. who, indeed, doubts that, did he inflate the lungs of a subject in the dissecting--room, he would instantly see the air making its way by this route, were there actually any such passage for it? but this office of the pulmonary veins, namely, the ransference of air from the lungs of the heart, is held of such importance, that hieronymus fabricius of aquapendente, contends that the lungs were made for the sake of this vessel, and that it constitutes the principal element in their structure. but i should like to be informed why, if the pulmonary vein were destined for the conveyance of air, it has the structure of a blood--vessel here. nature had rather need of annular tubes, such as those of the bronchi in order that they might always remain open, and not be liable to collapse; and that they might continue entirely free from blood, lest the liquid should interfere with the passage of the air, as it so obviously does when the lungs labour from being either greatly oppressed or loaded in a less degree with phlegm, as they are when the breathing is performed with a sibilous or rattling noise. still less is that opinion to be tolerated which, as a two-fold material, one aerial, one sanguineous, is required for the composition of vital spirits, supposes the blood to ooze through the septum of the heart from the right to the left ventricle by certain hidden porosities, and the air to be attracted from the lungs through the great vessel, the pulmonary vein; and which, consequently, will have it, that there are numerous porosities in the septum of the heart adapted for the transmission of the blood. but by hercules! no such pores can be demonstrated, nor in fact do any such exist. for the septum of the heart is of a denser and more compact structure than any portion of the body, except the bones and sinews. but even supposing that there were foramina or pores in this situation, how could one of the ventricles extract anything from the other--the left, e.g., obtain blood from the right, when we see that both ventricles contract and dilate simultaneously? why should we not rather believe that the right took spirits from the left, than that the left obtained blood from the right ventricle through these foramina? but it is certainly mysterious and incongruous that blood should be supposed to be most commodiously drawn through a set of obscure or invisible ducts, and air through perfectly open passages, at one and the same moment. and why, i ask, is recourse had to secret and invisible porosities, to uncertain and obscure channels, to explain the passage of the blood into the left ventricle, when there is so open a way through the pulmonary veins? i own it has always appeared extraordinary to me that they should have chosen to make, or rather to imagine, a way through the thick, hard, dense, and most compact septum of the heart, rather than take that by the open pulmonary vein, or even through the lax, soft and spongy substance of the lungs at large. besides, if the blood could permeate the substance of the septum, or could be imbibed from the ventricles, what use were there for the coronary artery and vain, branches of which proceed to the septum itself, to supply it with nourishment? and what is especially worthy of notice is this: if in the foetus, where everything is more lax and soft, nature saw herself reduced to the necessity of bringing the blood from the right to the left side of the heart by the foramen ovale, from the vena cava through the pulmonary vein, how should it be likely that in the adult she should pass it so commodiously, and without an effort through the septum of the ventricles which has now become denser by age? andreas laurentius, [footnote: lib. ix, cap. xi, quest. 12.] resting on the authority of galen [footnote: de locis affectia. lib. vi, cap. 7.] and the experience of hollerius, asserts and proves that the serum and pus in empyema, absorbed from the cavities of the chest into the pulmonary vein may be expelled and got rid of with the urine and feces through the left ventricle of the heart and arteries. he quotes the case of a certain person affected with melancholia, and who suffered from repeated fainting fits, who was relieved from the paroxysms on passing a quantity of turbid, fetid and acrid urine. but he died at last, worn out by disease; and when the body came to be opened after death, no fluid like that he had micturated was discovered either in the bladder or the kidneys; but in the left ventricle of the heart and cavity of the thorax plenty of it was met with. and then laurentius boasts that he had predicted the cause of the symptoms. for my own part, however, i cannot but wonder, since he had divined and predicted that heterogeneous matter could be discharged by the course he indicates, why he could not or would not perceive, and inform us that, in the natural state of things, the blood might be commodiously transferred from the lungs to the left ventricle of the heart by the very same route. since, therefore, from the foregoing considerations and many others to the same effect, it is plain that what has heretofore been said concerning the motion and function of the heart and arteries must appear obscure, inconsistent, or even impossible to him who carefully considers the entire subject, it would be proper to look more narrowly into the matter to contemplate the motion of the heart and arteries, not only in man, but in all animals that have hearts; and also, by frequent appeals to vivisection, and much ocular inspection, to investigate and discern the truth. on the motion of the heart and blood in animals chapter i the author's motives for writing when i first gave my mind to vivisections, as a means of discovering the motions and uses of the heart, and sought to discover these from actual inspection, and not from the writings of others, i found the task so truly arduous, so full of difficulties, that i was almost tempted to think, with fracastorius, that the motion of the heart was only to be comprehended by god. for i could neither rightly perceive at first when the systole and when the diastole took place, nor when and where dilatation and contraction occurred, by reason of the rapidity of the motion, which in many animals is accomplished in the twinkling of an eye, coming and going like a flash of lightning; so that the systole presented itself to me now from this point, now from that; the diastole the same; and then everything was reversed, the motions occurring, as it seemed, variously and confusedly together. my mind was therefore greatly unsettled nor did i know what i should myself conclude, nor what believe from others. i was not surprised that andreas laurentius should have written that the motion of the heart was as perplexing as the flux and reflux of euripus had appeared to aristotle. at length, by using greater and daily diligence and investigation, making frequent inspection of many and various animals, and collating numerous observations, i thought that i had attained to the truth, that i should extricate myself and escape from this labyrinth, and that i had discovered what i so much desired, both the motion and the use of the heart and arteries. from that time i have not hesitated to expose my views upon these subjects, not only in private to my friends, but also in public, in my anatomical lectures, after the manner of the academy of old. these views as usual, pleased some more, others less; some chid and calumniated me, and laid it to me as a crime that i had dared to depart from the precepts and opinions of all anatomists; others desired further explanations of the novelties, which they said were both worthy of consideration, and might perchance be found of signal use. at length, yielding to the requests of my friends, that all might be made participators in my labors, and partly moved by the envy of others, who, receiving my views with uncandid minds and understanding them indifferently, have essayed to traduce me publicly, i have moved to commit these things to the press, in order that all may be enabled to form an opinion both of me and my labours. this step i take all the more willingly, seeing that hieronymus fabricius of aquapendente, although he has accurately and learnedly delineated almost every one of the several parts of animals in a special work, has left the heart alone untouched. finally, if any use or benefit to this department of the republic of letters should accrue from my labours, it will, perhaps, be allowed that i have not lived idly, and as the old man in the comedy says: for never yet hath any one attained to such perfection, but that time, and place, and use, have brought addition to his knowledge; or made correction, or admonished him, that he was ignorant of much which he had thought he knew; or led him to reject what he had once esteemed of highest price. so will it, perchance, be found with reference to the heart at this time; or others, at least, starting hence, with the way pointed out to them, advancing under the guidance of a happier genius, may make occasion to proceed more fortunately, and to inquire more accurately. chapter ii on the motions of the heart as seen in the dissection of living animals in the first place, then, when the chest of a living animal is laid open and the capsule that immediately surrounds the heart is slit up or removed, the organ is seen now to move, now to be at rest; there is a time when it moves, and a time when it is motionless. these things are more obvious in the colder animals, such as toads, frogs, serpents, small fishes, crabs, shrimps, snails, and shell-fish. they also become more distinct in warm-blooded animals, such as the dog and hog, if they be attentively noted when the heart begins to flag, to move more slowly, and, as it were, to die: the movements then become slower and rarer, the pauses longer, by which it is made much more easy to perceive and unravel what the motions really are, and how they are performed. in the pause, as in death, the heart is soft, flaccid, exhausted, lying, as it were, at rest. in the motion, and interval in which this is accomplished, three principal circumstances are to be noted: 1. that the heart is erected, and rises upwards to a point, so that at this time it strikes against the breast and the pulse is felt externally. 2. that it is everywhere contracted, but more especially towards the sides so that it looks narrower, relatively longer, more drawn together. the heart of an eel taken out of the body of the animal and placed upon the table or the hand, shows these particulars; but the same things are manifest in the hearts of all small fishes and of those colder animals where the organ is more conical or elongated. 3. the heart being grasped in the hand, is felt to become harder during its action. now this hardness proceeds from tension, precisely as when the forearm is grasped, its tendons are perceived to become tense and resilient when the fingers are moved. 4. it may further be observed in fishes, and the colder blooded animals, such as frogs, serpents, etc., that the heart, when it moves, becomes of a paler color, when quiescent of a deeper blood-red color. from these particulars it appears evident to me that the motion of the heart consists in a certain universal tension--both contraction in the line of its fibres, and constriction in every sense. it becomes erect, hard, and of diminished size during its action; the motion is plainly of the same nature as that of the muscles when they contract in the line of their sinews and fibres; for the muscles, when in action, acquire vigor and tenseness, and from soft become hard, prominent, and thickened: and in the same manner the heart. we are therefore authorized to conclude that the heart, at the moment of its action, is at once constricted on all sides, rendered thicker in its parietes and smaller in its ventricles, and so made apt to project or expel its charge of blood. this, indeed, is made sufficiently manifest by the preceding fourth observation in which we have seen that the heart, by squeezing out the blood that it contains, becomes paler, and then when it sinks into repose and the ventricle is filled anew with blood, that the deeper crimson colour returns. but no one need remain in doubt of the fact, for if the ventricle be pierced the blood will be seen to be forcibly projected outwards upon each motion or pulsation when the heart is tense. these things, therefore, happen together or at the same instant: the tension of the heart, the pulse of its apex, which is felt externally by its striking against the chest, the thickening of its parietes, and the forcible expulsion of the blood it contains by the constriction of its ventricles. hence the very opposite of the opinions commonly received appears to be true; inasmuch as it is generally believed that when the heart strikes the breast and the pulse is felt without, the heart is dilated in its ventricles and is filled with blood; but the contrary of this is the fact, and the heart, when it contracts (and the impulse of the apex is conveyed through the chest wall), is emptied. whence the motion which is generally regarded as the diastole of the heart, is in truth its systole. and in like manner the intrinsic motion of the heart is not the diastole but the systole; neither is it in the diastole that the heart grows firm and tense, but in the systole, for then only, when tense, is it moved and made vigorous. neither is it by any means to be allowed that the heart only moves in the lines of its straight fibres, although the great vesalius giving this notion countenance, quotes a bundle of osiers bound in a pyramidal heap in illustration; meaning, that as the apex is approached to the base, so are the sides made to bulge out in the fashion of arches, the cavities to dilate, the ventricles to acquire the form of a cupping-glass and so to suck in the blood. but the true effect of every one of its fibres is to constringe the heart at the same time they render it tense; and this rather with the effect of thickening and amplifying the walls and substance of the organ than enlarging its ventricles. and, again, as the fibres run from the apex to the base, and draw the apex towards the base, they do not tend to make the walls of the heart bulge out in circles, but rather the contrary; inasmuch as every fibre that is circularly disposed, tends to become straight when it contracts; and is distended laterally and thickened, as in the case of muscular fibres in general, when they contract, that is, when they are shortened longitudinally, as we see them in the bellies of the muscles of the body at large. to all this let it be added, that not only are the ventricles contracted in virtue of the direction and condensation of their walls, but farther, that those fibres, or bands, styled nerves by aristotle, which are so conspicuous in the ventricles of the larger animals, and contain all the straight fibres (the parietes of the heart containing only circular ones), when they contract simultaneously by an admirable adjustment all the internal surfaces are drawn together as if with cords, and so is the charge of blood expelled with force. neither is it true, as vulgarly believed, that the heart by any dilatation or motion of its own, has the power of drawing the blood into the ventricles; for when it acts and becomes tense, the blood is expelled; when it relaxes and sinks together it receives the blood in the manner and wise which will by-and-by be explained. chapter iii of the motions of the arteries, as seen in the dissection of living animals in connexion with the motions of the heart these things are further to be observed having reference to the motions and pulses of the arteries. 1. at the moment the heart contracts, and when the breast is struck, when in short the organ is in its state of systole, the arteries are dilated, yield a pulse, and are in the state of diastole. in like manner, when the right ventricle contracts and propels its charge of blood, the pulmonary artery is distended at the same time with the other arteries of the body. 2. when the left ventricle ceases to act, to contract, to pulsate, the pulse in the arteries also ceases; further, when this ventricle contracts languidly, the pulse in the arteries is scarcely perceptible. in like manner, the pulse in the right ventricle failing, the pulse in the pulmonary artery ceases also. 3. further, when an artery is divided or punctured, the blood is seen to be forcibly propelled from the wound the moment the left ventricle contracts; and, again, when the pulmonary artery is wounded, the blood will be seen spouting forth with violence at the instant when the right ventricle contracts. so also in fishes, if the vessel which leads from the heart to the gills be divided, at the moment when the heart becomes tense and contracted, at the same moment does the blood flow with force from the divided vessel. in the same way, when we see the blood in arteriotomy projected now to a greater, now to a less distance, and that the greater jet corresponds to the diastole of the artery and to the time when the heart contracts and strikes the ribs, and is in its state of systole, we understand that the blood is expelled by the same movement. from these facts it is manifest, in opposition to commonly received opinions, that the diastole of the arteries corresponds with the time of the heart's systole; and that the arteries are filled and distended by the blood forced into them by the contraction of the ventricles; the arteries, therefore, are distended, because they are filled like sacs or bladders, and are not filled because they expand like bellows. it is in virtue of one and the same cause, therefore, that all the arteries of the body pulsate, viz., the contraction of the left ventricle; in the same way as the pulmonary artery pulsates by the contraction of the right ventricle. finally, that the pulses of the arteries are due to the impulses of the blood from the left ventricle, may be illustrated by blowing into a glove, when the whole of the fingers will be found to become distended at one and the same time, and in their tension to bear some resemblance to the pulse. for in the ratio of the tension is the pulse of the heart, fuller, stronger, and more frequent as that acts more vigorously, still preserving the rhythm and volume, and order of the heart's contractions. nor is it to be expected that because of the motion of the blood, the time at which the contraction of the heart takes place, and that at which the pulse in an artery (especially a distant one) is felt, shall be otherwise than simultaneous: it is here the same as in blowing up a glove or bladder; for in a plenum (as in a drum, a long piece of timber, etc.) the stroke and the motion occur at both extremities at the same time. aristotle, [footnote: de anim., iii, cap. 9.] too, has said, "the blood of all animals palpitates within their veins (meaning the arteries), and by the pulse is sent everywhere simultaneously." and further, [footnote: de respir., cap. 20] "thus do all the veins pulsate together and by successive strokes, because they all depend upon the heart; and, as it is always in motion, so are they likewise always moving together, but by successive movements." it is well to observe with galen, in this place, that the old philosophers called the arteries veins. i happened upon one occasion to have a particular case under my care, which plainly satisfied me of the truth: a certain person was affected with a large pulsating tumour on the right side of the neck, called an aneurism, just at that part where the artery descends into the axilla, produced by an erosion of the artery itself, and daily increasing in size; this tumour was visibly distended as it received the charge of blood brought to it by the artery, with each stroke of the heart; the connexion of parts was obvious when the body of the patient came to be opened after his death. the pulse in the corresponding arm was small, in consequence of the greater portion of the blood being diverted into the tumour and so intercepted. whence it appears that whenever the motion of the blood through the arteries is impeded, whether it be by compression or infarction, or interception, there do the remote divisions of the arteries beat less forcibly, seeing that the pulse of the arteries is nothing more than the impulse or shock of the blood in these vessels. chapter iv of the motion of the heart and its auricles, as seen in the bodies of living animals besides the motions already spoken of, we have still to consider those that appertain to the auricles. caspar bauhin and john riolan, [footnote: i bauhin, lib. ii. cap. ii. riolan. lib. viii, cap. i.] most learned men and skilful anatomists, inform us that from their observations, that if we carefully watch the movements of the heart in the vivisection of an animal, we shall perceive four motions distinct in time and in place, two of which are proper to the auricles, two to the ventricles. with all deference to such authority i say that there are four motions distinct in point of place, but not of time; for the two auricles move together, and so also do the two ventricles, in such wise that though the places be four, the times are only two. and this occurs in the following manner: there are, as it were, two motions going on together: one of the auricles, another of the ventricles; these by no means taking place simultaneously, but the motion of the auricles preceding, that of the heart following; the motion appearing to begin from the auricles and to extend to the ventricles. when all things are becoming languid, and the heart is dying, as also in fishes and the colder blooded animals there is a short pause between these two motions, so that the heart aroused, as it were, appears to respond to the motion, now more quickly, now more tardily; and at length, when near to death, it ceases to respond by its proper motion, but seems, as it were, to nod the head, and is so slightly moved that it appears rather to give signs of motion to the pulsating auricles than actually to move. the heart, therefore, ceases to pulsate sooner than the auricles, so that the auricles have been said to outlive it, the left ventricle ceasing to pulsate first of all; then its auricle, next the right ventricle; and, finally, all the other parts being at rest and dead, as galen long since observed, the right auricle still continues to beat; life, therefore, appears to linger longest in the right auricle. whilst the heart is gradually dying, it is sometimes seen to reply, after two or three contractions of the auricles, roused as it were to action, and making a single pulsation, slowly, unwillingly, and with an effort. but this especially is to be noted, that after the heart has ceased to beat, the auricles however still contracting, a finger placed upon the ventricles perceives the several pulsations of the auricles, precisely in the same way and for the same reason, as we have said, that the pulses of the ventricles are felt in the arteries, to wit, the distension produced by the jet of blood. and if at this time, the auricles alone pulsating, the point of the heart be cut off with a pair of scissors, you will perceive the blood flowing out upon each contraction of the auricles. whence it is manifest that the blood enters the ventricles, not by any attraction or dilatation of the heart, but by being thrown into them by the pulses of the auricles. and here i would observe, that whenever i speak of pulsations as occurring in the auricles or ventricles, i mean contractions: first the auricles contract, and then and subsequently the heart itself contracts. when the auricles contract they are seen to become whiter, especially where they contain but little blood; but they are filled as magazines or reservoirs of the blood, which is tending spontaneously and, by its motion in the veins, under pressure towards the centre; the whiteness indicated is most conspicuous towards the extremities or edges of the auricles at the time of their contractions. in fishes and frogs, and other animals which have hearts with but a single ventricle, and for an auricle have a kind of bladder much distended with blood, at the base of the organ, you may very plainly perceive this bladder contracting first, and the contraction of the heart or ventricle following afterwards. but i think it right to describe what i have observed of an opposite character: the heart of an eel, of several fishes, and even of some (of the higher) animals taken out of the body, pulsates without auricles; nay, if it be cut in pieces the several parts may still be seen contracting and relaxing; so that in these creatures the body of the heart may be seen pulsating and palpitating, after the cessation of all motion in the auricle. but is not this perchance peculiar to animals more tenacious of life, whose radical moisture is more glutinous, or fat and sluggish, and less readily soluble? the same faculty indeed appears in the flesh of eels, which even when skinned and embowelled, and cut into pieces, are still seen to move. experimenting with a pigeon upon one occasion, after the heart had wholly ceased to pulsate, and the auricles too had become motionless, i kept my finger wetted with saliva and warm for a short time upon the heart, and observed that under the influence of this fomentation it recovered new strength and life, so that both ventricles and auricles pulsated, contracting and relaxing alternately, recalled as it were from death to life. besides this, however, i have occasionally observed, after the heart and even its right auricle had ceased pulsating,--when it was in articulo mortis in short,--that an obscure motion, an undulation or palpitation, remained in the blood itself, which was contained in the right auricle, this being apparent so long as it was imbued with heat and spirit. and, indeed, a circumstance of the same kind is extremely manifest in the course of the generation of animals, as may be seen in the course of the first seven days of the incubation of the chick: a drop of blood makes its appearance which palpitates, as aristotle had already observed; from this, when the growth is further advanced and the chick is fashioned, the auricles of the heart are formed, which pulsating henceforth give constant signs of life. when at length, and after the lapse of a few days, the outline of the body begins to be distinguished, then is the ventricular part of the heart also produced, but it continues for a time white and apparently bloodless, like the rest of the animal; neither does it pulsate or give signs of motion. i have seen a similar condition of the heart in the human foetus about the beginning of the third month, the heart then being whitish and bloodless, although its auricles contained a considerable quantity of purple blood. in the same way in the egg, when the chick was formed and had increased in size, the heart too increased and acquired ventricles, which then began to receive and to transmit blood. and this leads me to remark that he who inquires very particularly into this matter will not conclude that the heart, as a whole, is the primum vivens, ultimum moriens,--the first part to live, the last to die,--but rather its auricles, or the part which corresponds to the auricles in serpents, fishes, etc., which both lives before the heart and dies after it. nay, has not the blood itself or spirit an obscure palpitation inherent in it, which it has even appeared to me to retain after death? and it seems very questionable whether or not we are to say that life begins with the palpitation or beating of the heart. the seminal fluid of all animals--the prolific spirit, as aristotle observed, leaves their body with a bound and like a living thing; and nature in death, as aristotle [footnote: de motu animal., cap. 8.] further remarks, retracing her steps, reverts to where she had set out, and returns at the end of her course to the goal whence she had started. as animal generation proceeds from that which is not animal, entity from nonentity, so, by a retrograde course, entity, by corruption, is resolved into nonentity, whence that in animals, which was last created, fails first and that which was first, fails last. i have also observed that almost all animals have truly a heart, not the larger creatures only, and those that have red blood, but the smaller, and pale-blooded ones also, such as slugs, snails, scallops, shrimps, crabs, crayfish, and many others; nay, even in wasps, hornets, and flies, i have, with the aid of a magnifying glass, and at the upper part of what is called the tail, both seen the heart pulsating myself, and shown it to many others. but in the pale-blooded tribes the heart pulsates sluggishly and deliberately, contracting slowly as in animals that are moribund, a fact that may readily be seen in the snail, whose heart will be found at the bottom of that orifice in the right side of the body which is seen to be opened and shut in the course of respiration, and whence saliva is discharged, the incision being made in the upper aspect of the body, near the part which corresponds to the liver. this, however, is to be observed: that in winter and the colder season, exsanguine animals, such as the snail, show no pulsation; they seem rather to live after the manner of vegetables, or of those other productions which are therefore designated plantanimals. it is also to be noted that all animals which have a heart have also auricles, or something analogous to auricles; and, further, that whenever the heart has a double ventricle, there are always two auricles present, but not otherwise. if you turn to the production of the chick in ovo, however, you will find at first no more a vesicle or auricle, or pulsating drop of blood; it is only by and by, when the development has made some progress, that the heart is fashioned; even so in certain animals not destined to attain to the highest perfection in their organization, such as bees, wasps, snails, shrimps, crayfish, etc., we only find a certain pulsating vesicle, like a sort of red or white palpitating point, as the beginning or principle of their life. we have a small shrimp in these countries, which is taken in the thames and in the sea, the whole of whose body is transparent; this creature, placed in a little water, has frequently afforded myself and particular friends an opportunity of observing the motions of the heart with the greatest distinctness, the external parts of the body presenting no obstacle to our view, but the heart being perceived as though it had been seen through a window. i have also observed the first rudiments of the chick in the course of the fourth or fifth day of the incubation, in the guise of a little cloud, the shell having been removed and the egg immersed in clear tepid water. in the midst of the cloudlet in question there was a bloody point so small that it disappeared during the contraction and escaped the sight, but in the relaxation it reappeared again, red and like the point of a pin; so that betwixt the visible and invisible, betwixt being and not being, as it were, it gave by its pulses a kind of representation of the commencement of life. chapter v of the motion, action and office of the heart from these and other observations of a similar nature, i am persuaded it will be found that the motion of the heart is as follows: first of all, the auricle contracts, and in the course of its contraction forces the blood (which it contains in ample quantity as the head of the veins, the store--house and cistern of the blood) into the ventricle, which, being filled, the heart raises itself straightway, makes all its fibres tense, contracts the ventricles, and performs a beat, by which beat it immediately sends the blood supplied to it by the auricle into the arteries. the right ventricle sends its charge into the lungs by the vessel which is called vena arteriosa, but which in structure and function, and all other respects, is an artery. the left ventricle sends its charge into the aorta, and through this by the arteries to the body at large. these two motions, one of the ventricles, the other of the auricles, take place consecutively, but in such a manner that there is a kind of harmony or rhythm preserved between them, the two concurring in such wise that but one motion is apparent, especially in the warmer blooded animals, in which the movements in question are rapid. nor is this for any other reason than it is in a piece of machinery, in which, though one wheel gives motion to another, yet all the wheels seem to move simultaneously; or in that mechanical contrivance which is adapted to firearms, where, the trigger being touched, down comes the flint, strikes against the steel, elicits a spark, which falling among the powder, ignites it, when the flame extends, enters the barrel, causes the explosion, propels the ball, and the mark is attained--all of which incidents, by reason of the celerity with which they happen, seem to take place in the twinkling of an eye. so also in deglutition: by the elevation of the root of the tongue, and the compression of the mouth, the food or drink is pushed into the fauces, when the larynx is closed by its muscles and by the epiglottis. the pharynx is then raised and opened by its muscles in the same way as a sac that is to be filled is lifted up and its mouth dilated. upon the mouthful being received, it is forced downwards by the transverse muscles, and then carried farther by the longitudinal ones. yet all these motions, though executed by different and distinct organs, are performed harmoniously, and in such order that they seem to constitute but a single motion and act, which we call deglutition. even so does it come to pass with the motions and action of the heart, which constitute a kind of deglutition, a transfusion of the blood from the veins to the arteries. and if anyone, bearing these things in mind, will carefully watch the motions of the heart in the body of a living animal, he will perceive not only all the particulars i have mentioned, viz., the heart becoming erect, and making one continuous motion with its auricles; but farther, a certain obscure undulation and lateral inclination in the direction of the axis of the right ventricle, as if twisting itself slightly in performing its work. and indeed everyone may see, when a horse drinks, that the water is drawn in and transmitted to the stomach at each movement of the throat, which movement produces a sound and yields a pulse both to the ear and the touch; in the same way it is with each motion of the heart, when there is the delivery of a quantity of blood from the veins to the arteries a pulse takes place, and can be heard within the chest. the motion of the heart, then, is entirely of this description, and the one action of the heart is the transmission of the blood and its distribution, by means of the arteries, to the very extremities of the body; so that the pulse which we feel in the arteries is nothing more than the impulse of the blood derived from the heart. whether or not the heart, besides propelling the blood, giving it motion locally, and distributing it to the body, adds anything else to it--heat, spirit, perfection,--must be inquired into by-and--by, and decided upon other grounds. so much may suffice at this time, when it is shown that by the action of the heart the blood is transfused through the ventricles from the veins to the arteries, and distributed by them to all parts of the body. the above, indeed, is admitted by all, both from the structure of the heart and the arrangement and action of its valves. but still they are like persons purblind or groping about in the dark, for they give utterance to various, contradictory, and incoherent sentiments, delivering many things upon conjecture, as we have already shown. the grand cause of doubt and error in this subject appears to me to have been the intimate connexion between the heart and the lungs. when men saw both the pulmonary artery and the pulmonary veins losing themselves in the lungs, of course it became a puzzle to them to know how or by what means the right ventricle should distribute the blood to the body, or the left draw it from the venae cavae. this fact is borne witness to by galen, whose words, when writing against erasistratus in regard to the origin and use of the veins and the coction of the blood, are the following [footnote: de placitis hippocratis et platonis, vi.]: "you will reply," he says, "that the effect is so; that the blood is prepared in the liver, and is thence transferred to the heart to receive its proper form and last perfection; a statement which does not appear devoid of reason; for no great and perfect work is ever accomplished at a single effort, or receives its final polish from one instrument. but if this be actually so, then show us another vessel which draws the absolutely perfect blood from the heart, and distributes it as the arteries do the spirits over the whole body." here then is a reasonable opinion not allowed, because, forsooth, besides not seeing the true means of transit, he could not discover the vessel which should transmit the blood from the heart to the body at large! but had anyone been there in behalf of erasistratus, and of that opinion which we now espouse, and which galen himself acknowledges in other respects consonant with reason, to have pointed to the aorta as the vessel which distributes the blood from the heart to the rest of the body, i wonder what would have been the answer of that most ingenious and learned man? had he said that the artery transmits spirits and not blood, he would indeed sufficiently have answered erasistratus, who imagined that the arteries contained nothing but spirits; but then he would have contradicted himself, and given a foul denial to that for which he had keenly contended in his writings against this very erasistratus, to wit, that blood in substance is contained in the arteries, and not spirits; a fact which he demonstrated not only by many powerful arguments, but by experiments. but if the divine galen will here allow, as in other places he does, "that all the arteries of the body arise from the great artery, and that this takes its origin from the heart; that all these vessels naturally contain and carry blood; that the three semilunar valves situated at the orifice of the aorta prevent the return of the blood into the heart, and that nature never connected them with this, the most noble viscus of the body, unless for some important end"; if, i say, this father of physicians concedes all these things,--and i quote his own words,--i do not see how he can deny that the great artery is the very vessel to carry the blood, when it has attained its highest term for term of perfection, from the heart for distribution to all parts of the body. or would he perchance still hesitate, like all who have come after him, even to the present hour, because he did not perceive the route by which the blood was transferred from the veins to the arteries, in consequence, as i have already said, of the intimate connexion between the heart and the lungs? and that this difficulty puzzled anatomists not a little, when in their dissections they found the pulmonary artery and left ventricle full of thick, black, and clotted blood, plainly appears, when they felt themselves compelled to affirm that the blood made its way from the right to the left ventricle by transuding through the septum of the heart. but this fancy i have already refuted. a new pathway for the blood must therefore be prepared and thrown open, and being once exposed, no further difficulty will, i believe, be experienced by anyone in admitting what i have already proposed in regard to the pulse of the heart and arteries, viz., the passage of the blood from the veins to the arteries, and its distribution to the whole of the body by means of these vessels. chapter vi of the course by which the blood is carried from the vena cava into the arteries, or from the right into the left ventricle of the heart since the intimate connexion of the heart with the lungs, which is apparent in the human subject, has been the probable cause of the errors that have been committed on this point, they plainly do amiss who, pretending to speak of the parts of animals generally, as anatomists for the most part do, confine their researches to the human body alone, and that when it is dead. they obviously do not act otherwise than he who, having studied the forms of a single commonwealth, should set about the composition of a general system of polity; or who, having taken cognizance of the nature of a single field, should imagine that he had mastered the science of agriculture; or who, upon the ground of one particular proposition, should proceed to draw general conclusions. had anatomists only been as conversant with the dissection of the lower animals as they are with that of the human body, the matters that have hitherto kept them in a perplexity of doubt would, in my opinion, have met them freed from every kind of difficulty. and first, in fishes, in which the heart consists of but a single ventricle, being devoid of lungs, the thing is sufficiently manifest. here the sac, which is situated at the base of the heart, and is the part analogous to the auricle in man, plainly forces the blood into the heart, and the heart, in its turn, conspicuously transmits it by a pipe or artery, or vessel analogous to an artery; these are facts which are confirmed by simple ocular inspection, as well as by a division of the vessel, when the blood is seen to be projected by each pulsation of the heart. the same thing is also not difficult of demonstration in those animals that have, as it were, no more than a single ventricle to the heart, such as toads, frogs, serpents, and lizards, which have lungs in a certain sense, as they have a voice. i have many observations by me on the admirable structure of the lungs of these animals, and matters appertaining, which, however, i cannot introduce in this place. their anatomy plainly shows us that the blood is transferred in them from the veins to the arteries in the same manner as in higher animals, viz., by the action of the heart; the way, in fact, is patent, open, manifest; there is no difficulty, no room for doubt about it; for in them the matter stands precisely as it would in man were the septum of his heart perforated or removed, or one ventricle made out of two; and this being the case, i imagine that no one will doubt as to the way by which the blood may pass from the veins into the arteries. but as there are actually more animals which have no lungs than there are furnished with them, and in like manner a greater number which have only one ventricle than there are with two, it is open to us to conclude, judging from the mass or multitude of living creatures, that for the major part, and generally, there is an open way by which the blood is transmitted from the veins through the sinuses or cavities of the heart into the arteries. i have, however, cogitating with myself, seen further, that the same thing obtained most obviously in the embryos of those animals that have lungs; for in the foetus the four vessels belonging to the heart, viz., the vena cava, the pulmonary artery, the pulmonary vein, and the great artery or aorta, are all connected otherwise than in the adult, a fact sufficiently known to every anatomist. the first contact and union of the vena cava with the pulmonary veins, which occurs before the cava opens properly into the right ventricle of the heart, or gives off the coronary vein, a little above its escape from the liver, is by a lateral anastomosis; this is an ample foramen, of an oval form, communicating between the cava and the pulmonary vein, so that the blood is free to flow in the greatest abundance by that foramen from the vena cava into the pulmonary vein, and left auricle, and from thence into the left ventricle. further, in this foramen ovale, from that part which regards the pulmonary vein, there is a thin tough membrane, larger than the opening, extended like an operculum or cover; this membrane in the adult blocking up the foramen, and adhering on all sides, finally closes it up, and almost obliterates every trace of it. in the foetus, however, this membrane is so contrived that falling loosely upon itself, it permits a ready access to the lungs and heart, yielding a passage to the blood which is streaming from the cava, and hindering the tide at the same time from flowing back into that vein. all things, in short, permit us to believe that in the embryo the blood must constantly pass by this foramen from the vena cava into the pulmonary vein, and from thence into the left auricle of the heart; and having once entered there, it can never regurgitate. another union is that by the pulmonary artery, and is effected when that vessel divides into two branches after its escape from the right ventricle of the heart. it is as if to the two trunks already mentioned a third were superadded, a kind of arterial canal, carried obliquely from the pulmonary artery, to perforate and terminate in the great artery or aorta. so that in the dissection of the embryo, as it were, two aortas, or two roots of the great artery, appear springing from the heart. this canal shrinks gradually after birth, and after a time becomes withered, and finally almost removed, like the umbilical vessels. the arterial canal contains no membrane or valve to direct or impede the flow of blood in this or in that direction: for at the root of the pulmonary artery, of which the arterial canal is the continuation in the foetus, there are three semilunar valves, which open from within outwards, and oppose no obstacle to the blood flowing in this direction or from the right ventricle into the pulmonary artery and aorta; but they prevent all regurgitation from the aorta or pulmonic vessels back upon the right ventricle; closing with perfect accuracy, they oppose an effectual obstacle to everything of the kind in the embryo. so that there is also reason to believe that when the heart contracts, the blood is regularly propelled by the canal or passage indicated from the right ventricle into the aorta. what is commonly said in regard to these two great communications, to wit, that they exist for the nutrition of the lungs, is both improbable and inconsistent; seeing that in the adult they are closed up, abolished, and consolidated, although the lungs, by reason of their heat and motion, must then be presumed to require a larger supply of nourishment. the same may be said in regard to the assertion that the heart in the embryo does not pulsate, that it neither acts nor moves, so that nature was forced to make these communications for the nutrition of the lungs. this is plainly false; for simple inspection of the incubated egg, and of embryos just taken out of the uterus, shows that the heart moves in them precisely as in adults, and that nature feels no such necessity. i have myself repeatedly seen these motions, and aristotle is likewise witness of their reality. "the pulse," he observes, "inheres in the very constitution of the heart, and appears from the beginning as is learned both from the dissection of living animals and the formation of the chick in the egg." [footnote: lib de spiritu, cap. v.] but we further observe that the passages in question are not only pervious up to the period of birth in man, as well as in other animals, as anatomists in general have described them, but for several months subsequently, in some indeed for several years, not to say for the whole course of life; as, for example, in the goose, snipe, and various birds and many of the smaller animals. and this circumstance it was, perhaps, that imposed upon botallus, who thought he had discovered a new passage for the blood from the vena cava into the left ventricle of the heart; and i own that when i met with the same arrangement in one of the larger members of the mouse family, in the adult state, i was myself at first led to something of a like conclusion. from this it will be understood that in the human embryo, and in the embryos of animals in which the communications are not closed, the same thing happens, namely, that the heart by its motion propels the blood by obvious and open passages from the vena cava into the aorta through the cavities of both the ventricles, the right one receiving the blood from the auricle, and propelling it by the pulmonary artery and its continuation, named the ductus arteriosus, into the aorta; the left, in like manner, charged by the contraction of its auricle, which has received its supply through the foramen ovale from the vena cava, contracting, and projecting the blood through the root of the aorta into the trunk of that vessel. in embryos, consequently, whilst the lungs are yet in a state of inaction, performing no function, subject to no motion any more than if they had not been present, nature uses the two ventricles of the heart as if they formed but one, for the transmission of the blood. the condition of the embryos of those animals which have lungs, whilst these organs are yet in abeyance and not employed, is the same as that of those animals which have no lungs. so it clearly appears in the case of the foetus that the heart by its action transfers the blood from the vena cava into the aorta, and that by a route as obvious and open, as if in the adult the two ventricles were made to communicate by the removal of their septum. we therefore find that in the greater number of animals-in all, indeed, at a certain period of their existence--the channels for the transmission of the blood through the heart are conspicuous. but we have to inquire why in some creatures--those, namely, that have warm blood, and that have attained to the adult age, man among the number--we should not conclude that the same thing is accomplished through the substance of the lungs, which in the embryo, and at a time when the function of these organs is in abeyance, nature effects by the direct passages described, and which, indeed, she seems compelled to adopt through want of a passage by the lungs; or why it should be better (for nature always does that which is best) that she should close up the various open routes which she had formerly made use of in the embryo and foetus, and still uses in all other animals. not only does she thereby open up no new apparent channels for the passages of the blood, but she even shuts up those which formerly existed. and now the discussion is brought to this point, that they who inquire into the ways by which the blood reaches the left ventricle of the heart: and pulmonary veins from the vena cava, will pursue the wisest course if they seek by dissection to discover the causes why in the larger and more perfect animals of mature age nature has rather chosen to make the blood percolate the parenchyma of the lungs, than, as in other instances, chosen a direct and obvious course--for i assume that no other path or mode of transit can be entertained. it must be because the larger and more perfect animals are warmer, and when adult their heat greater--ignited, as i might say, and requiring to be damped or mitigated, that the blood is sent through the lungs, in order that it may be tempered by the air that is inspired, and prevented from boiling up, and so becoming extinguished, or something else of the sort. but to determine these matters, and explain them satisfactorily, were to enter on a speculation in regard to the office of the lungs and the ends for which they exist. upon such a subject, as well as upon what pertains to respiration, to the necessity and use of the air, etc., as also to the variety and diversity of organs that exist in the bodies of animals in connexion with these matters, although i have made a vast number of observations, i shall not speak till i can more conveniently set them forth in a treatise apart, lest i should be held as wandering too wide of my present purpose, which is the use and motion of the heart, and be charged with speaking of things beside the question, and rather complicating and quitting than illustrating it. and now returning to my immediate subject, i go on with what yet remains for demonstration, viz., that in the more perfect and warmer adult animals, and man, the blood passes from the right ventricle of the heart by the pulmonary artery, into the lungs, and thence by the pulmonary veins into the left auricle, and from there into the left ventricle of the heart. and, first, i shall show that this may be so, and then i shall prove that it is so in fact. chapter vii the blood passes through the substance of the lungs from the right ventricle of the heart into the pulmonary veins and left ventricle that this is possible, and that there is nothing to prevent it from being so, appears when we reflect on the way in which water permeating the earth produces springs and rivulets, or when we speculate on the means by which the sweat passes through the skin, or the urine through the substance of the kidneys. it is well known that persons who use the spa waters or those of la madonna, in the territories of padua, or others of an acidulous or vitriolated nature, or who simply swallow drinks by the gallon, pass all off again within an hour or two by the bladder. such a quantity of liquid must take some short time in the concoction: it must pass through the liver (it is allowed by all that the juices of the food we consume pass twice through this organ in the course of the day); it must flow through the veins, through the tissues of the kidneys, and through the ureters into the bladder. to those, therefore, whom i hear denying that the blood, aye, the whole mass of the blood, may pass through the substance of the lungs, even as the nutritive juices percolate the liver, asserting such a proposition to be impossible, and by no means to be entertained as credible, i reply, with the poet, that they are of that race of men who, when they will, assent full readily, and when they will not, by no manner of means; who, when their assent is wanted, fear, and when it is not, fear not to give it. the substance of the liver is extremely dense, so is that of the kidney; the lungs, however, are of a much looser texture, and if compared with the kidneys are absolutely spongy. in the liver there is no forcing, no impelling power; in the lungs the blood is forced on by the pulse of the right ventricle, the necessary effect of whose impulse is the distension of the vessels and the pores of the lungs. and then the lungs, in respiration, are perpetually rising and falling: motions, the effect of which must needs be to open and shut the pores and vessels, precisely as in the case of a sponge, and of parts having a spongy structure, when they are alternately compressed and again are suffered to expand. the liver, on the contrary, remains at rest, and is never seen to be dilated or constricted. lastly, if no one denies the possibility in man, oxen, and the larger animals generally, of the whole of the ingested juices passing through the liver, in order to reach the vena cava, for this reason, that if nourishment is to go on, these juices must needs get into the veins, and there is no other way but the one indicated, why should not the same arguments be held of avail for the passage of the blood in adults through the lungs? why not maintain, with columbus, that skilful and learned anatomist, that it must be so from the capacity and structure of the pulmonary vessels, and from the fact of the pulmonary veins and ventricle corresponding with them, being always found to contain blood, which must needs have come from the veins, and by no other passage save through the lungs? columbus, and we also, from what precedes, from dissections, and other arguments, conceive the thing to be clear. but as there are some who admit nothing unless upon authority, let them learn that the truth i am contending for can be confirmed from galen's own words, namely, that not only may the blood be transmitted from the pulmonary artery into the pulmonary veins, then into the left ventricle of the heart, and from thence into the arteries of the body, but that this is effected by the ceaseless pulsation of the heart and the motion of the lungs in breathing. there are, as everyone knows, three sigmoid or semilunar valves situated at the orifice of the pulmonary artery, which effectually prevent the blood sent into the vessel from returning into the cavity of the heart. now galen, explaining the use of these valves, and the necessity for them, employs the following language: [footnote: de usu partium, lib. vi, cap. 10] "there is everywhere a mutual anastomosis and inosculation of the arteries with the veins, and they severally transmit both blood and spirit, by certain invisible and undoubtedly very narrow passages. now if the mouth of the pulmonary artery had stood in like manner continually open, and nature had found no contrivance for closing it when requisite, and opening it again, it would have been impossible that the blood could ever have passed by the invisible and delicate mouths, during the contractions of the thorax, into the arteries; for all things are not alike readily attracted or repelled; but that which is light is more readily drawn in, the instrument being dilated, and forced out again when it is contracted, than that which is heavy; and in like manner is anything drawn more rapidly along an ample conduit, and again driven forth, than it is through a narrow tube. but when the thorax is contracted the pulmonary veins, which are in the lungs, being driven inwardly, and powerfully compressed on every side, immediately force out some of the spirit they contain, and at the same time assume a certain portion of blood by those subtle mouths, a thing that could never come to pass were the blood at liberty to flow back into the heart through the great orifice of the pulmonary artery. but its return through this great opening being prevented, when it is compressed on every side, a certain portion of it distils into the pulmonary veins by the minute orifices mentioned." and shortly afterwards, in the next chapter, he says: "the more the thorax contracts, the more it strives to force out the blood, the more exactly do these membranes (viz., the semilunar valves) close up the mouth of the vessel, and suffer nothing to regurgitate." the same fact he has also alluded to in a preceding part of the tenth chapter: "were there no valves, a three-fold inconvenience would result, so that the blood would then perform this lengthened course in vain; it would flow inwards during the disastoles of the lungs and fill all their arteries; but in the systoles, in the manner of the tide, it would ever and anon, like the euripus, flow backwards and forwards by the same way, with a reciprocating motion, which would nowise suit the blood. this, however, may seem a matter of little moment: but if it meantime appear that the function of respiration suffer, then i think it would be looked upon as no trifle, etc." shortly afterwards he says: "and then a third inconvenience, by no means to be thought lightly of, would follow, were the blood moved backwards during the expirations, had not our maker instituted those supplementary membranes. "in the eleventh chapter he concludes: "that they (the valves) have all a common use, and that it is to prevent regurgitation or backward motion; each, however, having a proper function, the one set drawing matters from the heart, and preventing their return, the other drawing matters into the heart, and preventing their escape from it. for nature never intended to distress the heart with needless labour, neither to bring aught into the organ which it had been better to have kept away, nor to take from it again aught which it was requisite should be brought. since, then, there are four orifices in all, two in either ventricle, one of these induces, the other educes." and again he says: "farther, since there is one vessel, which consists of a simple covering implanted in the heart, and another which is double, extending from it (galen is here speaking of the right side of the heart, but i extend his observations to the left side also), a kind of reservoir had to be provided, to which both belonging, the blood should be drawn in by one, and sent out by the other." galen adduces this argument for the transit of the blood by the right ventricle from the vena cava into the lungs; but we can use it with still greater propriety, merely changing the terms, for the passage of the blood from the veins through the heart into the arteries. from galen, however, that great man, that father of physicians, it clearly appears that the blood passes through the lungs from the pulmonary artery into the minute branches of the pulmonary veins, urged to this both by the pulses of the heart and by the motions of the lungs and thorax; that the heart, moreover, is incessantly receiving and expelling the blood by and from its ventricles, as from a magazine or cistern, and for this end it is furnished with four sets of valves, two serving for the induction and two for the eduction of the blood, lest, like the euripus, it should be incommodiously sent hither and thither, or flow back into the cavity which it should have quitted, or quit the part where its presence was required, and so the heart might be oppressed with labour in vain, and the office of the lungs be interfered with. [footnote: see the commentary of the learned hofmann upon the sixth book of galen, "de usu partium," a work which i first saw after i had written what precedes.] finally, our position that the blood is continually permeating from the right to the left ventricle, from the vena cava into the aorta, through the porosities of the lungs, plainly appears from this, that since the blood is incessantly sent from the right ventricle into the lungs by the pulmonary artery, and in like manner is incessantly drawn from the lungs into the left ventricle, as appears from what precedes and the position of the valves, it cannot do otherwise than pass through continuously. and then, as the blood is incessantly flowing into the right ventricle of the heart, and is continually passed out from the left, as appears in like manner, and as is obvious, both to sense and reason, it is impossible that the blood can do otherwise than pass continually from the vena cava into the aorta. dissection consequently shows distinctly what takes place in the majority of animals, and indeed in all, up to the period of their maturity; and that the same thing occurs in adults is equally certain, both from galen's words, and what has already been said, only that in the former the transit is effected by open and obvious passages, in the latter by the hidden porosities of the lungs and the minute inosculations of vessels. it therefore appears that, although one ventricle of the heart, the left to wit, would suffice for the distribution of the blood over the body, and its eduction from the vena cava, as indeed is done in those creatures that have no lungs, nature, nevertheless, when she ordained that the same blood should also percolate the lungs, saw herself obliged to add the right ventricle, the pulse of which should force the blood from the vena cava through the lungs into the cavity of the left ventricle. in this way, it may be said, that the right ventricle is made for the sake of the lungs, and for the transmission of the blood through them, not for their nutrition; for it were unreasonable to suppose that the lungs should require so much more copious a supply of nutriment, and that of so much purer and more spirituous a nature as coming immediately from the ventricle of the heart, that either the brain, with its peculiarly pure substance, or the eyes, with their lustrous and truly admirable structure, or the flesh of the heart itself, which is more suitably nourished by the coronary artery. chapter viii of the quantity of blood passing through the heart from the veins to the arteries; and of the circular motion of the blood thus far i have spoken of the passage of the blood from the veins into the arteries, and of the manner in which it is transmitted and distributed by the action of the heart; points to which some, moved either by the authority of galen or columbus, or the reasonings of others, will give in their adhesion. but what remains to be said upon the quantity and source of the blood which thus passes is of a character so novel and unheard-of that i not only fear injury to myself from the envy of a few, but i tremble lest i have mankind at large for my enemies, so much doth wont and custom become a second nature. doctrine once sown strikes deep its root, and respect for antiquity influences all men. still the die is cast, and my trust is in my love of truth and the candour of cultivated minds. and sooth to say, when i surveyed my mass of evidence, whether derived from vivisections, and my various reflections on them, or from the study of the ventricles of the heart and the vessels that enter into and issue from them, the symmetry and size of these conduits,--for nature doing nothing in vain, would never have given them so large a relative size without a purpose,--or from observing the arrangement and intimate structure of the valves in particular, and of the other parts of the heart in general, with many things besides, i frequently and seriously bethought me, and long revolved in my mind, what might be the quantity of blood which was transmitted, in how short a time its passage might be effected, and the like. but not finding it possible that this could be supplied by the juices of the ingested aliment without the veins on the one hand becoming drained, and the arteries on the other getting ruptured through the excessive charge of blood, unless the blood should somehow find its way from the arteries into the veins, and so return to the right side of the heart, i began to think whether there might not be a motion, as it were, in a circle. now, this i afterwards found to be true; and i finally saw that the blood, forced by the action of the left ventricle into the arteries, was distributed to the body at large, and its several parts, in the same manner as it is sent through the lungs, impelled by the right ventricle into the pulmonary artery, and that it: then passed through the veins and along the vena cava, and so round to the left ventricle in the manner already indicated. this motion we may be allowed to call circular, in the same way as aristotle says that the air and the rain emulate the circular motion of the superior bodies; for the moist earth, warmed by the sun, evaporates; the vapours drawn upwards are condensed, and descending in the form of rain, moisten the earth again. by this arrangement are generations of living things produced; and in like manner are tempests and meteors engendered by the circular motion, and by the approach and recession of the sun. and similarly does it come to pass in the body, through the motion of the blood, that the various parts are nourished, cherished, quickened by the warmer, more perfect, vaporous, spirituous, and, as i may say, alimentive blood; which, on the other hand, owing to its contact with these parts, becomes cooled, coagulated, and so to speak effete. it then returns to its sovereign, the heart, as if to its source, or to the inmost home of the body, there to recover its state of excellence or perfection. here it renews its fluidity, natural heat, and becomes powerful, fervid, a kind of treasury of life, and impregnated with spirits, it might be said with balsam. thence it is again dispersed. all this depends on the motion and action of the heart. the heart, consequently, is the beginning of life; the sun of the microcosm, even as the sun in his turn might well be designated the heart of the world; for it is the heart by whose virtue and pulse the blood is moved, perfected, and made nutrient, and is preserved from corruption and coagulation; it is the household divinity which, discharging its function, nourishes, cherishes, quickens the whole body, and is indeed the foundation of life, the source of all action. but of these things we shall speak more opportunely when we come to speculate upon the final cause of this motion of the heart. as the blood-vessels, therefore, are the canals and agents that transport the blood, they are of two kinds, the cava and the aorta; and this not by reason of there being two sides of the body, as aristotle has it, but because of the difference of office, not, as is commonly said, in consequence of any diversity of structure, for in many animals, as i have said, the vein does not differ from the artery in the thickness of its walls, but solely in virtue of their distinct functions and uses. a vein and an artery, both styled veins by the ancients, and that not without reason, as galen has remarked, for the artery is the vessel which carries the blood from the heart to the body at large, the vein of the present day bringing it back from the general system to the heart; the former is the conduit from, the latter the channel to, the heart; the latter contains the cruder, effete blood, rendered unfit for nutrition; the former transmits the digested, perfect, peculiarly nutritive fluid. chapter ix that there is a circulation of the blood is confirmed from the first proposition but lest anyone should say that we give them words only, and make mere specious assertions without any foundation, and desire to innovate without sufficient cause, three points present themselves for confirmation, which, being stated, i conceive that the truth i contend for will follow necessarily, and appear as a thing obvious to all. first, the blood is incessantly transmitted by the action of the heart from the vena cava to the arteries in such quantity that it cannot be supplied from the ingesta, and in such a manner that the whole must very quickly pass through the organ; second, the blood under the influence of the arterial pulse enters and is impelled in a continuous, equable, and incessant stream through every part and member of the body, in much larger quantity than were sufficient for nutrition, or than the whole mass of fluids could supply; third, the veins in like manner return this blood incessantly to the heart from parts and members of the body. these points proved, i conceive it will be manifest that the blood circulates, revolves, propelled and then returning, from the heart to the extremities, from the extremities to the heart, and thus that it performs a kind of circular motion. let us assume, either arbitrarily or from experiment, the quantity of blood which the left ventricle of the heart will contain when distended, to be, say, two ounces, three ounces, or one ounce and a half--in the dead body i have found it to hold upwards of two ounces. let us assume further how much less the heart will hold in the contracted than in the dilated state; and how much blood it will project into the aorta upon each contraction; and all the world allows that with the systole something is always projected, a necessary consequence demonstrated in the third chapter, and obvious from the structure of the valves; and let us suppose as approaching the truth that the fourth, or fifth, or sixth, or even but the eighth part of its charge is thrown into the artery at each contraction; this would give either half an ounce, or three drachms, or one drachm of blood as propelled by the heart at each pulse into the aorta; which quantity, by reason of the valves at the root of the vessel, can by no means return into the ventricle. now, in the course of half an hour, the heart will have made more than one thousand beats, in some as many as two, three, and even four thousand. multiplying the number of drachms propelled by the number of pulses, we shall have either one thousand half ounces, or one thousand times three drachms, or a like proportional quantity of blood, according to the amount which we assume as propelled with each stroke of the heart, sent from this organ into the artery--a larger quantity in every case than is contained in the whole body! in the same way, in the sheep or dog, say but a single scruple of blood passes with each stroke of the heart, in one half-hour we should have one thousand scruples, or about three pounds and a half, of blood injected into the aorta; but the body of neither animal contains above four pounds of blood, a fact which i have myself ascertained in the case of the sheep. upon this supposition, therefore, assumed merely as a ground for reasoning, we see the whole mass of blood passing through the heart, from the veins to the arteries, and in like manner through the lungs. but let it be said that this does not take place in half an hour, but in an hour, or even in a day; any way, it is still manifest that more blood passes through the heart in consequence of its action, than can either be supplied by the whole of the ingesta, or than can be contained in the veins at the same moment. nor can it be allowed that the heart in contracting sometimes propels and sometimes does not propel, or at most propels but very little, a mere nothing, or an imaginary something: all this, indeed, has already been refuted, and is, besides, contrary both to sense and reason. for if it be a necessary effect of the dilatation of the heart that its ventricles become filled with blood, it is equally so that, contracting, these cavities should expel their contents; and this not in any trifling measure. for neither are the conduits small, nor the contractions few in number, but frequent, and always in some certain proportion, whether it be a third or a sixth, or an eighth, to the total capacity of the ventricles, so that a like proportion of blood must be expelled, and a like proportion received with each stroke of the heart, the capacity of the ventricle contracted always bearing a certain relation to the capacity of the ventricle when dilated. and since, in dilating, the ventricles cannot be supposed to get filled with nothing, or with an imaginary something, so in contracting they never expel nothing or aught imaginary, but always a certain something, viz., blood, in proportion to the amount of the contraction. whence it is to be concluded that if at one stroke the heart of man, the ox, or the sheep, ejects but a single drachm of blood and there are one thousand strokes in half an hour, in this interval there will have been ten pounds five ounces expelled; if with each stroke two drachms are expelled, the quantity would, of course, amount to twenty pounds and ten ounces; if half an ounce, the quantity would come to forty-one pounds and eight ounces; and were there one ounce, it would be as much as eighty-three pounds and four ounces; the whole of which, in the course of one-half hour, would have been transfused from the veins to the arteries. the actual quantity of blood expelled at each stroke of the heart, and the circumstances under which it is either greater or less than ordinary, i leave for particular determination afterwards, from numerous observations which i have made on the subject. meantime this much i know, and would here proclaim to all, that the blood is transfused at one time in larger, at another in smaller, quantity; and that the circuit of the blood is accomplished now more rapidly, now more slowly, according to the temperament, age, etc., of the individual, to external and internal circumstances, to naturals and non-naturals--sleep, rest, food, exercise, affections of the mind, and the like. but, supposing even the smallest quantity of blood to be passed through the heart and the lungs with each pulsation, a vastly greater amount would still be thrown into the arteries and whole body than could by any possibility be supplied by the food consumed. it could be furnished in no other way than by making a circuit and returning. this truth, indeed, presents itself obviously before us when we consider what happens in the dissection of living animals; the great artery need not be divided, but a very small branch only (as galen even proves in regard to man), to have the whole of the blood in the body, as well that of the veins as of the arteries, drained away in the course of no long time--some half-hour or less. butchers are well aware of the fact and can bear witness to it; for, cutting the throat of an ox and so dividing the vessels of the neck, in less than a quarter of an hour they have all the vessels bloodless--the whole mass of blood has escaped. the same thing also occasionally occurs with great rapidity in performing amputations and removing tumors in the human subject. nor would this argument lose of its force, did any one say that in killing animals in the shambles, and performing amputations, the blood escaped in equal, if not perchance in larger quantity by the veins than by the arteries. the contrary of this statement, indeed, is certainly the truth; the veins, in fact, collapsing, and being without any propelling power, and further, because of the impediment of the valves, as i shall show immediately, pour out but very little blood; whilst the arteries spout it forth with force abundantly, impetuously, and as if it were propelled by a syringe. and then the experiment is easily tried of leaving the vein untouched and only dividing the artery in the neck of a sheep or dog, when it will be seen with what force, in what abundance, and how quickly, the whole blood in the body, of the veins as well as of the arteries, is emptied. but the arteries receive blood from the veins in no other way than by transmission through the heart, as we have already seen; so that if the aorta be tied at the base of the heart, and the carotid or any other artery be opened, no one will now be surprised to find it empty, and the veins only replete with blood. and now the cause is manifest, why in our dissections we usually find so large a quantity of blood in the veins, so little in the arteries; why there is much in the right ventricle, little in the left, which probably led the ancients to believe that the arteries (as their name implies) contained nothing but spirits during the life of an animal. the true cause of the difference is perhaps this, that as there is no passage to the arteries, save through the lungs and heart, when an animal has ceased to breathe and the lungs to move, the blood in the pulmonary artery is prevented from passing into the pulmonary veins, and from thence into the left ventricle of the heart; just as we have already seen the same transit prevented in the embryo, by the want of movement in the lungs and the alternate opening, and shutting of their hidden and invisible porosities and apertures. but the heart not ceasing to act at the same precise moment as the lungs, but surviving them and continuing to pulsate for a time, the left ventricle and arteries go on distributing their blood to the body at large and sending it into the veins; receiving none from the lungs, however, they are soon exhausted, and left, as it were, empty. but even this fact confirms our views, in no trifling manner, seeing that it can be ascribed to no other than the cause we have just assumed. moreover, it appears from this that the more frequently or forcibly the arteries pulsate, the more speedily will the body be exhausted of its blood during hemorrhage. hence, also, it happens, that in fainting fits and in states of alarm, when the heart beats more languidly and less forcibly, hemorrhages are diminished and arrested. still further, it is from this, that after death, when the heart has ceased to beat, it is impossible, by dividing either the jugular or femoral veins and arteries, by any effort, to force out more than one-half of the whole mass of the blood. neither could the butchers ever bleed the carcass effectually did he neglect to cut the throat of the ox which he has knocked on the head and stunned, before the heart had ceased beating. finally, we are now in a condition to suspect wherefore it is that no one has yet said anything to the purpose upon the anastomosis of the veins and arteries, either as to where or how it is effected, or for what purpose. i now enter upon the investigation of the subject. chapter x the first position: of the quantity of blood passing from the veins to the arteries. and that there is a circuit of the blood, freed from objections, and farther confirmed by experiment so far our first position is confirmed, whether the thing be referred to calculation or to experiment and dissection, viz., that the blood is incessantly poured into the arteries in larger quantities than it can be supplied by the food; so that the whole passing over in a short space of time, it is matter of necessity that the blood perform a circuit, that it return to whence it set out. but if anyone shall here object that a large quantity may pass through and yet no necessity be found for a circulation, that all may come from the meat and drink consumed, and quote as an illustration the abundant supply of milk in the mammae--for a cow will give three, four, and even seven gallons and more in a day, and a woman two or three pints whilst nursing a child or twins, which must manifestly be derived from the food consumed; it may be answered that the heart by computation does as much and more in the course of an hour or two. and if not yet convinced, he shall still insist that when an artery is divided, a preternatural route is, as it were, opened, and that so the blood escapes in torrents, but that the same thing does not happen in the healthy and uninjured body when no outlet is made; and that in arteries filled, or in their natural state, so large a quantity of blood cannot pass in so short a space of time as to make any return necessary--to all this it may be answered that, from the calculation already made, and the reasons assigned, it appears that by so much as the heart in its dilated state contains, in addition to its contents in the state of constriction, so much in a general way must it emit upon each pulsation, and in such quantity must the blood pass, the body being entire and naturally constituted. but in serpents, and several fishes, by tying the veins some way below the heart you will perceive a space between the ligature and the heart speedily to become empty; so that, unless you would deny the evidence of your senses, you must needs admit the return of the blood to the heart. the same thing will also plainly appear when we come to discuss our second position. let us here conclude with a single example, confirming all that has been said, and from which everyone may obtain conviction through the testimony of his own eyes. if a live snake be laid open, the heart will be seen pulsating quietly, distinctly, for more than an hour, moving like a worm, contracting in its longitudinal dimensions, (for it is of an oblong shape), and propelling its contents. it becomes of a paler colour in the systole, of a deeper tint in the diastole; and almost all things else are seen by which i have already said that the truth i contend for is established, only that here everything takes place more slowly, and is more distinct. this point in particular may be observed more clearly than the noonday sun: the vena cava enters the heart at its lower part, the artery quits it at the superior part; the vein being now seized either with forceps or between the finger and the thumb, and the course of the blood for some space below the heart interrupted, you will perceive the part that intervenes between the fingers and the heart almost immediately to become empty, the blood being exhausted by the action of the heart; at the same time the heart will become of a much paler colour, even in its state of dilatation, than it was before; it is also smaller than at first, from wanting blood: and then it begins to beat more slowly, so that it seems at length as if it were about to die. but the impediment to the flow of blood being removed, instantly the colour and the size of the heart are restored. if, on the contrary, the artery instead of the vein be compressed or tied, you will observe the part between the obstacle and the heart, and the heart itself, to become inordinately distended, to assume a deep purple or even livid colour, and at length to be so much oppressed with blood that you will believe it about to be choked; but the obstacle removed, all things immediately return to their natural state and colour, size, and impulse. here then we have evidence of two kinds of death: extinction from deficiency, and suffocation from excess. examples of both have now been set before you, and you have had opportunity of viewing the truth contended for with your own eyes in the heart. chapter xi the second position is demonstrated that this may the more clearly appear to everyone, i have here to cite certain experiments, from which it seems obvious that the blood enters a limb by the arteries, and returns from it by the veins; that the arteries are the vessels carrying the blood from the heart, and the veins the returning channels of the blood to the heart; that in the limbs and extreme parts of the body the blood passes either immediately by anastomosis from the arteries into the veins, or mediately by the porosities of the flesh, or in both ways, as has already been said in speaking of the passage of the blood through the lungs whence it appears manifest that in the circuit the blood moves from that place to this place, and from that point to this one; from the centre to the extremities, to wit; and from the extreme parts back to the centre. finally, upon grounds of calculation, with the same elements as before, it will be obvious that the quantity can neither be accounted for by the ingeata, nor yet be held necessary to nutrition. the same thing will also appear in regard to ligatures, and wherefore they are said to draw; though this is neither from the heat, nor the pain, nor the vacuum they occasion, nor indeed from any other cause yet thought of; it will also explain the uses and advantages to be derived from ligatures in medicine, the principle upon which they either suppress or occasion hemorrhage; how they induce sloughing and more extensive mortification in extremities; and how they act in the castration of animals and the removal of warts and fleshy tumours. but it has come to pass, from no one having duly weighed and understood the cause and rationale of these various effects, that though almost all, upon the faith of the old writers, recommend ligatures in the treatment of disease, yet very few comprehend their proper employment, or derive any real assistance from them in effecting cures. ligatures are either very tight or of medium tightness. a ligature i designate as tight or perfect when it so constricts an extremity that no vessel can be felt pulsating beyond it. such a ligature we use in amputations to control the flow of blood; and such also are employed in the castration of animals and the ablation of tumours. in the latter instances, all afflux of nutriment and heat being prevented by the ligature, we see the testes and large fleshy tumours dwindle, die, and finally fall off. ligatures of medium tightness i regard as those which compress a limb firmly all round, but short of pain, and in such a way as still suffers a certain degree of pulsation to be felt in the artery beyond them. such a ligature is in use in blood-letting, an operation in which the fillet applied above the elbow is not drawn so tight but that the arteries at the wrist may still be felt beating under the finger. now let anyone make an experiment upon the arm of a man, either using such a fillet as is employed in blood-letting, or grasping the limb lightly with his hand, the best subject for it being one who is lean, and who has large veins, and the best time after exercise, when the body is warm, the pulse is full, and the blood carried in larger quantity to the extremities, for all then is more conspicuous; under such circumstances let a ligature be thrown about the extremity, and drawn as tightly as can be borne, it will first be perceived that beyond the ligature, neither in the wrist nor anywhere else, do the arteries pulsate, at the same time that immediately above the ligature the artery begins to rise higher at each diastole, to throb mere violently, and to swell in its vicinity with a kind of tide, as if it strove to break through and overcome the obstacle to its current; the artery here, in short, appears as if it were preternaturally full. the hand under such circumstances retains its natural colour and appearance; in the course of time it begins to fall somewhat in temperature, indeed, but nothing is drawn into it. after the bandage has been kept on for some short time in this way, let it be slackened a little, brought to that state or term of medium tightness which is used in bleeding, and it will be seen that the whole hand and arm will instantly become deeply coloured and distended, and the veins show themselves tumid and knotted; after ten or twelve pulses of the artery, the hand will be perceived excessively distended, injected, gorged with blood, drawn, as it is said, by this medium ligature, without pain, or heat, or any horror of a vacuum, or any other cause yet indicated. if the finger be applied over the artery as it is pulsating by the edge of the fillet, at the moment of slackening it, the blood will be felt to glide through, as it were, underneath the finger; and he, too, upon whose arm the experiment is made, when the ligature is slackened, is distinctly conscious of a sensation of warmth, and of something, viz., a stream of blood suddenly making its way along the course of the vessels and diffusing itself through the hand, which at the same time begins to feel hot, and becomes distended. as we had noted, in connexion with the tight ligature, that the artery above the bandage was distended and pulsated, not below it, so, in the case of the moderately tight bandage, on the contrary, do we find that the veins below, never above, the fillet, swell, and become dilated, whilst the arteries shrink; and such is the degree of distension of the veins here, that it is only very strong pressure that will force the blood beyond the fillet, and cause any of the veins in the upper part of the arm to rise. from these facts it is easy for every careful observer to learn that the blood enters an extremity by the arteries; for when they are effectually compressed nothing is drawn to the member; the hand preserves its colour; nothing flows into it, neither is it distended; but when the pressure is diminished, as it is with the bleeding fillet, it is manifest that the blood is instantly thrown in with force, for then the hand begins to swell; which is as much as to say, that when the arteries pulsate the blood is flowing through them, as it is when the moderately tight ligature is applied; but where they do not pulsate, as, when a tight ligature is used, they cease from transmitting anything, they are only distended above the part where the ligature is applied. the veins again being compressed, nothing can flow through them; the certain indication of which is, that below the ligature they are much more tumid than above it, and than they usually appear when there is no bandage upon the arm. it therefore plainly appears that the ligature prevents the return of the blood through the veins to the parts above it, and maintains those beneath it in a state of permanent distension. but the arteries, in spite of its pressure, and under the force and impulse of the heart, send on the blood from the internal parts of the body to the parts beyond the ligature. and herein consists the difference between the tight and the medium ligature, that the former not only prevents the passage of the blood in the veins, but in the arteries also; the latter, however, whilst it does not prevent the force of the pulse from extending beyond it, and so propelling the blood to the extremities of the body, compresses the veins, and greatly or altogether impedes the return of the blood through them. seeing, therefore, that the moderately tight ligature renders the veins turgid and distended, and the whole hand full of blood, i ask, whence is this? does the blood accumulate below the ligature coming through the veins, or through the arteries, or passing by certain hidden porosities? through the veins it cannot come; still less can it come through invisible channels; it must needs, then, arrive by the arteries, in conformity with all that has been already said. that it cannot flow in by the veins appears plainly enough from the fact that the blood cannot be forced towards the heart unless the ligature be removed; when this is done suddenly all the veins collapse, and disgorge themselves of their contents into the superior parts, the hand at the same time resumes its natural pale colour, the tumefaction and the stagnating blood having disappeared. moreover, he whose arm or wrist has thus been bound for some little time with the medium bandage, so that it has not only got swollen and livid but cold, when the fillet is undone is aware of something cold making its way upwards along with the returning blood, and reaching the elbow or the axilla. and i have myself been inclined to think that this cold blood rising upwards to the heart was the cause of the fainting that often occurs after blood-letting: fainting frequently supervenes even in robust subjects, and mostly at the moment of undoing the fillet, as the vulgar say, from the turning of the blood. farther, when we see the veins below the ligature instantly swell up and become gorged, when from extreme tightness it is somewhat relaxed, the arteries meantime continuing unaffected, this is an obvious indication that the blood passes from the arteries into the veins, and not from the veins into the arteries, and that there is either an anastomosis of the two orders of vessels, or porosities in the flesh and solid parts generally that are permeable to the blood it is farther an indication that the veins have frequent communications with one another, because they all become turgid together, whilst under the medium ligature applied above the elbow; and if any single small vein be pricked with a lancet, they all speedily shrink, and disburthening themselves into this they subside almost simultaneously. these considerations will enable anyone to understand the nature of the attraction that is exerted by ligatures, and perchance of fluxes generally; how, for example, when the veins are compressed by a bandage of medium tightness applied above the elbow, the blood cannot escape, whilst it still continues to be driven in, by the forcing power of the heart, by which the parts are of necessity filled, gorged with blood. and how should it be otherwise? heat and pain and a vacuum draw, indeed; but in such wise only that parts are filled, not preternaturally distended or gorged, and not so suddenly and violently overwhelmed with the charge of blood forced in upon them, that the flesh is lacerated and the vessels ruptured. nothing of the kind as an effect of heat, or pain, or the vacuum force, is either credible or demonstrable. besides, the ligature is competent to occasion the afflux in question without either pain, or heat, or a vacuum. were pain in any way the cause, how should it happen that, with the arm bound above the elbow, the hand and fingers should swell being the bandage, and their veins become distended? the pressure of the bandage certainly prevents the blood from getting there by the veins. and then, wherefore is there neither swelling nor repletion of the veins, nor any sign or symptom of attraction or afflux, above the ligature? but this is the obvious cause of the preternatural attraction and swelling below the bandage, and in the hand and fingers, that the blood is entering abundantly, and with force, but cannot pass out again. now is not this the cause of all tumefaction, as indeed avicenna has it, and of all oppressive redundancy in parts, that the access to them is open, but the egress from them is. closed? whence it comes that they are gorged and tumefied. and may not the same thing happen in local inflammations, where, so long as the swelling is on the increase, and has not reached its extreme term, a full pulse is felt in the part, especially when the disease is of the more acute kind, and the swelling usually takes place most rapidly. but these are matters for after discussion. or does this, which occurred in my own case, happen from the same cause? thrown from a carriage upon one occasion, i struck my forehead a blow upon the place where a twig of the artery advances from the temple, and immediately, within the time in which twenty beats could have been made i felt a tumour the size of an egg developed, without either heat or any great pain: the near vicinity of the artery had caused the blood to be effused into the bruised part with unusual force and velocity. and now, too, we understand why in phlebotomy we apply our ligature above the part that is punctured, not below it; did the flow come from above, not from below, the constriction in this case would not only be of no service, but would prove a positive hindrance; it would have to be applied below the orifice, in order to have the flow more free, did the blood descend by the veins from superior to inferior parts; but as it is elsewhere forced through the extreme arteries into the extreme veins, and the return in these last is opposed by the ligature, so do they fill and swell, and being thus filled and distended, they are made capable of projecting their charge with force, and to a distance, when any one of them is suddenly punctured; but the ligature being slackened, and the returning channels thus left open, the blood forthwith no longer escapes, save by drops; and, as all the world knows, if in performing phlebotomy the bandage be either slackened too much or the limb be bound too tightly, the blood escapes without force, because in the one case the returning channels are not adequately obstructed; in other the channels of influx, the arteries, are impeded. chapter xii that there is a circulation of the blood is shown from the second position demonstrated if these things be so, another point which i have already referred to, viz., the continual passage of the blood through the heart will also be confirmed. we have seen, that the blood passes from the arteries into the veins, not from the veins into the arteries; we have seen, farther, that almost the whole of the blood may be withdrawn from a puncture made in one of the cutaneous veins of the arm if a bandage properly applied be used; we have seen, still farther, that the blood flows so freely and rapidly that not only is the whole quantity which was contained in the arm beyond the ligature, and before the puncture was made, discharged, but the whole which is contained in the body, both that of the arteries and that of the veins. whence we must admit, first, that the blood is sent along with an impulse, and that it is urged with force below the ligature; for it escapes with force, which force it receives from the pulse and power of the heart; for the force and motion of the blood are derived from the heart alone. second, that the afflux proceeds from the heart, and through the heart by a course from the great veins; for it gets into the parts below the ligature through the arteries, not through the veins; and the arteries nowhere receive blood from the veins, nowhere receive blood save and except from the left ventricle of the heart. nor could so large a quantity of blood be drawn from one vein (a ligature having been duly applied), nor with such impetuousity, such readiness, such celerity, unless through the medium of the impelling power of the heart. but if all things be as they are now represented, we shall feel ourselves at liberty to calculate the quantity of the blood, and to reason on its circular motion. should anyone, for instance, performing phlebotomy, suffer the blood to flow in the manner it usually does, with force and freely, for some half hour or so, no question but that the greatest part of the blood being abstracted, faintings and syncopes would ensue, and that not only would the arteries but the great veins also be nearly emptied of their contents. it is only consonant with reason to conclude that in the course of the half hour hinted at, so much as has escaped has also passed from the great veins through the heart into the aorta. and further, if we calculate how many ounces flow through one arm, or how many pass in twenty or thirty pulsations under the medium ligature, we shall have some grounds for estimating how much passes through the other arm in the same space of time: how much through both lower extremities, how much through the neck on either side, and through all the other arteries and veins of the body, all of which have been supplied with fresh blood, and as this blood must have passed through the lungs and ventricles of the heart, and must have come from the great veins, we shall perceive that a circulation is absolutely necessary, seeing that the quantities hinted at cannot be supplied immediately from the ingesta, and are vastly more than can be requisite for the mere nutrition of the parts. it is still further to be observed, that in practising phlebotomy the truths contended for are sometimes confirmed in another way; for having tied up the arm properly, and made the puncture duly, still, if from alarm or any other causes, a state of faintness supervenes, in which the heart always pulsates more languidly, the blood does not flow freely, but distils by drops only. the reason is, that with a somewhat greater than usual resistance offered to the transit of the blood by the bandage, coupled with the weaker action of the heart, and its diminished impelling power, the stream cannot make its way under the ligature; and farther, owing to the weak and languishing state of the heart, the blood is not transferred in such quantity as wont from the veins to the arteries through the sinuses of that organ. so also, and for the same reasons, are the menstrual fluxes of women, and indeed hemorrhages of every kind, controlled. and now, a contrary state of things occurring, the patient getting rid of his fear and recovering his courage, the pulse strength is increased, the arteries begin again to beat with greater force, and to drive the blood even into the part that is bound; so that the blood now springs from the puncture in the vein, and flows in continuous stream. chapter xiii the third position is confirmed: and the circulation of the blood is demonstrated from it thus far we have spoken of the quantity of blood passing through the heart and the lungs in the centre of the body, and in like manner from the arteries into the veins in the peripheral parts and the body at large. we have yet to explain, however, in what manner the blood finds its way back to the heart from the extremities by the veins, and how and in what way these are the only vessels that convey the blood from the external to the central parts; which done, i conceive that the three fundamental propositions laid down for the circulation of the blood will be so plain, so well established, so obviously true, that they may claim general credence. now the remaining position will be made sufficiently clear from the valves which are found in the cavities of the veins themselves, from the uses of these, and from experiments cognisable by the senses. the celebrated hieronymus fabricius of aquapendente, a most skilful anatomist, and venerable old man, or, as the learned riolan will have it, jacobus silvius, first gave representations of the valves in the veins, which consist of raised or loose portions of the inner membranes of these vessels, of extreme delicacy, and a sigmoid or semilunar shape. they are situated at different distances from one another, and diversely in different individuals; they are connate at the sides of the veins; they are directed upwards towards the trunks of the veins; the two--for there are for the most part two together--regard each other, mutually touch, and are so ready to come into contact by their edges, that if anything attempts to pass from the trunks into the branches of the veins, or from the greater vessels into the less, they completely prevent it; they are farther so arranged, that the horns of those that succeed are opposite the middle of the convexity of those that and so on alternately. the discoverer of these valves did not rightly understand their use, nor have succeeding anatomists added anything to our knowledge: for their office is by no means explained when we are told that it is to hinder the blood, by its weight, from all flowing into inferior parts; for the edges of the valves in the jugular veins hang downwards, and are so contrived that they prevent the blood from rising upwards; the valves, in a word, do not invariably look upwards, but always toward the trunks of the veins, invariably towards the seat of the heart. i, and indeed others, have sometimes found valves in the emulgent veins, and in those of the mesentery, the edges of which were directed towards the vena cava and vena portae. let it be added that there are no valves in the arteries, and that dogs, oxen, etc., have invariably valves at the divisions of their crural veins, in the veins that meet towards the top of the os sacrum, and in those branches which come from the haunches, in which no such effect of gravity from the erect position was to be apprehended. neither are there valves in the jugular veins for the purpose of guarding against apoplexy, as some have said; because in sleep the head is more apt to be influenced by the contents of the carotid arteries. neither are the valves present, in order that the blood may be retained in the divarications or smaller trunks and minuter branches, and not be suffered to flow entirely into the more open and capacious channels; for they occur where there are no divarications; although it must be owned that they are most frequent at the points where branches join. neither do they exist for the purpose of rendering the current of blood more slow from the centre of the body; for it seems likely that the blood would be disposed to flow with sufficient slowness of its own accord, as it would have to pass from larger into continually smaller vessels, being separated from the mass and fountain head, and attaining from warmer into colder places. but the valves are solely made and instituted lest the blood should pass from the greater into the lesser veins, and either rupture them or cause them to become varicose; lest, instead of advancing from the extreme to the central parts of the body, the blood should rather proceed along the veins from the centre to the extremities; but the delicate valves, while they readily open in the right direction, entirely prevent all such contrary motion, being so situated and arranged, that if anything escapes, or is less perfectly obstructed by the cornua of the one above, the fluid passing, as it were, by the chinks between the cornua, it is immediately received on the convexity of the one beneath, which is placed transversely with reference to the former, and so is effectually hindered from getting any farther. and this i have frequently experienced in my dissections of the veins: if i attempted to pass a probe from the trunk of the veins into one of the smaller branches, whatever care i took i found it impossible to introduce it far any way, by reason of the valves; whilst, on the contrary, it was most easy to push it along in the opposite direction, from without inwards, or from the branches towards the trunks and roots. in many places two valves are so placed and fitted, that when raised they come exactly together in the middle of the vein, and are there united by the contact of their margins; and so accurate is the adaptation, that neither by the eye nor by any other means of examination, can the slightest chink along the line of contact be perceived. but if the probe be now introduced from the extreme towards the more central parts, the valves, like the floodgates of a river, give way, and are most readily pushed aside. the effect of this arrangement plainly is to prevent all motion of the blood from the heart and vena cava, whether it be upwards towards the head, or downwards towards the feet, or to either side towards the arms, not a drop can pass; all motion of the blood, beginning; in the larger and tending towards the smaller veins, is opposed and resisted by them; whilst the motion that proceeds from the lesser to end in the larger branches is favoured, or, at all events, a free and open passage is left for it. but that this truth may be made the more apparent, let an arm be tied up above the elbow as if for phlebotomy (a, a, fig. 1). at intervals in the course of the veins, especially in labouring people and those whose veins are large, certain knots or elevations (b, c, d, e, f) will be perceived, and this not only at the places where a branch is received (e, f), but also where none enters (c, d): these knots or risings are all formed by valves, which thus show themselves externally. and now if you press the blood from the space above one of the valves, from h to o, (fig. 2,) and keep the point of a finger upon the vein inferiorly, you will see no influx of blood from above; the portion of the vein between the point of the finger and the valve o will be obliterated; yet will the vessel continue sufficiently distended above the valve (o, g). the blood being thus pressed out and the vein emptied, if you now apply a finger of the other hand upon the distended part of the vein above the valve o, (fig. 3,) and press downwards, you will find that you cannot force the blood through or beyond the valve; but the greater effort you use, you will only see the portion of vein that is between the finger and the valve become more distended, that portion of the vein which is below the valve remaining all the while empty (h, o, fig. 3). it would therefore appear that the function of the valves in the veins is the same as that of the three sigmoid valves which we find at the commencement of the aorta and pulmonary artery, viz., to prevent all reflux of the blood that is passing over them. [note.--woodcuts of the veins of the arm to which these letters and figures refer appear here in the original.--c. n. b. c] farther, the arm being bound as before, and the veins looking full and distended, if you press at one part in the course of a vein with the point of a finger (l, fig. 4), and then with another finger streak the blood upwards beyond the next valve (n), you will perceive that this portion of the vein continues empty (l, n), and that the blood cannot retrograde, precisely as we have already seen the case to be in fig. 2; but the finger first applied (h, fig. 2, l, fig. 4), being removed, immediately the vein is filled from below, and the arm becomes as it appears at d c, fig. 1. that the blood in the veins therefore proceeds from inferior or more remote parts, and towards the heart, moving in these vessels in this and not in the contrary direction, appears most obviously. and although in some places the valves, by not acting with such perfect accuracy, or where there is but a single valve, do not seem totally to prevent the passage of the blood from the centre, still the greater number of them plainly do so; and then, where things appear contrived more negligently, this is compensated either by the more frequent occurrence or more perfect action of the succeeding valves, or in some other way: the veins in short, as they are the free and open conduits of the blood returning to the heart, so are they effectually prevented from serving as its channels of distribution from the heart. but this other circumstance has to be noted: the arm being bound, and the veins made turgid, and the valves prominent, as before, apply the thumb or finger over a vein in the situation of one of the valves in such a way as to compress it, and prevent any blood from passing upwards from the hand; then, with a finger of the other hand, streak the blood in the vein upwards till it has passed the next valve above (n, fig. 4), the vessel now remains empty; but the finger at l being removed for an instant, the vein is immediately filled from below; apply the finger again, and having in the same manner streaked the blood upwards, again remove the finger below, and again the vessel becomes distended as before; and this repeat, say a thousand times, in a short space of time. and now compute the quantity of blood which you have thus pressed up beyond the valve, and then multiplying the assumed quantity by one thousand, you will find that so much blood has passed through a certain portion of the vessel; and i do now believe that you will find yourself convinced of the circulation of the blood, and of its rapid motion. but if in this experiment you say that a violence is done to nature, i do not doubt but that, if you proceed in the same way, only taking as great a length of vein as possible, and merely remark with what rapidity the blood flows upwards, and fills the vessel from below, you will come to the same conclusion. chapter xiv conclusion of the demonstration of the circulation and now i may be allowed to give in brief my view of the circulation of the blood, and to propose it for general adoption. since all things, both argument and ocular demonstration, show that the blood passes through the lungs, and heart by the force of the ventricles, and is sent for distribution to all parts of the body, where it makes its way into the veins and porosities of the flesh, and then flows by the veins from the circumference on every side to the centre, from the lesser to the greater veins, and is by them finally discharged into the vena cava and right auricle of the heart, and this in such a quantity or in such a flux and reflux thither by the arteries, hither by the veins, as cannot possibly be supplied by the ingesta, and is much greater than can be required for mere purposes of nutrition; it is absolutely necessary to conclude that the blood in the animal body is impelled in a circle, and is in a state of ceaseless motion; that this is the act or function which the heart performs by means of its pulse; and that it is the sole and only end of the motion and contraction of the heart. chapter xv the circulation of the blood is further confirmed by probable reasons it will not be foreign to the subject if i here show further, from certain familiar reasonings, that the circulation is matter both of convenience and necessity. in the first place, since death is a corruption which takes place through deficiency of heat, [footnote: aristoteles de respirations, lib. ii et iii: de part. animal. et alibi.] and since all living things are warm, all dying things cold, there must be a particular seat and fountain, a kind of home and hearth, where the cherisher of nature, the original of the native fire, is stored and preserved; from which heat and life are dispensed to all parts as from a fountain head; from which sustenance may be derived; and upon which concoction and nutrition, and all vegetative energy may depend. now, that the heart is this place, that the heart is the principle of life, and that all passes in the manner just mentioned, i trust no one will deny. the blood, therefore, required to have motion, and indeed such a motion that it should return again to the heart; for sent to the external parts of the body far from its fountain, as aristotle says, and without motion it would become congealed. for we see motion generating and keeping up heat and spirits under ail circumstances, and rest allowing them to escape and be dissipated. the blood, therefore, becoming thick or congealed by the cold of the extreme and outward parts, and robbed of its spirits, just as it is in the dead, it was imperative that from its fount and origin, it should again receive heat and spirits, and all else requisite to its preservation--that, by returning, it should be renovated and restored. we frequently see how the extremities are chilled by the external cold, how the nose and cheeks and hands look blue, and how the blood, stagnating in them as in the pendent or lower parts of a corpse, becomes of a dusky hue; the limbs at the same time getting torpid, so that they can scarcely be moved, and seem almost to have lost their vitality. now they can by no means be so effectually, and especially so speedily restored to heat and colour and life, as by a new efflux and contact of heat from its source. but how can parts attract in which the heat and life are almost extinct? or how should they whose passages are filled with condensed and frigid blood, admit fresh aliment--renovated blood --unless they had first got rid of their old contents? unless the heart were truly that fountain where life and heat are restored to the refrigerated fluid, and whence new blood, warm, imbued with spirits, being sent out by the arteries, that which has become cooled and effete is forced on, and all the particles recover their heat which was failing, and their vital stimulus wellnigh exhausted. hence it is that if the heart be unaffected, life and health may be restored to almost all the other parts of the body; but if the heart be chilled, or smitten with any serious disease, it seems matter of necessity that the whole animal fabric should suffer and fall into decay. when the source is corrupted, there is nothing, as aristotle says, [footnote: de part. animal., iii.] which can be of service either to it or aught that depends on it. and hence, by the way, it may perchance be why grief, and love, and envy, and anxiety, and all affections of the mind of a similar kind are accompanied with emaciation and decay, or with disordered fluids and crudity, which engender all manner of diseases and consume the body of man. for every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart, and there induces change from the natural constitution, in the temperature, the pulse and the rest, which impairing all nutrition in its source and abating the powers at large, it is no wonder that various forms of incurable disease in the extremities and in the trunk are the consequence, inasmuch as in such circumstances the whole body labours under the effects of vitiated nutrition and a want of native heat. moreover, when we see that all animals live through food digested in their interior, it is imperative that the digestion and distribution be perfect, and, as a consequence, that there be a place and receptacle where the aliment is perfected and whence it is distributed to the several members. now this place is the heart, for it is the only organ in the body which contains blood for the general use; all the others receive it merely for their peculiar or private advantage, just as the heart also has a supply for its own especial behoof in its coronary veins and arteries. but it is of the store which the heart contains in its auricles and ventricles that i here speak. then the heart is the only organ which is so situated and constituted that it can distribute the blood in due proportion to the several parts of the body, the quantity sent to each being according to the dimensions of the artery which supplies it, the heart serving as a magazine or fountain ready to meet its demands. further, a certain impulse or force, as well as an impeller or forcer, such as the heart, was required to effect this distribution and motion of the blood; both because the blood is disposed from slight causes, such as cold, alarm, horror, and the like, to collect in its source, to concentrate like parts to a whole, or the drops of water spilt upon a table to the mass of liquid; and because it is forced from the capillary veins into the smaller ramifications, and from these into the larger trunks by the motion of the extremities and the compression of the muscles generally. the blood is thus more disposed to move from the circumference to the centre than in the opposite direction, even were there no valves to oppose its motion; wherefore, that it may leave its source and enter more confined and colder channels, and flow against the direction to which it spontaneously inclines, the blood requires both force and impelling power. now such is the heart and the heart alone, and that in the way and manner already explained. chapter xvi the circulation of the blood is further proved from certain consequences there are still certain problems, which, taken as consequences of this truth assumed as proven, are not without their use in exciting belief, as it were, a posteriore; and which, although they may seem to be involved in much doubt and obscurity, nevertheless readily admit of having reasons and causes assigned for them. of such a nature are those that present themselves in connexion with contagions, poisoned wounds, the bites of serpents and rabid animals, lues venerea and the like. we sometimes see the whole system contaminated, though the part first infected remains sound; the lues venerea has occasionally made its attack with pains in the shoulders and head, and other symptoms, the genital organs being all the while unaffected; and then we know that the wound made by a rabid dog having healed, fever and a train of disastrous symptoms may nevertheless supervene. whence it appears that the contagion impressed upon or deposited in a particular part, is by-and-by carried by the returning current of blood to the heart, and by that organ is sent to contaminate the whole body. in tertian fever, the morbific cause seeking the heart in the first instance, and hanging about the heart and lungs, renders the patient short-winded, disposed to sighing, and indisposed to exertion, because the vital principle is oppressed and the blood forced into the lungs and rendered thick. it does not pass through them, (as i have myself seen in opening the bodies of those who had died in the beginning of the attack,) when the pulse is always frequent, small, and occasionally irregular; but the heat increasing, the matter becoming attenuated, the passages forced, and the transit made, the whole body begins to rise in temperature, and the pulse becomes fuller and stronger. the febrile paroxysm is fully formed, whilst the preternatural heat kindled in the heart is thence diffused by the arteries through the whole body along with the morbific matter, which is in this way overcome and dissolved by nature. when we perceive, further, that medicines applied externally exert their influence on the body just as if they had been taken internally, the truth we are contending for is confirmed. colocynth and aloes in this way move the belly, cantharides excites the urine, garlic applied to the soles of the feet assists expectoration, cordials strengthen, and an infinite number of examples of the same kind might be cited. perhaps it will not, therefore, be found unreasonable, if we say that the veins, by means of their orifices, absorb some of the things that are applied externally and carry this inwards with the blood, not otherwise, it may be, than those of the mesentery imbibe the chyle from the intestines and carry it mixed with the blood to the liver. for the blood entering the mesentery by the coeliac artery, and the superior and inferior mesenteries, proceeds to the intestines, from which, along with the chyle that has been attracted into the veins, it returns by their numerous ramifications into the vena portae of the liver, and from this into the vena cava, and this in such wise that the blood in these veins has the same colour and consistency as in other veins, in opposition to what many believe to be the fact. nor indeed can we imagine two contrary motions in any capillary system--the chyle upwards, the blood downwards. this could scarcely take place, and must be held as altogether improbable. but is not the thing rather arranged as it is by the consummate providence of nature? for were the chyle mingled with the blood, the crude with the digested, in equal proportions, the result would not be concoction, transmutation, and sanguification, but rather, and because they are severally active and passive, a mixture or combination, or medium compound of the two, precisely as happens when wine is mixed with water and syrup. but when a very minute quantity of chyle is mingled with a very large quantity of circulating blood, a quantity of chyle that bears no kind of proportion to the mass of blood, the effect is the same, as aristotle says, as when a drop of water is added to a cask of wine, or the contrary; the mass does not then present itself as a mixture, but is still sensibly either wine or water. so in the mesenteric veins of an animal we do not find either chyme or chyle and blood, blended together or distinct, but only blood, the same in colour, consistency, and other sensible properties, as it appears in the veins generally. still as there is a certain though small and inappreciable portion of chyle or incompletely digested matter mingled with the blood, nature has interposed the liver, in whose meandering channels it suffers delay and undergoes additional change, lest arriving prematurely and crude at the heart, it should oppress the vital principle. hence in the embryo, there is almost no use for the liver, but the umbilical vein passes directly through, a foramen or an anastomosis existing from the vena portae. the blood returns from the intestines of the foetus, not through the liver, but into the umbilical vein mentioned, and flows at once into the heart, mingled with the natural blood which is returning from the placenta; whence also it is that in the development of the foetus the liver is one of the organs that is last formed. i have observed all the members, perfectly marked out in the human foetus, even the genital organs, whilst there was yet scarcely any trace of the liver. and indeed at the period when all the parts, like the heart itself in the beginning, are still white, and except in the veins there is no appearance of redness, you shall see nothing in the seat of the liver but a shapeless collection, as it were, of extravasated blood, which you might take for the effects of a contusion or ruptured vein. but in the incubated egg there are, as it were, two umbilical vessels, one from the albumen passing entire through the liver, and going straight to the heart; another from the yelk, ending in the vena portae; for it appears that the chick, in the first instance, is entirely formed and nourished by the white; but by the yelk after it has come to perfection and is excluded from the shell; for this part may still be found in the abdomen of the chick many days after its exclusion, and is a substitute for the milk to other animals. but these matters will be better spoken of in my observations on the formation of the foetus, where many propositions, the following among the number, will be discussed: wherefore is this part formed or perfected first, that last, and of the several members, what part is the cause of another? and there are many points having special reference to the heart, such as wherefore does it first acquire consistency, and appear to possess life, motion, sense, before any other part of the body is perfected, as aristotle says in his third book, "de partibus animalium"? and so also of the blood, wherefore does it precede all the rest? and in what way does it possess the vital and animal principle, and show a tendency to motion, and to be impelled hither and thither, the end for which the heart appears to be made? in the same way, in considering the pulse, why should one kind of pulse indicate death, another recovery? and so of all the other kinds of pulse, what may be the cause and indication of each? likewise we must consider the reason of crises and natural critical discharges; of nutrition, and especially the distribution of the nutriment; and of defluxions of every description. finally, reflecting on every part of medicine, physiology, pathology, semeiotics and therapeutics, when i see how many questions can be answered, how many doubts resolved, how much obscurity illustrated by the truth we have declared, the light we have made to shine, i see a field of such vast extent in which i might proceed so far, and expatiate so widely, that this my tractate would not only swell out into a volume, which was beyond my purpose, but my whole life, perchance, would not suffice for its completion. in this place, therefore, and that indeed in a single chapter, i shall only endeavour to refer the various particulars that present themselves in the dissection of the heart and arteries to their several uses and causes; for so i shall meet with many things which receive light from the truth i have been contending for, and which, in their turn, render it more obvious. and indeed i would have it confirmed and illustrated by anatomical arguments above all others. there is but a single point which indeed would be more correctly placed among our observations on the use of the spleen, but which it will not be altogether impertinent to notice in this place incidentally. from the splenic branch which passes into the pancreas, and from the upper part, arise the posterior coronary, gastric, and gastroepiploic veins, all of which are distributed upon the stomach in numerous branches and twigs, just as the mesenteric vessels are upon the intestines. in a similar way, from the inferior part of the same splenic branch, and along the back of the colon and rectum proceed the hemorrhoidal veins. the blood returning by these veins, and bringing the cruder juices along with it, on the one hand from the stomach, where they are thin, watery, and not yet perfectly chylified; on the other thick and more earthy, as derived from the faeces, but all poured into this splenic branch, are duly tempered by the admixture of contraries; and nature mingling together these two kinds of juices, difficult of coction by reason of most opposite defects, and then diluting them with a large quantity of warm blood, (for we see that the quantity returned from the spleen must be very large when we contemplate the size of its arteries,) they are brought to the porta of the liver in a state of higher preparation. the defects of either extreme are supplied and compensated by this arrangement of the veins. chapter xvii the motion and circulation of the blood are confirmed from the particulars apparent in the structure of the heart, and from those things which dissection unfolds i do not find the heart as a distinct and separate part in all animals; some, indeed, such as the zoophytes, have no heart; this is because these animals are coldest, of one great bulk, of soft texture, or of a certain uniform sameness or simplicity of structure; among the number i may instance grubs and earth-worms, and those that are engendered of putrefaction and do not preserve their species. these have no heart, as not requiring any impeller of nourishment into the extreme parts; for they have bodies which are connate and homogeneous and without limbs; so that by the contraction and relaxation of the whole body they assume and expel, move and remove, the aliment. oysters, mussels, sponges, and the whole genus of zoophytes or plant-animals have no heart, for the whole body is used as a heart, or the whole animal is a heart. in a great number of animals,--almost the whole tribe of insects--we cannot see distinctly by reason of the smallness of the body; still in bees, flies, hornets, and the like we can perceive something pulsating with the help of a magnifying-glass; in pediculi, also, the same thing may be seen, and as the body is transparent, the passage of the food through the intestines, like a black spot or stain, may be perceived by the aid of the same magnifying-glass. but in some of the pale-blooded and colder animals, as in snails, whelks, shrimps, and shell-fish, there is a part which pulsates, --a kind of vesicle or auricle without a heart,--slowly, indeed, and not to be perceived except in the warmer season of the year. in these creatures this part is so contrived that it shall pulsate, as there is here a necessity for some impulse to distribute the nutritive fluid, by reason of the variety of organic parts, or of the density of the substance; but the pulsations occur unfrequently, and sometimes in consequence of the cold not at all, an arrangement the best adapted to them as being of a doubtful nature, so that sometimes they appear to live, sometimes to die; sometimes they show the vitality of an animal, sometimes of a vegetable. this seems also to be the case with the insects which conceal themselves in winter, and lie, as it were, defunct, or merely manifesting a kind of vegetative existence. but whether the same thing happens in the case of certain animals that have red blood, such as frogs, tortoises, serpents, swallows, may be very properly doubted. in all the larger and warmer animals which have red blood, there was need of an impeller of the nutritive fluid, and that, perchance, possessing a considerable amount of power. in fishes, serpents, lizards, tortoises, frogs, and others of the same kind there is a heart present, furnished with both an auricle and a ventricle, whence it is perfectly true, as aristotle has observed, [footnote: de part. animal., lib. iii.] that no sanguineous animal is without a heart, by the impelling power of which the nutritive fluid is forced, both with greater vigour and rapidity, to a greater distance; and not merely agitated by an auricle, as it is in lower forms. and then in regard to animals that are yet larger, warmer, and more perfect, as they abound in blood, which is always hotter and more spirituous, and which possess bodies of greater size and consistency, these require a larger, stronger, and more fleshy heart, in order that the nutritive fluid may be propelled with yet greater force and celerity. and further, inasmuch as the more perfect animals require a still more perfect nutrition, and a larger supply of native heat, in order that the aliment may be thoroughly concocted and acquire the last degree of perfection, they required both lungs and a second ventricle, which should force the nutritive fluid through them. every animal that has lungs has, therefore, two ventricles to its heart--one right, the other left; and wherever there is a right, there also is there a left ventricle; but the contrary of this does not hold good: where there is a left there is not always a right ventricle. the left ventricle i call that which is distinct in office, not in place from the other, that one, namely, which distributes the blood to the body at large, not to the lungs only. hence the left ventricle seems to form the principle part of the heart; situated in the middle, more strongly marked, and constructed with greater care, the heart seems formed for the sake of the left ventricle, and the right but to minister to it. the right neither reaches to the apex of the heart nor is it nearly of such strength, being three times thinner in its walls, and in some sort jointed on to the left (as aristotle says), though, indeed, it is of greater capacity, inasmuch as it has not only to supply material to the left ventricle, but likewise to furnish aliment to the lungs. it is to be observed, however, that all this is otherwise in the embryo, where there is not such a difference between the two ventricles. there, as in a double nut, they are nearly equal in all respects, the apex of the right reaching to the apex of the left, so that the heart presents itself as a sort of doublepointed cone. and this is so, because in the foetus, as already said, whilst the blood is not passing through the lungs from the right to the left cavities of the heart, it flows by the foramen ovale and ductus arteriosus directly from the vena cava into the aorta, whence it is distributed to the whole body. both ventricles have, therefore, the same office to perform, whence their equality of constitution. it is only when the lungs come to be used and it is requisite that the passages indicated should be blocked up that the difference in point of strength and other things between the two ventricles begins to be apparent. in the altered circumstances the right has only to drive the blood through the lungs, whilst the left has to propel it through the whole body. there are, moreover, within the heart numerous braces, in the form of fleshy columns and fibrous bands, which aristotle, in his third book on "respiration," and the "parts of animals," entitles nerves. these are variously extended, and are either distinct or contained in grooves in the walls and partition, where they occasion numerous pits or depressions. they constitute a kind of small muscles, which are superadded and supplementary to the heart, assisting it to execute a more powerful and perfect contraction, and so proving subservient to the complete expulsion of the blood. they are, in some sort, like the elaborate and artful arrangement of ropes in a ship, bracing the heart on every side as it contracts, and so enabling it more effectually and forcibly to expel the charge of blood from its ventricles. this much is plain, at all events, that in some animals they are less strongly marked than in others; and, in all that have them, they are more numerous and stronger in the left than in the right ventricle; and while some have them present in the left, yet they are absent in the right ventricle. in man they are more numerous in the left than in the right ventricle, more abundant in the ventricles than in the auricles; and occasionally there appear to be none present in the auricles. they are numerous in the large, more muscular and hardier bodies of countrymen, but fewer in more slender frames and in females. in those animals in which the ventricles of the heart are smooth within and entirely without fibres of muscular bands, or anything like hollow pits, as in almost all the smaller birds, the partridge and the common fowl, serpents, frogs, tortoises, and most fishes, there are no chordae tendineae, nor bundles of fibres, neither are there any tricuspid valves in the ventricles. some animals have the right ventricle smooth internally, but the left provided with fibrous bands, such as the goose, swan, and larger birds; and the reason is the same here as elsewhere. as the lungs are spongy and loose and soft, no great amount of force is required to force the blood through them; therefore the right ventricle is either without the bundles in question, or they are fewer and weaker, and not so fleshy or like muscles. those of the left ventricle, however, are both stronger and more numerous, more fleshy and muscular, because the left ventricle requires to be stronger, inasmuch as the blood which it propels has to be driven through the whole body. and this, too, is the reason why the left ventricle occupies the middle of the heart, and has parietes three times thicker and stronger than those of the right hence all animals--and among men it is similar--that are endowed with particularly strong frames, and with large and fleshy limbs at a great distance from the heart, have this central organ of greater thickness, strength, and muscularity. this is manifest and necessary. those, on the contrary, that are of softer and more slender make have the heart more flaccid, softer, and internally either less or not at all fibrous. consider, farther, the use of the several valves, which are all so arranged that the blood, once received into the ventricles of the heart, shall never regurgitate; once forced into the pulmonary artery and aorta, shall not flow back upon the ventricles. when the valves are raised and brought together, they form a three-cornered line, such as is left by the bite of a leech; and the more they are forced, the more firmly do they oppose the passage of the blood. the tricuspid valves are placed, like gate-keepers, at the entrance into the ventricles from the venae cavae and pulmonary veins, lest the blood when most forcibly impelled should flow back. it is for this reason that they are not found in all animals, nor do they appear to have been constructed with equal care, in all animals in which they are found. in some they are more accurately fitted, in others more remissly or carelessly contrived, and always with a view to their being closed under a greater or a slighter force of the ventricle. in the left ventricle, therefore, in order that the occlusion may be the more perfect against the greater impulse, there are only two valves, like a mitre, and produced into an elongated cone, so that they come together and touch to their middle; a circumstance which perhaps led aristotle into the error of supposing this ventricle to be double, the division taking place transversely. for the same reason, and that the blood may not regurgitate upon the pulmonary veins, and thus the force of the ventricle in propelling the blood through the system at large come to be neutralized, it is that these mitral valves excel those of the right ventricle in size and strength and exactness of closing. hence it is essential that there can be no heart without a ventricle, since this must be the source and store-house of the blood. the same law does not hold good in reference to the brain. for almost no genus of birds has a ventricle in the brain, as is obvious in the goose and swan, the brains of which nearly equal that of a rabbit in size; now rabbits have ventricles in the brain, whilst the goose has none. in like manner, wherever the heart has a single ventricle, there is an auricle appended, flaccid, membranous, hollow, filled with blood; and where there are two ventricles, there are likewise two auricles. on the other hand, some animals have an auricle without any ventricle; or, at all events, they have a sac analogous to an auricle; or the vein itself, dilated at a particular part, performs pulsations, as is seen in hornets, bees, and other insects, which certain experiments of my own enable me to demonstrate, have not only a pulse, but a respiration in that part which is called the tail, whence it is that this part is elongated and contracted now more rarely, now more frequently, as the creature appears to be blown and to require a large quantity of air. but of these things, more in our "treatise on respiration." it is in like manner evident that the auricles pulsate, contract, as i have said before, and throw the blood into the ventricles; so that wherever there is a ventricle, an auricle is necessary, not merely that it may serve, according to the general belief, as a source and magazine for the blood: for what were the use of its pulsations had it only to contain? the auricles are prime movers of the blood, especially the right auricle, which, as already said, is "the first to live, the last to die"; whence they are subservient to sending the blood into the ventricles, which, contracting continuously, more readily and forcibly expel the blood already in motion; just as the ballplayer can strike the ball more forcibly and further if he takes it on the rebound than if he simply threw it. moreover, and contrary to the general opinion, neither the heart nor anything else can dilate or distend itself so as to draw anything into its cavity during the diastole, unless, like a sponge, it has been first compressed and is returning to its primary condition. but in animals all local motion proceeds from, and has its origin in, the contraction of some part; consequently it is by the contraction of the auricles that the blood is thrown into the ventricles, as i have already shown, and from there, by the contraction of the ventricles, it is propelled and distributed. concerning local motions, it is true that the immediate moving organ in every motion of an animal primarily endowed with a motive spirit (as aristotle has it [footnote: in the book de spiritu, and elsewhere.]) is contractile; in which way the word veopou is derived from veuw, nuto, contraho; and if i am permitted to proceed in my purpose of making a particular demonstration of the organs of motion in animals from observations in my possession, i trust i shall be able to make sufficiently plain how aristotle was acquainted with the muscles, and advisedly referred all motion in animals to the nerves, or to the contractile element, and, therefore, called those little bands in the heart nerves. but that we may proceed with the subject which we have in hand, viz., the use of the auricles in filling the ventricles, we should expect that the more dense and compact the heart, the thicker its parietes, the stronger and more muscular must be the auricle to force and fill it, and vice versa. now this is actually so: in some the auricle presents itself as a sanguinolent vesicle, as a thin membrane containing blood, as in fishes, in which the sac that stands in lieu of the auricles is of such delicacy and ample capacity that it seems to be suspended or to float above the heart. in those fishes in which the sac is somewhat more fleshy, as in the carp, barbel, tench, and others, it bears a wonderful and strong resemblance to the lungs. in some men of sturdier frame and stouter make the right auricle is so strong, and so curiously constructed on its inner surface of bands and variously interlacing fibres, that it seems to equal in strength the ventricle of the heart in other subjects; and i must say that i am astonished to find such diversity in this particular in different individuals. it is to be observed, however, that in the foetus the auricles are out of all proportion large, which is because they are present before the heart makes its appearance or suffices for its office even when it has appeared, and they, therefore, have, as it were, the duty of the whole heart committed to them, as has already been demonstrated. but what i have observed in the formation of the foetus, as before remarked (and aristotle had already confirmed all in studying the incubated egg), throws the greatest light and likelihood upon the point. whilst the foetus is yet in the form of a soft worm, or, as is commonly said, in the milk, there is a mere bloody point or pulsating vesicle, a portion apparently of the umbilical vein, dilated at its commencement or base. afterwards, when the outline of the foetus is distinctly indicated and it begins to have greater bodily consistence, the vesicle in question becomes more fleshy and stronger, changes its position, and passes into the auricles, above which the body of the heart begins to sprout, though as yet it apparently performs no office. when the foetus is farther advanced, when the bones can be distinguished from the fleshy parts and movements take place, then it also has a heart which pulsates, and, as i have said, throws blood by either ventricle from the vena cava into the arteries. thus nature, ever perfect and divine, doing nothing in vain, has neither given a heart where it was not required, nor produced it before its office had become necessary; but by the same stages in the development of every animal, passing through the forms of all, as i may say (ovum, worm, foetus), it acquires perfection in each. these points will be found elsewhere confirmed by numerous observations on the formation of the foetus. finally, it is not without good grounds that hippocrates in his book, "de corde," entitles it a muscle; its action is the same; so is its functions, viz., to contract and move something else-in this case the charge of the blood. farther, we can infer the action and use of the heart from the arrangement of its fibres and its general structures, as in muscles generally. all anatomists admit with galen that the body of the heart is made up of various courses of fibres running straight, obliquely, and transversely, with reference to one another; but in a heart which has been boiled, the arrangement of the fibres is seen to be different. all the fibres in the parietes and septum are circular, as in the sphincters; those, again, which are in the columns extend lengthwise, and are oblique longitudinally; and so it comes to pass that when all the fibres contract simultaneously, the apex of the cone is pulled towards its base by the columns, the walls are drawn circularly together into a globe--the whole heart, in short, is contracted and the ventricles narrowed. it is, therefore, impossible not to perceive that, as the action of the organ is so plainly contraction, its function is to propel the blood into the arteries. nor are we the less to agree with aristotle in regard to the importance of the heart, or to question if it receives sense and motion from the brain, blood from the liver, or whether it be the origin of the veins and of the blood, and such like. they who affirm these propositions overlook, or do not rightly understand, the principal argument, to the effect that the heart is the first part which exists, and that it contains within itself blood, life, sensation, and motion, before either the brain or the liver were created or had appeared distinctly, or, at all events, before they could perform any function. the heart, ready furnished with its proper organs of motion, like a kind of internal creature, existed before the body. the first to be formed, nature willed that it should afterwards fashion, nourish, preserve, complete the entire animal, as its work and dwellingplace: and as the prince in a kingdom, in whose hands lie the chief and highest authority, rules over all, the heart is the source and foundation from which all power is derived, on which all power depends in the animal body. many things having reference to the arteries farther illustrate and confirm this truth. why does not the pulmonary vein pulsate, seeing that it is numbered among the arteries? or wherefore is there a pulse in the pulmonary artery? because the pulse of the arteries is derived from the impulse of the blood. why does an artery differ so much from a vein in the thickness and strength of its coats? because it sustains the shock of the impelling heart and streaming blood. hence, as perfect nature does nothing in vain, and suffices under all circumstances, we find that the nearer the arteries are to the heart, the more do they differ from the veins in structure; here they are both stronger and more ligamentous, whilst in extreme parts of the body, such as the feet and hands, the brain, the mesentery, and the testicles, the two orders of vessels are so much alike that it is impossible to distinguish between them with the eye. now this is for the following very sufficient reasons: the more remote the vessels are from the heart, with so much the less force are they distended by the stroke of the heart, which is broken by the great distance at which it is given. add to this that the impulse of the heart exerted upon the mass of blood, which must needs fill the trunks and branches of the arteries, is diverted, divided, as it were, and diminished at every subdivision, so that the ultimate capillary divisions of the arteries look like veins, and this not merely in constitution, but in function. they have either no perceptible pulse, or they rarely exhibit one, and never except where the heart beats more violently than usual, or at a part where the minute vessel is more dilated or open than elsewhere. it, therefore, happens that at times we are aware of a pulse in the teeth, in inflammatory tumours, and in the fingers; at another time we feel nothing of the sort. by this single symptom i have ascertained for certain that young persons whose pulses are naturally rapid were labouring under fever; and in like manner, on compressing the fingers in youthful and delicate subjects during a febrile paroxysm, i have readily perceived the pulse there. on the other hand, when the heart pulsates more languidly, it is often impossible to feel the pulse not merely in the fingers, but the wrist, and even at the temple, as in persons afflicted with lipothymiae asphyxia, or hysterical symptoms, and in the debilitated and moribund. here surgeons are to be advised that, when the blood escapes with force in the amputation of limbs, in the removal of tumours, and in wounds, it constantly comes from an artery; not always indeed per saltum, because the smaller arteries do not pulsate, especially if a tourniquet has been applied. for the same reason the pulmonary artery not only has the structure of an artery, but it does not differ so widely from the veins in the thickness of its walls as does the aorta. the aorta sustains a more powerful shock from the left than the pulmonary artery does from the right ventricle, and the walls of this last vessel are thinner and softer than those of the aorta in the same proportion as the walls of the right ventricle of the heart are weaker and thinner than those of the left ventricle. in like manner the lungs are softer and laxer in structure than the flesh and other constituents of the body, and in a similar way the walls of the branches of the pulmonary artery differ from those of the vessels derived from the aorta. and the same proportion in these particulars is universally preserved. the more muscular and powerful men are, the firmer their flesh; the stronger, thicker, denser, and more fibrous their hearts, the thicker, closer, and stronger are the auricles and arteries. again, in those animals the ventricles of whose hearts are smooth on their inner surface, without villi or valves, and the walls of which are thin, as in fishes, serpents, birds, and very many genera of animals, the arteries differ little or nothing in the thickness of their coats from the veins. moreover, the reason why the lungs have such ample vessels, both arteries and veins (for the capacity of the pulmonary veins exceeds that of both crural and jugular vessels), and why they contain so large a quantity of blood, as by experience and ocular inspection we know they do, admonished of the fact indeed by aristotle, and not led into error by the appearances found in animals which have been bled to death, is, because the blood has its fountain, and storehouse, and the workshop of its last perfection, in the heart and lungs. why, in the same way, we find in the course of our anatomical dissections the pulmonary vein and left ventricle so full of blood, of the same black colour and clotted character as that with which the right ventricle and pulmonary artery are filled, is because the blood is incessantly passing from one side of the heart to the other through the lungs. wherefore, in fine, the pulmonary artery has the structure of an artery, and the pulmonary veins have the structure of veins. in function and constitution and everything else the first is an artery, the others are veins, contrary to what is commonly believed; and the reason why the pulmonary artery has so large an orifice is because it transports much more blood than is requisite for the nutrition of the lungs. all these appearances, and many others, to be noted in the course of dissection, if rightly weighed, seem clearly to illustrate and fully to confirm the truth contended for throughout these pages, and at the same time to oppose the vulgar opinion; for it would be very difficult to explain in any other way to what purpose all is constructed and arranged as we have seen it to be. the three original publications on vaccination against smallpox by edward jenner introductory note edward jenner was born at his father's vicarage at berkeley, gloucestershire, england, on may 17, 1749. after leaving school, he was apprenticed to a local surgeon, and in 1770 he went to london and became a resident pupil under the great surgeon and anatomist, john hunter, with whom he remained on intimate terms for the rest of hunter's life. in 1773 he took up practise at berkeley, where, except for numerous visits to london, he spent the rest of his life. he died of apoplexy on january 26, 1823. jenner's scientific interests were varied, but the importance of his work in vaccination has overshadowed his other results. early in his career he had begun to observe the phenomena of cowpox, a disease common in the rural parts of the western counties of england, and he was familiar with the belief, current among the peasantry, that a person who had suffered from the cowpox could not take smallpox. finally, in 1796, he made his first experiment in vaccination, inoculating a boy of eight with cowpox, and, after his recovery, with smallpox; with the result that the boy did not take the latter disease. jenner's first paper on his discovery was never printed; but in 1798 appeared the first of the following treatises. its reception by the medical profession was highly discouraging; but progress began when cline, the surgeon of st. thomas's hospital, used the treatment with success. jenner continued his investigations, publishing his results from time to time, and gradually gaining recognition; though opposition to his theory and practise was at first vehement, and has never entirely disappeared. in 1802, parliament voted him 10,000 pounds, and in 1806, 20,000 pounds, in recognition of the value of his services, and the sacrifices they had entailed. as early as 1807, bavaria made vaccination compulsory; and since that date most of the european governments have officially encouraged or compelled the practise; and smallpox has ceased to be the almost universal scourge it was before jenner's discovery. to c.h. parry, m.d. at bath my dear friend: in the present age of scientific investigation it is remarkable that a disease of so peculiar a nature as the cow-pox, which has appeared in this and some of the neighbouring counties for such a series of years, should so long have escaped particular attention. finding the prevailing notions on the subject, both among men of our profession and others, extremely vague and indeterminate, and conceiving that facts might appear at once both curious and useful, i have instituted as strict an inquiry into the causes and effects of this singular malady as local circumstances would admit. the following pages are the result, which, from motives of the most affectionate regard, are dedicated to you, by your sincere friend, edward jenner. berkeley, gloucestershire, june 21st, 1798. vaccination against smallpox i an inquiry into the causes and effects of the variole vaccine, or cow-pox. 1798 the deviation of man from the stage in which he was originally placed by nature seems to have proved to him a prolific source of diseases. from the love of splendour, from the indulgences of luxury, and from his fondness for amusement he has familiarised himself with a great number of animals, which may not originally have been intended for his associates. the wolf, disarmed of ferocity, is now pillowed in the lady's lap. [footnote: the late mr. john hunter proved, by experiments, that the dog is the wolf in a degenerate state.] the cat, the little tiger of our island, whose natural home is the forest, is equally domesticated and caressed. the cow, the hog, the sheep, and the horse, are all, for a variety of purposes, brought under his care and dominion. there is a disease to which the horse, from his state of domestication, is frequently subject. the farriers have called it the grease. it is an inflammation and swelling in the heel, from which issues matter possessing properties of a very peculiar kind, which seems capable of generating a disease in the human body (after it has undergone the modification which i shall presently speak of), which bears so strong a resemblance to the smallpox that i think it highly probable it may be the source of the disease. in this dairy country a great number of cows are kept, and the office of milking is performed indiscriminately by men and maid servants. one of the former having been appointed to apply dressings to the heels of a horse affected with the grease, and not paying due attention to cleanliness, incautiously bears his part in milking the cows, with some particles of the infectious matter adhering to his fingers. when this is the case, it commonly happens that a disease is communicated to the cows, and from the cows to the dairymaids, which spreads through the farm until the most of the cattle and domestics feel its unpleasant consequences. this disease has obtained the name of the cow-pox. it appears on the nipples of the cows in the form of irregular pustules. at their first appearance they are commonly of a palish blue, or rather of a colour somewhat approaching to livid, and are surrounded by an erysipelatous inflammation. these pustules, unless a timely remedy be applied, frequently degenerate into phagedenic ulcers, which prove extremely troublesome. [footnote: they who attend sick cattle in this country find a speedy remedy for stopping the progress of this complaint in those applications which act chemically upon the morbid matter, such as the solutions of the vitriolum zinci and the vitriolum cupri, etc.] the animals become indisposed, and the secretion of milk is much lessened. inflamed spots now begin to appear on different parts of the hands of the domestics employed in milking, and sometimes on the wrists, which quickly run on to suppuration, first assuming the appearance of the small vesications produced by a burn. most commonly they appear about the joints of the fingers and at their extremities; but whatever parts are affected, if the situation will admit, these superficial suppurations put on a circular form, with their edges more elevated than their centre, and of a colour distantly approaching to blue. absorption takes place, and tumours appear in each axilla. the system becomes affected--the pulse is quickened; and shiverings, succeeded by heat, with general lassitude and pains about the loins and limbs, with vomiting, come on. the head is painful, and the patient is now and then even affected with delirium. these symptoms, varying in their degrees of violence, generally continue from one day to three or four, leaving ulcerated sores about the hands, which, from the sensibility of the parts, are very troublesome, and commonly heal slowly, frequently becoming phagedenic, like those from whence they sprung. the lips, nostrils, eyelids, and other parts of the body are sometimes affected with sores; but these evidently arise from their being heedlessly rubbed or scratched with the patient's infected fingers. no eruptions on the skin have followed the decline of the feverish symptoms in any instance that has come under my inspection, one only excepted, and in this case a very few appeared on the arms: they were very minute, of a vivid red colour, and soon died away without advancing to maturation; so that i cannot determine whether they had any connection with the preceding symptoms. thus the disease makes its progress from the horse [footnote: jenner's conclusion that "grease" and cow-pox were the same disease has since been proved erroneous; but this error has not invalidated his main conclusion as to the relation of cow-pox and smallpox.--editor.] to the nipple of the cow, and from the cow to the human subject morbid matter of various kinds, when absorbed into the system, may produce effects in some degree similar; but what renders the cow-pox virus so extremely singular is that the person who has been thus affected is forever after secure from the infection of the smallpox; neither exposure to the variolous effluvia, nor the insertion of the matter into the skin, producing this distemper. in support of so extraordinary a fact, i shall lay before my reader a great number of instances. [footnote: it is necessary to observe that pustulous sores frequently appear spontaneously on the nipples of cows, and instances have occurred, though very rarely, of the hands of the servants employed in milking being affected with sores in consequence, and even of their feeling an indisposition from absorption. these pustules arc of a much milder nature than those which arise from that contagion which constitutes the true cow-pox. they are always free from the bluish or livid tint so conspicuous in the pustules in that disease. no erysipelas attends them, nor do they shew any phagedenic disposition as in the other case, but quickly terminate in a scab without creating any apparent disorder in the cow. this complaint appears at various seasons of the year, but most commonly in the spring, when the cows are first taken from their winter food and fed with grass. it is very apt to appear also when they are suckling their young. but this disease is not to be considered as similar in any respect to that of which i am treating, as it is incapable of producing any specific effects on the human constitution. however, it is of the greatest consequence to point it out here, lest the want of discrimination should occasion an idea of security from the infection of the smallpox, which might prove delusive.] case i.--joseph merret, now an under gardener to the earl of berkeley, lived as a servant with a farmer near this place in the year 1770, and occasionally assisted in milking his master's cows. several horses belonging to the farm began to have sore heels, which merret frequently attended. the cows soon became affected with the cow-pox, and soon after several sores appeared on his hands. swellings and stiffness in each axilla followed, and he was so much indisposed for several days as to be incapable of pursuing his ordinary employment. previously to the appearance of the distemper among the cows there was no fresh cow brought into the farm, nor any servant employed who was affected with the cow-pox. in april, 1795, a general inoculation taking place here, merret was inoculated with his family; so that a period of twenty-five years had elapsed from his having the cow-pox to this time. however, though the variolous matter was repeatedly inserted into his arm, i found it impracticable to infect him with it; an efflorescence only, taking on an erysipelatous look about the centre, appearing on the skin near the punctured parts. during the whole time that his family had the smallpox, one of whom had it very full, he remained in the house with them, but received no injury from exposure to the contagion. it is necessary to observe that the utmost care was taken to ascertain, with the most scrupulous precision, that no one whose case is here adduced had gone through the smallpox previous to these attempts to produce that disease. had these experiments been conducted in a large city, or in a populous neighbourhood, some doubts might have been entertained; but here, where population is thin, and where such an event as a person's having had the smallpox is always faithfully recorded, as risk of inaccuracy in this particular can arise. case ii.--sarah portlock, of this place, was infected with the cow-pox when a servant at a farmer's in the neighbourhood, twenty-seven years ago. [footnote: i have purposely selected several cases in which the disease had appeared at a very distant period previous to the experiments made with variolous matter, to shew that the change produced in the constitution is not affected by time.] in the year 1792, conceiving herself, from this circumstance, secure from the infection of the smallpox, she nursed one of her own children who had accidentally caught the disease, but no indisposition ensued. during the time she remained in the infected room, variolous matter was inserted into both her arms, but without any further effect than in the preceding case. case iii.--john phillips, a tradesman of this town, had the cowpox at so early a period as nine years of age. at the age of sixty-two i inoculated him, and was very careful in selecting matter in its most active state. it was taken from the arm of a boy just before the commencement of the eruptive fever, and instantly inserted. it very speedily produced a sting-like feel in the part. an efflorescence appeared, which on the fourth day was rather extensive, and some degree of pain and stiffness were felt about the shoulder; but on the fifth day these symptoms began to disappear, and in a day or two after went entirely off, without producing any effect on the system. case iv.--mary barge, of woodford, in this parish, was inoculated with variolous matter in the year 1791. an efflorescence of a palish red colour soon appeared about the parts where the matter was inserted, and spread itself rather extensively, but died away in a few days without producing any variolous symptoms. [footnote: it is remarkable that variolous matter, when the system is disposed to reject it, should excite inflammation on the part to which it is applied more speedily than when it produces the smallpox. indeed, it becomes almost a criterion by which we can determine whether the infection will be received or not. it seems as if a change, which endures through life, had been produced in the action, or disposition to action, in the vessels of the skin; and it is remarkable, too, that whether this change has been effected by the smallpox or the cow-pox that the disposition to sudden cuticular inflammation is the same on the application of variolous matter.] she has since been repeatedly employed as a nurse to smallpox patients, without experiencing any ill consequences. this woman had the cow-pox when she lived in the service of a farmer in this parish thirty-one years before. case v.--mrs. h---, a respectable gentlewoman of this town, had the cow-pox when very young. she received the infection in rather an uncommon manner: it was given by means of her handling some of the same utensils [footnote: when the cow-pox has prevailed in the dairy, it has often been communicated to those who have not milked the cows, by the handle of the milk pail.] which were in use among the servants of the family, who had the disease from milking infected cows. her hands had many of the cow-pox sores upon them, and they were communicated to her nose, which became inflamed and very much swollen. soon after this event mrs. h---was exposed to the contagion of the smallpox, where it was scarcely possible for her to have escaped, had she been susceptible of it, as she regularly attended a relative who had the disease in so violent a degree that it proved fatal to him. in the year 1778 the smallpox prevailed very much at berkeley, and mrs. h----, not feeling perfectly satisfied respecting her safety (no indisposition having followed her exposure to the smallpox), i inoculated her with active variolous matter. the same appearance followed as in the preceding cases--an efflorescence on the arm without any effect on the constitution. case vi.--it is a fact so well known among our dairy farmers that those who have had the smallpox either escape the cow-pox or are disposed to have it slightly, that as soon as the complaint shews itself among the cattle, assistants are procured, if possible, who are thus rendered less susceptible of it, otherwise the business of the farm could scarcely go forward. in the month of may, 1796, the cow-pox broke out at mr. baker's, a farmer who lives near this place. the disease was communicated by means of a cow which was purchased in an infected state at a neighbouring fair, and not one of the farmer's cows (consisting of thirty) which were at that time milked escaped the contagion. the family consisted of a man servant, two dairymaids, and a servant boy, who, with the farmer himself, were twice a day employed in milking the cattle. the whole of this family, except sarah wynne, one of the dairymaids, had gone through the smallpox. the consequence was that the farmer and the servant boy escaped the infection of the cow-pox entirely, and the servant man and one of the maid servants had each of them nothing more then a sore on one of their fingers, which produced no disorder in the system. but the other dairymaid, sarah wynne, who never had the smallpox, did not escape in so easy a manner. she caught the complaint from the cows, and was affected with the symptoms described on page 154 in so violent a degree that she was confined to her bed, and rendered incapable for several days of pursuing her ordinary vocations in the farm. march 28, 1797, i inoculated this girl and carefully rubbed the variolous matter into two slight incisions made upon the left arm. a little inflammation appeared in the usual manner around the parts where the matter was inserted, but so early as the fifth day it vanished entirely without producing any effect on the system. case vii.--although the preceding history pretty clearly evinces that the constitution is far less susceptible of the contagion of the cow-pox after it has felt that of the smallpox, and although in general, as i have observed, they who have had the smallpox, and are employed in milking cows which are infected with the cowpox, either escape the disorder, or have sores on the hands without feeling any general indisposition, yet the animal economy is subject to some variation in this respect, which the following relation will point out: in the summer of the year 1796 the cow-pox appeared at the farm of mr. andrews, a considerable dairy adjoining to the town of berkeley. it was communicated, as in the preceding instance, by an infected cow purchased at a fair in the neighbourhood. the family consisted of the farmer, his wife, two sons, a man and a maid servant; all of whom, except the farmer (who was fearful of the consequences), bore a part in milking the cows. the whole of them, exclusive of the man servant, had regularly gone through the smallpox; but in this case no one who milked the cows escaped the contagion. all of them had sores upon their hands, and some degree of general indisposition, preceded by pains and tumours in the axillas: but there was no comparison in the severity of the disease as it was felt by the servant man, who had escaped the smallpox, and by those of the family who had not, for, while he was confined to his bed, they were able, without much inconvenience, to follow their ordinary business. february the 13th, 1797, i availed myself of an opportunity of inoculating william rodway, the servant man above alluded to. variolous matter was inserted into both his arms: in the right, by means of superficial incisions, and into the left by slight punctures into the cutis. both were perceptibly inflamed on the third day. after this the inflammation about the punctures soon died away, but a small appearance of erysipelas was manifest about the edges of the incisions till the eighth day, when a little uneasiness was felt for the space of half an hour in the right axilla. the inflammation then hastily disappeared without producing the most distant mark of affection of the system. case viii.--elizabeth wynne, aged fifty-seven, lived as a servant with a neighbouring farmer thirty-eight years ago. she was then a dairymaid, and the cow-pox broke out among the cows. she caught the disease with the rest of the family, but, compared with them, had it in a very slight degree, one very small sore only breaking out on the little finger of her left hand, and scarcely any perceptible indisposition, following it. as the malady had shewn itself in so slight a manner, and as it had taken place at so distant a period of her life, i was happy with the opportunity of trying the effects of variolous matter upon her constitution, and on the 28th of march, 1797, i inoculated her by making two superficial incisions on the left arm, on which the matter was cautiously rubbed. a little efflorescence soon appeared, and a tingling sensation was felt about the parts where the matter was inserted until the third day, when both began to subside, and so early as the fifth day it was evident that no indisposition would follow. case ix.--although the cow-pox shields the constitution from the smallpox, and the smallpox proves a protection against its own future poison, yet it appears that the human body is again and again susceptible of the infectious matter of the cow-pox, as the following history will demonstrate. william smith, of pyrton in this parish, contracted this disease when he lived with a neighbouring farmer in the year 1780. one of the horses belonging to the farm had sore heels, and it fell to his lot to attend him. by these means the infection was carried to the cows, and from the cows it was communicated to smith. on one of his hands were several ulcerated sores, and he was affected with such symptoms as have been before described. in the year 1791 the cow-pox broke out at another farm where he then lived as a servant, and he became affected with it a second time; and in the year 1794 he was so unfortunate as to catch it again. the disease was equally as severe the second and third time as it was on the first. [footnote: this is not the case in general--a second attack is commonly very slight, and so, i am informed, it is among the cows.] in the spring of the year 1795 he was twice inoculated, but no affection of the system could be produced from the variolous matter; and he has since associated with those who had the smallpox in its most contagious state without feeling any effect from it. case x.--simon nichols lived as a servant with mr. bromedge, a gentleman who resides on his own farm in this parish, in the year 1782. he was employed in applying dressings to the sore heels of one of his master's horses, and at the same time assisted in milking the cows. the cows became affected in consequence, but the disease did not shew itself on their nipples till several weeks after he had begun to dress the horse. he quitted mr. bromedge's service, and went to another farm without any sores upon him; but here his hands soon began to be affected in the common way, and he was much indisposed with the usual symptoms. concealing the nature of the malady from mr. cole, his new master, and being there also employed in milking, the cowpox was communicated to the cows. some years afterward nichols was employed in a farm where the smallpox broke out, when i inoculated him with several other patients, with whom he continued during the whole time of their confinement. his arm inflamed, but neither the inflammation nor his associating with the inoculated family produced the least effect upon his constitution. case xi.--william stinchcomb was a fellow servant with nichols at mr. bromedge's farm at the time the cattle had the cow-pox, and he was, unfortunately, infected by them. his left hand was very severely affected with several corroding ulcers, and a tumour of considerable size appeared in the axilla of that side. his right hand had only one small tumour upon it, and no sore discovered itself in the corresponding axilla. in the year 1792 stinchcomb was inoculated with variolous matter, but no consequences ensued beyond a little inflammation in the arm for a few days. a large party were inoculated at the same time, some of whom had the disease in a more violent degree than is commonly seen from inoculation. he purposely associated with them, but could not receive the smallpox. during the sickening of some of his companions their symptoms so strongly recalled to his mind his own state when sickening with the cow--pox that he very pertinently remarked their striking similarity. case xii.--the paupers of the village of tortworth, in this county, were inoculated by mr. henry jenner, surgeon, of berkeley, in the year 1795. among them, eight patients presented themselves who had at different periods of their lives had the cow-pox. one of them, hester walkley, i attended with that disease when she lived in the service of a farmer in the same village in the year 1782; but neither this woman, nor any other of the patients who had gone through the cow-pox, received the variolous infection either from the arm or from mixing in the society of the other patients who were inoculated at the same time. this state of security proved a fortunate circumstance, as many of the poor women were at the same time in a state of pregnancy. case xiii.--one instance has occurred to me of the system being affected from the matter issuing from the heels of horses, and of its remaining afterwards unsusceptible of the variolous contagion; another, where the smallpox appeared obscurely; and a third, in which its complete existence was positively ascertained. first, thomas pearce is the son of a smith and farrier near to this place. he never had the cow-pox; but, in consequence of dressing horses with sore heels at his father's, when a lad, he had sores on his fingers which suppurated, and which occasioned a pretty severe indisposition. six years afterwards i inserted variolous matter into his arm repeatedly, without being able to produce any thing more than slight inflammation, which appeared very soon after the matter was applied, and afterwards i exposed him to the contagion of the smallpox with as little effect. [footnote: it is a remarkable fact, and well known to many, that we are frequently foiled in our endeavours to communicate the smallpox by inoculation to blacksmiths, who in the country are farriers. they often, as in the above instance, either resist the contagion entirely, or have the disease anomalously. shall we not be able to account for this on a rational principle?] case xiv.--secondly, mr. james cole, a farmer in this parish, had a disease from the same source as related in the preceding case, and some years after was inoculated with variolous matter. he had a little pain in the axilla and felt a slight indisposition for three or four hours. a few eruptions shewed themselves on the forehead, but they very soon disappeared without advancing to maturation. case xv.--although in the former instances the system seemed to be secured, or nearly so, from variolous infection, by the absorption of matter from the sores produced by the diseased heels of horses, yet the following case decisively proves that this cannot be entirely relied upon until a disease has been generated by the morbid matter from the horse on the nipple of the cow, and passed through that medium to the human subject. mr. abraham riddiford, a farmer at stone in this parish, in consequence of dressing a mare that had sore heels, was affected with very painful sores in both his hands, tumours in each axilla, and severe and general indisposition. a surgeon in the neighbourhood attended him, who knowing the similarity between the appearance of the sores upon his hands and those produced by the cow-pox, and being acquainted also with the effects of that disease on the human constitution, assured him that he never need to fear the infection of the smallpox; but this assertion proved fallacious, for, on being exposed to the infection upwards of twenty years afterwards, he caught the disease, which took its regular course in a very mild way. there certainly was a difference perceptible, although it is not easy to describe it, in the general appearance of the pustules from that which we commonly see. other practitioners who visited the patient at my request agreed with me in this point, though there was no room left for suspicion as to the reality of the disease, as i inoculated some of his family from the pustules, who had the smallpox, with its usual appearances, in consequence. case xvi.--sarah nelmes, a dairymaid at a farmer's near this place, was infected with the cow-pox from her master's cows in may, 1796. she received the infection on a part of her hand which had been previously in a slight degree injured by a scratch from a thorn. a large pustulous sore and the usual symptoms accompanying the disease were produced in consequence. the pustule was so expressive of the true character of the cow-pox, as it commonly appears upon the hand, that i have given a representation of it in the annexed plate. the two small pustules on the wrists arose also from the application of the virus to some minute abrasions of the cuticle, but the livid tint, if they ever had any, was not conspicuous at the time i saw the patient. the pustule on the forefinger shews the disease in an earlier stage. it did not actually appear on the hand of this young woman, but was taken from that of another, and is annexed for the purpose of representing the malady after it has newly appeared. case xvii.--the more accurately to observe the progress of the infection i selected a healthy boy, about eight years old, for the purpose of inoculation for the cow-pox. the matter was taken from a sore on the hand of a dairymaid [footnote: from the sore on the hand of sarah nelmes. see the preceding case.], who was infected by her master's cows, and it was inserted, on the 14th of may, 1796, into the arm of the boy by means of two superficial incisions, barely penetrating the cutis, each about half an inch long. on the seventh day he complained of uneasiness in the axilla, and on the ninth he became a little chilly, lost his appetite, and had a slight headache. during the whole of this day he was perceptibly indisposed, and spent the night with some degree of restlessness, but on the day following he was perfectly well. the appearance of the incisions in their progress to a state of maturation were much the same as when produced in a similar manner by variolous matter. the only difference which i perceived was in the state of the limpid fluid arising from the action of the virus, which assumed rather a darker hue, and in that of the efflorescence spreading round the incisions, which had more of an erysipelatous look than we commonly perceive when variolous matter has been made use of in the same manner; but the whole died away (leaving on the inoculated parts scabs and subsequent eschars) without giving me or my patient the least trouble. in order to ascertain whether the boy, after feeling so slight an affection of the system from the cow--pox virus, was secure from the contagion of the smallpox, he was inoculated the 1st of july following with variolous matter, immediately taken from a pustule. several slight punctures and incisions were made on both his arms, and the matter was carefully inserted, but no disease followed. the same appearances were observable on the arms as we commonly see when a patient has had variolous matter applied, after having either the cow--pox or smallpox. several months afterwards he was again inoculated with variolous matter, but no sensible effect was produced on the constitution. here my researches were interrupted till the spring of the year 1798, when, from the wetness of the early part of the season, many of the farmers' horses in this neighbourhood were affected with sore heels, in consequence of which the cow--pox broke out among several of our dairies, which afforded me an opportunity of making further observations upon this curious disease. a mare, the property of a person who keeps a dairy in a neighbouring parish, began to have sore heels the latter end of the month of february, 1798, which were occasionally washed by the servant men of the farm, thomas virgoe, william wherret, and william haynes, who in consequence became affected with sores in their hands, followed by inflamed lymphatic glands in the arms and axillae, shiverings succeeded by heat, lassitude, and general pains in the limbs. a single paroxysm terminated the disease; for within twenty--four hours they were free from general indisposition, nothing remaining but the sores on their hands. haynes and virgoe, who had gone through the smallpox from inoculation, described their feelings as very similar to those which affected them on sickening with that malady. wherret never had had the smallpox. haynes was daily employed as one of the milkers at the farm, and the disease began to shew itself among the cows about ten days after he first assisted in washing the mare's heels. their nipples became sore in the usual way, with bluish pustules; but as remedies were early applied, they did not ulcerate to any extent. case xviii.--john baker, a child of five years old, was inoculated march 16, 1798, with matter taken from a pustule on the hand of thomas virgoe, one of the servants who had been infected from the mare's heels. he became ill on the sixth day with symptoms similar to those excited by cow--pox matter. on the eighth day he was free from indisposition. there was some variation in the appearance of the pustule on the arm. although it somewhat resembled a smallpox pustule, yet its similitude was not so conspicuous as when excited by matter from the nipple of the cow, or when the matter has passed from thence through the medium of the human subject. this experiment was made to ascertain the progress and subsequent effects of the disease when thus propagated. we have seen that the virus from the horge, when it proves infectious to the human subject, is not to be relied upon as rendering the system secure from variolous infection, but that the matter produced by it upon the nipple of the cow is perfectly so. whether its passing from the horse through the human constitution, as in the present instance, will produce a similar effect, remains to be decided. this would mow have been effected, but the boy was rendered unit for inoculation from having felt the effects of a contagious fever in a workhouse soon after this experiment was made. case xix.--william summers, a child of five years and a half old, was inoculated the same day with baker, with matter taken from the nipples of one of the infected cows, at the farm alluded to. he became indisposed on the sixth day, vomited once, and felt the usual slight symptoms till the eighth day, when he appeared perfectly well. the progress of the pustule, formed by the infection of the virus, was similar to that noticed in case xvii, with this exception, its being free from the livid tint observed in that instance. case xx.-from william summers the disease was transferred to william pead, a boy of eight years old, who was inoculated march 28th. on the sixth day he complained of pain in the axilla, and on the seventh was affected with the common symptoms of a patient sickening with the smallpox from inoculation, which did not terminate till the third day after the seizure. so perfect was the similarity to the variolous fever that i was induced to examine the skin, conceiving there might have been some eruptions, but none appeared. the efflorescent blush around the part punctured in the boy's arm was so truly characteristic of that which appears on variolous inoculation that i have given a representation of it. the drawing was made when the pustule was beginning to die away and the areola retiring from the centre. case xxi.-april 5th: several children and adults were inoculated from the arm of william pead. the greater part of them sickened on the sixth day, and were well on the seventh, but in three of the number a secondary indisposition arose in consequence of an extensive erysipelatous inflammation which appeared on the inoculated arms. it seemed to arise from the state of the pustule, which spread out, accompanied with some degree of pain, to about half the diameter of a sixpence. one of these patients was an infant of half a year old. by the application of mercurial ointment to the inflamed parts (a treatment recommended under similar circumstances in the inoculated smallpox) the complaint subsided without giving much trouble. hannah excell, an healthy girl of seven years old, and one of the patients above mentioned, received the infection from the insertion of the virus under the cuticle of the arm in three distinct points. the pustules which arose in consequence so much resembled, on the twelfth day, those appearing from the infection of variolous matter, that an experienced inoculator would scarcely have discovered a shade of difference at that period. experience now tells me that almost the only variation which follows consists in the pustulous fluids remaining limpid nearly to the time of its total disappearance; and not, as in the direct smallpox, becoming purulent. case xxii.--from the arm of this girl matter was taken and inserted april 12th into the arms of john macklove, one year and a half old, robert f. jenner, eleven months old, mary pead, five years old, and mary james, six years old. [footnote: perhaps a few touches with the lapis septicus would have proved equally efficacious.] among these, robert f. jenner did not receive the infection. the arms of the other three inflamed properly and began to affect the system in the usual manner; but being under some apprehensions from the preceding cases that a troublesome erysipelas might arise, i determined on making an experiment with the view of cutting off its source. accordingly, after the patients had felt an indisposition of about twelve hours, i applied in two of these cases out of the three, on the vesicle formed by the virus, a little mild caustic, composed of equal parts of quick--lime and soap, and suffered it to remain on the part six hours. [footnote: what effect would a similar treatment produce in inoculation for the smallpox?] it seemed to give the children but little uneasiness, and effectually answered my intention in preventing the appearance of erysipelas. indeed, it seemed to do more, for in half an hour after its application the indisposition of the children ceased. these precautions were perhaps unnecessary, as the arm of the third child, mary pead, which was suffered to take its common course, scabbed quickly, without any erysipelas. case xxiii.--from this child's arm matter was taken and transferred to that of j. barge, a boy of seven years old. he sickened on the eighth day, went through the disease with the usual slight symptoms, and without any inflammation on the arm beyond the common efflorescence surrounding the pustule, an appearance so often seen in inoculated smallpox. after the many fruitless attempts to give the smallpox to those who had had the cow-pox, it did not appear necessary, nor was it convenient to me, to inoculate the whole of those who had been the subjects of these late trials; yet i thought it right to see the effects of variolous matter on some of them, particularly william summers, the first of these patients who had been infected with matter taken from the cow. he was, therefore, inoculated with variolous matter from a fresh pustule; but, as in the preceding cases, the system did not feel the effects of it in the smallest degree. i had an opportunity also of having this boy and william pead inoculated by my nephew, mr. henry jenner, whose report to me is as follows: "i have inoculated pead and barge, two of the boys whom you lately infected with the cow-pox. on the second day the incisions were inflamed and there was a pale inflammatory stain around them. on the third day these appearances were still increasing and their arms itched considerably. on the fourth day the inflammation was evidently subsiding, and on the sixth day it was scarcely perceptible. no symptom of indisposition followed. "to convince myself that the variolous matter made use of was in a perfect state i at the same time inoculated a patient with some of it who never had gone through the cow-pox, and it produced the smallpox in the usual regular manner." these experiments afforded me much satisfaction; they proved that the matter, in passing from one human subject to another, through five gradations, lost none of its original properties, j. barge being the fifth who received the infection successively from william summers, the boy to whom it was communicated from the cow. i shall now conclude this inquiry with some general observations on the subject, and on some others which are interwoven with it. although i presume it may be unnecessary to produce further testimony in support of my assertion "that the cow--pox protects the human constitution from the infection of the smallpox," yet it affords me considerable satisfaction to say that lord somerville, the president of the board of agriculture, to whom this paper was shewn by sir joseph banks, has found upon inquiry that the statements were confirmed by the concurring testimony of mr. dolland, a surgeon, who resides in a dairy country remote from this, in which these observations were made. with respect to the opinion adduced "that the source of the infection is a peculiar morbid matter arising in the horse," although i have not been able to prove it from actual experiments conducted immediately under my own eye, yet the evidence i have adduced appears sufficient to establish it. they who are not in the habit of conducting experiments may not be aware of the coincidence of circumstances necessary for their being managed so as to prove perfectly decisive; nor how often men engaged in professional pursuits are liable to interruptions which disappoint them almost at the instant of their being accomplished: however, i feel no room for hesitation respecting the common origin of the disease, being well convinced that it never appears among the cows (except it can be traced to a cow introduced among the general herd which has been previously infected, or to an infected servant) unless they have been milked by some one who, at the same time, has the care of a horse affected with diseased heels. the spring of the year 1797, which i intended particularly to have devoted to the completion of this investigation, proved, from its dryness, remarkably adverse to my wishes;-for it frequently happens, while the farmers' horses are exposed to the cold rains which fall at that season, that their heels become diseased, and no cow-pox then appeared in the neighbourhood. the active quality of the virus from the horses' heels is greatly increased after it has acted on the nipples of the cow, as it rarely happens that the horse affects his dresser with sores, and as rarely that a milkmaid escapes the infection when she milks infected cows. it is most active at the commencement of the disease, even before it has acquired a pus-like appearance; indeed, i am not confident whether this property in the matter does not entirely cease as soon as it is secreted in the form of pus. i am induced to think it does cease [footnote: it is very easy to procure pus from old sores on the heels of horses. this i have often inserted into scratches made with a lancet, on the sound nipples of cows, and have seen no other effects from it than simple inflamation.], and that it is the thin, darkishlooking fluid only, oozing from the newly-formed cracks in the heels, similar to what sometimes appears from erysipelatous blisters, which gives the disease. nor am i certain that the nipples of the cows are at all times in a state to receive the infection. the appearance of the disease in the spring and the early part of the summer, when they are disposed to be affected with spontaneous eruptions so much more frequently than at other seasons, induces me to think that the virus from the horse must be received upon them when they are in this state, in order to produce effects: experiments, however, must determine these points. but it is clear that when the cow-pox virus is once generated, that the cows cannot resist the contagion, in whatever state their nipples may chance to be, if they are milked with an infected hand. whether the matter, either from the cow or the horse, will affect the sound skin of the human body, i cannot positively determine; probably it will not, unless on those parts where the cuticle is extremely thin, as on the lips, for example. i have known an instance of a poor girl who produced an ulceration on her lip by frequently holding her finger to her mouth to cool the raging of a cow-pox sore by blowing upon it. the hands of the farmers' servants here, from the nature of their employments, are constantly exposed to those injuries which occasion abrasions of the cuticle, to punctures from thorns, and such like accidents; so that they are always in a state to feel the consequence of exposure to infectious matter. it is singular to observe that the cow--pox virus, although it renders the constitution unsusceptible of the variolous, should nevertheless, leave it unchanged with respect to its own action. i have already produced an instance [footnote: see case ix.] to point out this, and shall now corroborate it with another. elizabeth wynne, who had the cow-pox in the year 1759, was inoculated with variolous matter, without effect, in the year 1797, and again caught the cow-pox in the year 1798. when i saw her, which was on the eighth day after she received the infection, i found her affected with general lassitude, shiverings, alternating with heat, coldness of the extremities, and a quick and irregular pulse. these symptoms were preceded by a pain in the axilla. on her hand was one large pustulous sore, which resembled that delineated in plate no. i. (plate appears in original.) it is curious also to observe that the virus, which with respect to its effects is undetermined and uncertain previously to its passing from the horse through the medium of the cow, should then not only become more active, but should invariably and completely possess those specific properties which induce in the human constitution symptoms similar to those of the variolous fever, and effect in it that peculiar change which for ever renders it unsusceptible of the variolous contagion. may it not then be reasonably conjectured that the source of the smallpox is morbid matter of a peculiar kind, generated by a disease in the horse, and that accidental circumstances may have again and again arisen, still working new changes upon it until it has acquired the contagious and malignant form under which we now commonly see it making its devastations amongst us? and, from a consideration of the change which the infectious matter undergoes from producing a disease on the cow, may we not conceive that many contagious diseases, now prevalent among us, may owe their present appearance not to a simple, but to a compound, origin? for example, is it difficult to imagine that the measles, the scarlet fever, and the ulcerous sore throat with a spotted skin have all sprung from the same source, assuming some variety in their forms according to the nature of their new combinations? the same question will apply respecting the origin of many other contagious diseases which bear a strong analogy to each other. there are certainly more forms than one, without considering the common variation between the confluent and distinct, in which the smallpox appears in what is called the natural way. about seven years ago a species of smallpox spread through many of the towns and villages of this part of gloucestershire: it was of so mild a nature that a fatal instance was scarcely ever heard of, and consequently so little dreaded by the lower orders of the community that they scrupled not to hold the same intercourse with each other as if no infectious disease had been present among them. i never saw nor heard of an instance of its being confluent. the most accurate manner, perhaps, in which i can convey an idea of it is by saying that had fifty individuals been taken promiscuously and infected by exposure to this contagion, they would have had as mild and light a disease as if they had been inoculated with variolous matter in the usual way. the harmless manner in which it shewed itself could not arise from any peculiarity either in the season or the weather, for i watched its progress upwards of a year without perceiving any variation in its general appearance. i consider it then as a variety of the smallpox. [footnote: my friend, dr. hicks, of bristol, who, during the prevalence of this distemper, was resident at gloucester, and physician of the hospital there (where it was soon after its first appearance in this country), had opportunities of making numerous observations upon it, which it is his intention to communicate to the public.]. in some of the preceding cases i have noticed the attention that was paid to the state of the variolous matter previous to the experiment of inserting it into the arms of those who had gone through the cow-pox. this i conceived to be of great importance in conducting these experiments, and, were it always properly attended to by those who inoculate for the smallpox, it might prevent much subsequent mischief and confusion. with the view of enforcing so necessary a precaution i shall take the liberty of digressing so far as to point out some unpleasant facts relative to mismanagement in this particular, which have fallen under my own observation. a medical gentleman (now no more), who for many years inoculated in this neighbourhood, frequently preserved the variolous matter intended for his use on a piece of lint or cotton, which, in its fluid state, was put into a vial, corked, and conveyed into a warm pocket; a situation certainly favourable for speedily producing putrefaction in it. in this state (not unfrequently after it had been taken several days from the pustules) it was inserted into the arms of his patients, and brought on inflammation of the incised parts, swellings of the axillary glands, fever, and sometimes eruptions. but what was this disease? certainly not the smallpox; for the matter having from putrefaction lost or suffered a derangement in its specific properties, was no longer capable of producing that malady, those who had been inoculated in this manner being as much subject to the contagion of the smallpox as if they had never been under the influence of this artificial disease; and many, unfortunately, fell victims to it, who thought themselves in perfect security. the same unfortunate circumstance of giving a disease, supposed to be the smallpox, with inefficacious variolous matter, having occurred under the direction of some other practitioners within my knowledge, and probably from the same incautious method of securing the variolous matter, i avail myself of this opportunity of mentioning what i conceive to be of great importance; and, as a further cautionary hint, i shall again digress so far as to add another observation on the subject of inoculation. whether it be yet ascertained by experiment that the quantity of variolous matter inserted into the skin makes any difference with respect to the subsequent mildness or violence of the disease, i know not; but i have the strongest reason for supposing that if either the punctures or incisions be made so deep as to go through it and wound the adipose membrane, that the risk of bringing on a violent disease is greatly increased. i have known an inoculator whose practice was "to cut deep enough (to use his own expression) to see a bit of fat." and there to lodge the matter. the great number of bad cases, independent of inflammations and abscesses on the arms, and the fatality which attended this practice, was almost inconceivable; and i cannot account for it on any other principle than that of the matter being placed in this situation instead of the skin. it was the practice of another, whom i well remember, to pinch up a small portion of the skin on the arms of his patients and to pass through it a needle, with a thread attached to it previously dipped in variolous matter. the thread was lodged in the perforated part, and consequently left in contact with the cellular membrane. this practice was attended with the same ill success as the former. although it is very improbable that any one would now inoculate in this rude way by design, yet these observations may tend to place a double guard over the lancet, when infants, whose skins are comparatively so very thin, fall under the care of the inoculator. a very respectable friend of mine, dr. hardwicke, of sodbury, in this county, inoculated great numbers of patients previous to the introduction of the more modern method by sutton, and with such success that a fatal instance occurred as rarely as since that method has been adopted. it was the doctor's practice to make as slight an incision as possible upon the skin, and there to lodge a thread saturated with the variolous matter. when his patients became indisposed, agreeably to the custom then prevailing, they were directed to go to bed and were kept moderately warm. is it not probable then that the success of the modern practice may depend more upon the method of invariably depositing the virus in or upon the skin, than on the subsequent treatment of the disease? i do not mean to insinuate that exposure to cool air, and suffering the patient to drink cold water when hot and thirsty, may not moderate the eruptive symptoms and lessen the number of pustules; yet, to repeat my former observation, i cannot account for the uninterrupted success, or nearly so, of one practitioner, and the wretched state of the patients under the care of another, where, in both instances, the general treatment did not differ essentially, without conceiving it to arise from the different modes of inserting the matter for the purpose of producing the disease. as it is not the identical matter inserted which is absorbed into the constitution, but that which is, by some peculiar process in the animal economy, generated by it, is it not probable that different parts of the human body may prepare or modify the virus differently? although the skin, for example, adipose membrane, or mucous membranes are all capable of producing the variolous virus by the stimulus given by the particles originally deposited upon them, yet i am induced to conceive that each of these parts is capable of producing some variation in the qualities of the matter previous to its affecting the constitution. what else can constitute the difference between the smallpox when communicated casually or in what has been termed the natural way, or when brought on artificially through the medium of the skin? after all, are the variolous particles, possessing their true specific and contagious principles, ever taken up and conveyed by the lymphatics unchanged into the blood vessels? i imagine not. were this the case, should we not find the blood sufficiently loaded with them in some stages of the smallpox to communicate the disease by inserting it under the cuticle, or by spreading it on the surface of an ulcer? yet experiments have determined the impracticability of its being given in this way; although it has been proved that variolous matter, when much diluted with water and applied to the skin in the usual manner, will produce the disease. but it would be digressing beyond a proper boundary to go minutely into this subject here. at what period the cow-pox was first noticed here is not upon record. our oldest farmers were not unacquainted with it in their earliest days, when it appeared among their farms without any deviation from the phaenomena which it now exhibits. its connection with the smallpox seems to have been unknown to them. probably the general introduction of inoculation first occasioned the discovery. its rise in this country may not have been of very remote date, as the practice of milking cows might formerly have been in the hands of women only; which i believe is the case now in some other dairy countries, and, consequently, that the cows might not in former times have been exposed to the contagious matter brought by the men servants from the heels of horses. [footnote: i have been informed from respectable authority that in ireland, although dairies abound in many parts of the island, the disease is entirely unknown. the reason seems obvious. the business of the dairy is conducted by women only. were the meanest vassal among the men employed there as a milker at a dairy, he would feel his situation unpleasant beyond all endurance.] indeed, a knowledge of the source of the infection is new in the minds of most of the farmers in this neighbourhood, but it has at length produced good consequences; and it seems probable, from the precautions they are now disposed to adopt, that the appearance of the cow-pox here may either be entirely extinguished or become extremely rare. should it be asked whether this investigation is a matter of mere curiosity, or whether it tends to any beneficial purpose, i should answer that, notwithstanding the happy effects of inoculation, with all the improvements which the practice has received since its first introduction into this country, it not very unfrequently produces deformity of the skin, and sometimes, under the best management, proves fatal. these circumstances must naturally create in every instance some degree of painful solicitude for its consequences. but as i have never known fatal effects arise from the cow-pox, even when impressed in the most unfavourable manner, producing extensive inflammations and suppurations on the hands; and as it clearly appears that this disease leaves the constitution in a state of perfect security from the infection of the smallpox, may we not infer that a mode of inoculation may be introduced preferable to that at present adopted, especially among those families which, from previous circumstances, we may judge to be predisposed to have the disease unfavourably? it is an excess in the number of pustules which we chiefly dread in the smallpox; but in the cowpox no pustules appear, nor does it seem possible for the contagious matter to produce the disease from effluvia, or by any other means than contact, and that probably not simply between the virus and the cuticle; so that a single individual in a family might at any time receive it without the risk of infecting the rest or of spreading a distemper that fills a country with terror. several instances have come under my observation which justify the assertion that the disease cannot be propagated by effluvia. the first boy whom i inoculated with the matter of cow-pox slept in a bed, while the experiment was going forward, with two children who never had gone through either that disease or the smallpox, without infecting either of them. a young woman who had the cow-pox to a great extent, several sores which maturated having appeared on the hands and wrists, slept in the same bed with a fellow-dairymaid who never had been infected with either the cow-pox or the smallpox, but no indisposition followed. another instance has occurred of a young woman on whose hands were several large suppurations from the cow-pox, who was at the same time a daily nurse to an infant, but the complaint was not communicated to the child. in some other points of view the inoculation of this disease appears preferable to the variolous inoculation. in constitutions predisposed to scrophula, how frequently we see the inoculated smallpox rouse into activity that distressful malady! this circumstance does not seem to depend on the manner in which the distemper has shewn itself, for it has as frequently happened among those who have had it mildly as when it has appeared in the contrary way. there are many who, from some peculiarity in the habit, resist the common effects of variolous matter inserted into the skin, and who are in consequence haunted through life with the distressing idea of being insecure from subsequent infection. a ready mode of dissipating anxiety originating from such a cause must now appear obvious. and, as we have seen that the constitution may at any time be made to feel the febrile attack of cow-pox, might it not, in many chronic diseases, be introduced into the system, with the probability of affording relief, upon well-known physiological principles? although i say the system may at any time be made to feel the febrile attack of cow-pox, yet i have a single instance before me where the virus acted locally only, but it is not in the least probable that the same person would resist the action both of the cow-pox virus and the variolous. elizabeth sarfenet lived as a dairymaid at newpark farm, in this parish. all the cows and the servants employed in milking had the cow-pox; but this woman, though she had several sores upon her fingers, felt no tumours in the axillae, nor any general indisposition. on being afterwards casually exposed to variolous infection, she had the smallpox in a mild way. hannah pick, another of the dairymaids who was a fellow-servant with elizabeth sarfenet when the distemper broke out at the farm, was, at the same time, infected; but this young woman had not only sores upon her hands, but felt herself also much indisposed for a day or two. after this, i made several attempts to give her the smallpox by inoculation, but they all proved fruitless. from the former case then we see that the animal economy is subject to the same laws in one disease as the other. the following case, which has very lately occurred, renders it highly probable that not only the heels of the horse, but other parts of the body of that animal, are capable of generating the virus which produces the cow-pox. an extensive inflammation of the erysipelatous kind appeared without any apparent cause upon the upper part of the thigh of a sucking colt, the property of mr. millet, a farmer at rockhampton, a village near berkeley. the inflammation continued several weeks, and at length terminated in the formation of three or four small abscesses. the inflamed parts were fomented, and dressings were applied by some of the same persons who were employed in milking the cows. the number of cows milked was twenty-four, and the whole of them had the cow-pox. the milkers, consisting of the farmer's wife, a man and a maidservant, were infected by the cows. the man-servant had previously gone through the smallpox, and felt but little of the cow-pox. the servant maid had some years before been infected with the cow-pox, and she also felt it now in a slight degree; but the farmer's wife, who never had gone through either of the diseases, felt its effects very severely. that the disease produced upon the cows by the colt and from thence conveyed to those who milked them was the true and not the spurious cow-pox, there can be scarcely any room for suspicion; yet it would have been more completely satisfactory had the effects of variolous matter been ascertained on the farmer's wife, but there was a peculiarity in her situation which prevented my making the experiment. thus far have i proceeded in an inquiry founded, as it must appear, on the basis of experiment; in which, however, conjecture has been occasionally admitted in order to present to persons well situated for such discussions objects for a more minute investigation. in the mean time i shall myself continue to prosecute this inquiry, encouraged by the hope of its becoming essentially beneficial to mankind. ii further observations on the variola vaccinae, or cow-pox. 1799 although it has not been in my power to extend the inquiry into the causes and effects of the variolae vaccinae much beyond its original limits, yet, perceiving that it is beginning to excite a general spirit of investigation, i think it of importance, without delay, to communicate such facts as have since occurred, and to point out the fallacious sources from whence a disease imitative of the true variolae vaccinae might arise, with the view of preventing those who may inoculate from producing a spurious disease; and, further, to enforce the precaution suggested in the former treatise on the subject, of subduing the inoculated pustule as soon as it has sufficiently produced its influence on the constitution. from a want of due discrimination of the real existence of the disease, either in the brute or in the human subject, and also of that stage of it in which it is capable of producing the change in the animal economy which renders it unsusceptible of the contagion of the smallpox, unpleasant consequences might ensue, the source of which, perhaps, might not be suspected by one inexperienced in conducting such experiments. my late publication contains a relation of most of the facts which had come under my own inspection at the time it was written, interspersed with some conjectural observations. since then dr. g. pearson has established an inquiry into the validity of my principal assertion, the result of which cannot but be highly flattering to my feelings. it contains not a single case which i think can be called an exception to the fact i was so firmly impressed with--that the cow-pox protects the human body from the smallpox. i have myself received some further confirmations, which shall be subjoined. i have lately also been favoured with a letter from a gentleman of great respectability (dr. ingenhousz), informing me that, on making an inquiry into the subject in the county of wilts, he discovered that a farmer near calne had been infected with the smallpox after having had the cow-pox, and that the disease in each instance was so strongly characterized as to render the facts incontrovertible. the cow-pox, it seems, from the doctor's information, was communicated to the farmer from his cows at the time that they gave out an offensive stench from their udders. some other instances have likewise been represented to me of the appearance of the disease, apparently marked with its characteristic symptoms, and yet that the patients have afterwards had the smallpox. on these cases i shall, for the present, suspend any particular remarks, but hope that the general observations i have to offer in the sequel will prove of sufficient weight to render the idea of their ever having had existence, but as cases of spurious cow-pox, extremely doubtful. ere i proceed let me be permitted to observe that truth, in this and every other physiological inquiry that has occupied my attention, has ever been the object of my pursuit, and should it appear in the present instance that i have been led into error, fond as i may appear of the offspring of my labours, i had rather see it perish at once than exist and do a public injury. i shall proceed to enumerate the sources, or what appear to me as such, of a spurious cow-pox. first: that arising from pustules on the nipples or udder of the cow; which pustules contain no specific virus. secondly: from matter (although originally possessing the specific virus) which has suffered a decomposition, either from putrefaction or from any other cause less obvious to the senses. thirdly: from matter taken from an ulcer in an advanced stage, which ulcer arose from a true cow pock. fourthly: from matter produced on the human skin from contact with some peculiar morbid matter generated by a horse. on these subjects i shall offer some comments: first, to what length pustulous diseases of the udder and nipples of the cow may extend it is not in my power to determine; but certain it is that these parts of the animal are subject to some variety of maladies of this nature; and as many of these eruptions (probably all of them) are capable of giving a disease to the human body, would it not be discreet for those engaged in this investigation to suspend controversy and cavil until they can ascertain with precision what is and what is not the cow-pox? for example: a farmer who is not conversant with any of these maladies, but who may have heard of the cow-pox in general terms, may acquaint a neighbouring surgeon that the distemper appears at his farm. the surgeon, eager to make an experiment, takes away matter, inoculates, produces a sore, uneasiness in the axilla, and perhaps some affection of the system. this is one way in which a fallacious idea of security both in the mind of the inoculater and the patient may arise; for a disease may thus have been propagated from a simple eruption only. one of the first objects then of this pursuit, as i have observed, should be, to learn how to distinguish with accuracy between that peculiar pustule which is the true cow pock, and that which is spurious. until experience has determined this, we view our object through a mist. let us, for instance, suppose that the smallpox and the chicken-pox were at the same time to spread among the inhabitants of a country which had never been visited by either of these distempers, and where they were quite unknown before: what confusion would arise! the resemblance between the symptoms of the eruptive fever and between the pustules in either case would be so striking that a patient who had gone through the chicken-pox to any extent would feel equally easy with regard to his future security from the smallpox as the person who had actually passed through that disease. time and future observation would draw the line of distinction. so i presume it will be with the cow-pox until it is more generally understood. all cavilling, therefore, on the mere report of those who tell us they have had this distemper, and are afterwards found susceptible of the smallpox, should be suspended. to illustrate this i beg leave to give the following history: sarah merlin, of the parish of eastington in this county, when about thirteen or fourteen years of age lived as a servant with farmer clarke, who kept a dairy consisting of about eighteen cows at stonehouse, a neighbouring village. the nipples and udders of three of the cows were extensively affected with large white blisters. these cows the girl milked daily, and at the time she assisted, with two others, in milking the rest of the herd. it soon appeared that the disease was communicated to the girl. the rest of the cows escaped the infection, although they were milked several days after the three above specified, had these eruptions on the nipples and udders, and even after the girl's hand became sore. the two others who were engaged in milking, although they milked the cows indiscriminately, received no injury. on the fingers of each of the girl's hands there appeared several large white blisters--she supposes about three or four on each finger. the hands and arms inflamed and swelled, but no constitutional indisposition followed. the sores were anointed with some domestic ointment and got well without ulcerating. as this malady was called the cow-pox, and recorded as such in the mind of the patient, she became regardless of the smallpox; but, on being exposed to it some years afterwards she was infected, and had a full burthen. now had any one conversant with the habits of the disease heard this history, they would have had no hesitation in pronouncing it a case of spurious cow-pox; considering its deviation in the numerous blisters which appeared on the girl's hands; their termination without ulceration; its not proving more generally contagious at the farm, either among the cattle or those employed in milking; and considering also that the patient felt no general indisposition, although there was so great a number of vesicles. this is perhaps the most deceptious form in which an eruptive disease can be communicated from the cow, and it certainly requires some attention in discriminating it. the most perfect criterion by which the judgment may be guided is perhaps that adopted by those who attend infected cattle. these white blisters on the nipples, they say, never eat into the fleshy parts like those which are commonly of a bluish cast, and which constitute the true cow-pox, but that they affect the skin only, quickly end in scabs, and are not nearly so infectious. that which appeared to me as one cause of spurious eruptions, i have already remarked in the former treatise, namely, the transition that the cow makes in the spring from a poor to a nutritious diet, and from the udder's becoming at this time more vascular than usual for the supply of milk. but there is another source of inflammation and pustules which i believe is not uncommon in all the dairy counties in the west of england. a cow intended to be exposed for sale, having naturally a small udder, is previously for a day or two neither milked artificially nor is her calf suffered to have access to her. thus the milk is preternaturally accumulated, and the udder and nipples become greatly distended. the consequences frequently are inflammation and eruptions which maturate. whether a disease generated in this way has the power of affecting the constitution in any peculiar manner i cannot presume positively to determine. it has been conjectured to have been a cause of the true cow-pox, though my inquiries have not led me to adopt this supposition in any one instance; on the contrary, i have known the milkers affected by it, but always found that an affection thus induced left the system as susceptible of the smallpox as before. what is advanced in my second position i consider also of very great importance, and i could wish it to be strongly impressed on the minds of all who may be disposed to conclude hastily on my observations, whether engaged in their investigation by experiments or not to place this in its clearest point of view (as the similarity between the action of the smallpox and the cow-pox matter is so obvious) it will be necessary to consider what we sometimes observe to take place in inoculation for the smallpox when imperfect variolous matter is made use of. the concise history on this subject that was brought forward respecting what i had observed in this neighbourhood [footnote: inquiry into the causes and effects of the variolae vaccinae, p.56 of the original article]. i perceive, by a reference since made to the memoirs of the medical society of london, may be considered as no more than a corroboration of the facts very clearly detailed by mr. kite [footnote: see an account of some anomalous appearances consequent to the inoculation of the smallpox, by charles kite, surgeon, of gravesend, in the memoirs of the medical society of london, vol. iv, p. 114.]. to this copious evidence i have to add still more in the following communications from mr. earle, surgeon, of frampton-upon-severn, in this county, which i deem the more valuable, as he has with much candour permitted me to make them public: "sir: "i have read with satisfaction your late publication on the variolae vaccinae, and being, among many other curious circumstances, particularly struck with that relating to the inefficacy of smallpox matter in a particular state, i think it proper to lay before you the following facts which came within my own knowledge, and which certainly tend to strengthen the opinions advanced in pages 56 and 57 of your treatise. "in march, 1784, a general inoculation took place at arlingham in this county. i inoculated several patients with active variolous matter, all of whom had the disease in a favourable way; but the matter being all used, and not being able to procure any more in the state i wished, i was under the necessity of taking it from a pustule which, experience has since proved, was advanced too far to answer the purpose i intended. of five persons inoculated with this last matter, four took the smallpox afterwards in the natural way, one of whom died, three recovered, and the other, being cautioned by me to avoid as much as possible the chance of catching it, escaped from the disease through life. he died of another disorder about two years ago. "although one of these cases ended unfortunate, yet i cannot suppose that any medical man will think me careless or inattentive in their management; for i conceive the appearances were such as might have induced any one to suppose that the persons were perfectly safe from future infection. inflammation in every case took place in the arm, and fever came on with a considerable degree of pain in the axilla. in some of their arms the inflammation and suppuration were more violent than is commonly observed when perfect matter is made use of; in one there was an ulcer which cast off several large sloughs. about the ninth day eruptions appeared, which died away earlier than common without maturation. from these circumstances i should suppose that no medical practitioner would scarcely have entertained a doubt but that these patients had been infected with a true smallpox; yet i must confess that some small degree of doubt presented itself to me at the speedy disappearance of the eruptions; and in order, as far as i could, to ascertain their safety, i sent one of them to a much older practitioner than myself. this gentleman, on hearing the circumstances of the case, pronounced the patient perfectly secure from future infection. "the following facts are also a striking proof of the truth of your observations on this subject: "in the year 1789 i inoculated three children of mr. coaley, of hurst farm in this county. the arms inflamed properly, fever and pain in the axillae came on precisely the same as in the former cases, and in ten days eruptions appeared, which disappeared in the course of two days. i must observe that the matter here made use of was procured for me by a friend; but no doubt it was in an improper state; for, from the similarity of these cases to those which happened at arlingham five years before, i was somewhat alarmed for their safety, and desired to inoculate them again: which being permitted, i was particularly careful to procure matter in its most perfect state. all the children took the smallpox from this second inoculation, and all had a very full burthen. these facts i conceive strikingly corroborate your opinion relative to the different states of matter; for in both instances that i have mentioned it was capable of producing something strongly resembling the true smallpox, although it afterwards proved not to be so. "as i think the communication of these cases is a duty i owe to the public, you are at liberty to make what use you please of this letter. i remain, &c., "john earle. "frampton-upon severn, gloucestershire, november 10, 1798. "p. s. i think it necessary to observe that i can pronounce, with the greatest certainty, that the matter with which the arlingham patients were inoculated was taken from a true smallpox pustule. i took it myself from a subject that had a very full burthen." certain then it is that variolous matter may undergo such a change from the putrefactive process, as well as from some of the more obscure and latent processes of nature, as will render it incapable of giving the smallpox in such a manner as to secure the human constitution from future infection, although we see at the same time it is capable of exciting a disease which bears so strong a resemblance to it as to produce inflammation and matter in the incised skin (frequently, indeed, more violent than when it produces its effects perfectly), swelling of the axillary glands, general indisposition, and eruptions. so strongly persuaded was the gentleman, whose practice i have mentioned in page 56 of the late treatise, that he could produce a mild smallpox by his mode of managing the matter, that he spoke of it as a useful discovery until convinced of his error by the fatal consequence which ensued. after this ought we to be in the smallest degree surprised to find, among a great number of individuals who, by living in dairies, have been casually exposed to the cow-pox virus when in a state analogous to that of the smallpox above described, some who may have had the disease so imperfectly as not to render them secure from variolous attacks? for the matter, when burst from the pustules on the nipples of the cow, by being exposed, from its lodgment there, to the heat of an inflamed surface, and from being at the same time in a situation to be occasionally moistened with milk, is often likely to be in a state conducive to putrefaction; and thus, under some modification of decomposition, it must, of course, sometimes find access to the hand of the milker in such a way as to infect him. what confusion should we have were there no other mode of inoculating the smallpox than such as would happen from handling the diseased skin of a person labouring under that distemper in some of its advanced and loathsome stages! it must be observed that every case of cow-pox in the human species, whether communicated by design or otherwise, is to be considered as a case of inoculation. and here i may be allowed to make an observation on the case of the farmer communicated to me by dr. ingenhousz. that he was exposed to the matter when it had undergone the putrefactive change is highly probable from the doctor's observing that the sick cows at the farm gave out an offensive stench from their udders. however, i must remark that it is unusual for cattle to suffer to such an extent, when disordered with the cowpox, as to make a bystander sensible of any ill smell. i have often stood among a herd which had the distemper without being conscious of its presence from any particular effluvia. indeed, in this neighbourhood it commonly receives an early check from escharotic applications of the cow leech. it has been conceived to be contagious without contact; but this idea cannot be well founded because the cattle in one meadow do not infect those in another (although there may be no other partition than a hedge) unless they be handled or milked by those who bring the infectious matter with them; and of course, the smallest particle imaginable, when applied to a part susceptible of its influence, may produce the effect. among the human species it appears to be very clear that the disease is produced by contact only. all my attempts, at least, to communicate it by effluvia have hitherto proved ineffectual. as well as the perfect change from that state in which variolous matter is capable of producing full and decisive effects on the constitution, to that wherein its specific properties are entirely lost, it may reasonably be supposed that it is capable of undergoing a variety of intermediate changes. the following singular occurrences in ten cases of inoculation, obligingly communicated to me by mr. trye, senior surgeon to the infirmary at glocester, seem to indicate that the variolous matter, previously to its being taken from the patient for the intended purpose, was beginning to part with some of its original properties, or, in other words, that it had suffered a partial decomposition. mr. trye says: "i inoculated ten children with matter taken at one time and from the same subject. i observed no peculiarity in any of them previously to their inoculation, nor did any thing remarkable appear in their arms till after the decline of the disease. two infants of three months old had erysipelas about the incisions, in one of them extending from the shoulders to the fingers' ends. another infant had abscesses in the cellular substance in the neighbourhood of the incisions, and five or six of the rest had axillary abscesses. the matter was taken from the distinct smallpox late in its progress, and when some pustules had been dried. it was received upon glass and slowly dried by the fire. all the children had pustules which maturated, so that i suppose them all secure from future infection; at least, as secure as any others whom i have ever inoculated. my practice never afforded a sore arm before." in regard to my former observation on the improper and dangerous mode of preserving variolous matter, i shall here remark that it seems not to have been clearly understood. finding that it has been confounded with the more eligible modes of preservation, i will explain myself further. when the matter is taken from a fit pustule and properly prepared for preservation, it may certainly be kept without losing its specific properties a great length of time; for instance, when it is previously dried in the open air on some compact body, as a quill or a piece of glass, and afterwards secured in a small vial. [footnote: thus prepared, the cow-pox virus was found perfectly active, and possessing all its specific properties, at the end of three months.] but when kept several days in a state of moisture, and during that time exposed to a warm temperature, i do not think it can be relied upon as capable of giving a perfect disease, although, as i have before observed, the progress of the symptoms arising from the action of the imperfect matter bear so strong a resemblance to the smallpox when excited completely. thirdly. that the first formed virus, or what constitutes the true cow-pox pustule, invariably possesses the power i have ascribed to it, namely, that of affecting the constitution with a specific disease, is a truth that no subsequent occurrence has yet led me to doubt. but as i am now endeavouring to guard the public as much as possible against erroneous conclusions, i shall observe that when this pustule has degenerated into an ulcer (to which state it is often disposed to pass unless timely checked), i suspect that matter possessing very different properties may sooner or later be produced; and although it may have passed that stage wherein the specific properties of the matter secreted are no longer present in it, yet when applied to a sore (as in the casual way) it might dispose that sore to ulcerate, and from its irritation the system would probably become affected; and thus, by assuming some of its strongest characters, it would imitate the genuine cow-pox. from the preceding observations on the matter of smallpox when decomposed it must, i conceive, be admitted that cow-pox matter in the state now described may produce a disease, the effects of which may be felt both locally and generally, yet that the disease thus induced may not be effectual in obviating the future effects of variolous contagion. in the case of mary miller, related by mr. kite in the volume above alluded to, it appears that the inflammation and suppuration of the inoculated arm were more than usually severe, although the system underwent no specific change from the action of the virus; which appears from the patient's sickening seven weeks afterwards with the natural smallpox, which went through its course. some of the cases communicated by mr. earle tend further to confirm this fact, as the matter there manifestly produced ulceration on the inoculated part to a considerable extent. fourthly. whether the cow-pox is a spontaneous disease in the cow, or is to be attributed to matter conveyed to the animal, as i have conceived, from the horse, is a question which, though i shall not attempt now fully to discuss, yet i shall digress so far as to adduce some further observations, and to give my reasons more at large for taking up an opinion that to some had appeared fanciful. the aggregate of these observations, though not amounting to positive proof, forms presumptive evidence of so forcible a kind that i imagine it might, on any other person, have made the same impression it did on me, without fixing the imputation of credulity. first: i conceived this was the source, from observing that where the cow-pox had appeared among the dairies here (unless it could be traced to the introduction of an infected cow or servant) it had been preceded at the farm by a horse diseased in the manner already described, which horse had been attended by some of the milkers. secondly: from its being a popular opinion throughout this great dairy country, and from its being insisted on by those who here attend sick cattle. thirdly: from the total absence of the disease in ireland and scotland, where the men-servants are not employed in the dairies. [footnote: this information was communicated to me from the first authority.] fourthly: from having observed that morbid matter generated by the horse frequently communicates, in a casual way, a disease to the human subject so like the cow-pox that, in many cases, it would be difficult to make the distinction between one and the other. [footnote: the sound skin does not appear to be susceptible of this virus when inserted into it, but, when previously diseased from little accidents, its effects are often conspicuous.] fifthly: from being induced to suppose, from experiments, that some of those who had been thus affected from the horse resisted the smallpox. sixthly: from the progress and general appearance of the pustule on the arm of the boy whom i inoculated with matter taken from the hand of a man infected by a horse; and from the similarity to the cow-pox of general constitutional symptoms which followed. [footnote: this case (on which i laid no inconsiderable stress in my late treatise, as presumptive evidence of the fact adduced) seems to have been either mistaken or overlooked by those who have commented upon it. (see case xviii, p. 36.) the boy, unfortunately, died of a fever at a parish workhouse before i had an opportunity of observing what effects would have been produced by the matter of smallpox.] i fear it would be trespassing too far to adduce the general testimony of our farmers in support of this opinion; yet i beg leave to introduce an extract of a letter on this subject from the rev. mr. moore, of chalford hill, in this county: "in the month of november, 1797, my horse had diseased heels, which was certainly what is termed the grease; and at a short subsequent period my cow was also affected with what a neighbouring farmer (who was conversant with the complaints of cattle) pronounced to be the cow-pox, which he at the same time observed my servant would be infected with: and this proved to be the case; for he had eruptions on his hands, face, and many, parts of the body, the pustules appearing large, and not much like the smallpox, for which he had been inoculated a year and a half before, and had then a very heavy burthen. the pustules on the face might arise from contact with his hands, as he had a habit of rubbing his forehead, where the sores were the largest and the thickest. "the boy associated with the farmer's sons during the continuance of the disease, neither of whom had had the smallpox, but they felt no ill effects whatever. he was not much indisposed, as the disease did not prevent him from following his occupations as usual. no other person attended the horse or milked the cow but the lad above mentioned. i am firmly of opinion that the disease in the heels of the horse, which was a virulent grease, was the origin of the servant's and the cow's malady." but to return to the more immediate object of this proposition. from the similarity of symptoms, both constitutional and local, between the cow-pox and the disease received from morbid matter generated by a horse, the common people in this neighbourhood, when infected with this disease, through a strange perversion of terms, frequently call it the cow-pox. let us suppose, then, such a malady to appear among some of the servants at a farm, and at the same time that the cow-pox were to break out among the cattle; and let us suppose, too, that some of the servants were infected in this way, and that others received the infection from the cows. it would be recorded at the farm, and among the servants themselves wherever they might afterwards be dispersed, that they had all had the cow-pox. but it is clear that an individual thus infected from the horse would neither be for a certainty secure himself, nor would he impart security to others were they inoculated by virus thus generated. he still would be in danger of taking the smallpox. yet were this to happen before the nature of the cowpox be more maturely considered by the public my evidence on the subject might be depreciated unjustly. for an exemplification of what is here advanced relative to the nature of the infection when received directly from the horse see inquiry into the causes and effects of the variolae vaccinae, pp. 27, 28, 29, 30, and p. 35; and by way of further example, i beg leave to subjoin the following intelligence received from mr. fewster, surgeon, of thornbury, in this county, a gentleman perfectly well acquainted with the appearances of the cow-pox on the human subject: "william morris, aged thirty-two, servant to mr. cox of almondsbury, in this county, applied to me the 2d of april, 1798. he told me that, four days before, be found a stiffness and swelling in both his hands, which were so painful it was with difficulty he continued his work; that he had been seized with pain in his head, small of the back, and limbs, and with frequent chilly fits succeeded by fever. on examination i found him still affected with these symptoms, and that there was a great prostration of strength. many parts of his hands on the inside were chapped, and on the middle joint of the thumb of the right hand there was a small phagedenic ulcer, about the size of a large pea, discharging an ichorous fluid. on the middle finger of the same hand there was another ulcer of a similar kind. these sores were of a circular form, and he described their first appearance as being somewhat like blisters arising from a burn. he complained of excessive pain, which extended up his arm into the axilla. these symptoms and appearances of the sores were so exactly like the cow-pox that i pronounced he had taken the distemper from milking cows. he assured me he had not milked a cow for more than half a year, and that his master's cows had nothing the matter with them. i then asked him if his master had a greasy horse, which he answered in the affirmative, and further said that he had constantly dressed him twice a day for the [footnote: hc--vol.88] last three weeks or more, and remarked that the smell of his hands was much like that of the horses's heels. on the 5th of april i again saw him, and found him still complaining of pain in both hands, nor were his febrile symptoms at all relieved. the ulcers had now spread to the size of a seven-shilling gold coin, and another ulcer, which i had not noticed before, appeared on the first joint of the forefinger of the left hand, equally painful with that on the right. i ordered him to bathe his hands in warm bran and water, applied escharotics to the ulcers, and wrapped his hands up in a soft cataplasm. the next day he was much relieved, and in something more than a fortnight got well. he lost his nails from the thumb and fingers that were ulcerated." the sudden disappearance of the symptoms in this case after the application of the escharotics to the sores is worthy of observation; it seems to show that they were kept up by the irritation of the ulcers. the general symptoms which i have already described of the cowpox, when communicated in a casual way to any great extent, will, i am convinced, from the many cases i have seen, be found accurate; but from the very slight indisposition which ensues in cases of inoculation, where the pustule, after affecting the constitution, quickly runs into a scab spontaneously, or is artificially suppressed by some proper application, i am induced to believe that the violence of the symptoms may be ascribed to the inflammation and irritation of the ulcers (when ulceration takes place to any extent, as in the casual cow-pox), and that the constitutional symptoms which appear during the presence of the sore, while it assumes the character of a pustule only, are felt but in a very trifling degree. this mild affection of the system happens when the disease makes but a slight local impression on those who have been accidentally infected by cows; and, as far as i have seen, it has uniformly happened among those who have been inoculated, when a pustule only and no great degree of inflammation or any ulceration has taken place from the inoculation. the following cases will strengthen this opinion. the cow-pox appeared at a farm in the village of stonehouse, in this county, about michaelmas last, and continued gradually to pass from one cow to another till the end of november, on the twenty-sixth of that month some ichorous matter was taken from a cow and dried upon a quill. on the 2d of december some of it was inserted into a scratch, made so superficial that no blood appeared, on the arms of susan phipps, a child seven years old. the common inflammatory appearances took place in consequence, and advanced till the fifth day, when they had so much subsided that i did not conceive any thing further would ensue. 6th: appearances stationary. 7th: the inflammation began to advance. 8th: a vesication, perceptible on the edges, forming, as in the inoculated smallpox, an appearance not unlike a grain of wheat, with the cleft, or indentation in the centre. 9th: pain in the axilla. 10th: a little headache; pulse, 110; tongue not discoloured; countenance in health. 11th, 12th: no perceptible illness; pulse about 100. 13th: the pustule was now surrounded by an efflorescence, interspersed with very minute confluent pustules to the extent of about an inch. some of these pustules advanced in size and maturated. so exact was the resemblance of the arm at this stage to the general appearance of the inoculated smallpox that mr. d., a neighbouring surgeon, who took some matter from it, and who had never seen the cow-pox before, declared he could not perceive any difference. [footnote: that the cow-pox was a supposed guardian of the constitution from the action of the smallpox has been a prevalent idea for a long time past; but the similarity in the constitutional effects between one disease and the other could never have been so accurately observed had not the inoculation of the cow-pox placed it in a new and stronger point of view. this practice, too, has shewn us, what before lay concealed, the rise and progress of the pustule formed by the insertion of the virus, which places in a most conspicuous light its striking resemblance to the pustule formed from the inoculated smallpox.] the child's arm now shewed a disposition to scab, and remained nearly stationary for two or three days, when it began to run into an ulcerous state, and then commenced a febrile indisposition accompanied with an increase of axillary tumour. the ulcer continued spreading near a week, during which time the child continued ill, when it increased to a size nearly as large as a shilling. it began now to discharge pus; granulations sprang up, and it healed. this child had before been of a remarkably sickly constitution, but is now in very high health. mary hearn, twelve years of age, was inoculated with matter taken from the arm of susan phipps. 6th day: a pustule beginning to appear, slight pain in the axilla. 7th: a distinct vesicle formed. 8th: the vesicle increasing; edges very red; no deviation in its appearance at this time from the inoculated smallpox. 9th: no indisposition; pustule advancing. 10th: the patient felt this evening a slight febrile attack. 11th: free from indisposition. 12th, 13th: the same. 14th: an efflorescence of a faint red colour extending several inches round the arm. the pustule, beginning to shew a disposition to spread, was dressed with an ointment composed of hydrarg. nit. rub. and ung. cerce. the efflorescence itself was covered with a plaster of ung. hydr. fort. in six hours it was examined, when it was found that the efflorescence had totally disappeared. the application of the ointment with the hydr. nit. rub. was made use of for three days, when, the state of the pustule remaining stationary, it was exchanged for the ung. hydr. nit. this appeared to have a more active effect than the former, and in two or three days the virus seemed to be subdued, when a simple dressing was made use of; but the sore again shewing a disposition to inflame, the ung. hydr. nit. was again applied, and soon answered the intended purpose effectually. the girl, after the tenth day, when, as has been observed, she became a little ill, shewed not the least symptom of indisposition. she was afterwards exposed to the action of variolous; matter, and completely resisted it. susan phipps also went through a similar trial. conceiving these cases to be important, i have given them in detail: first, to urge the precaution of using such means as may stop the progress of the pustule; and, secondly, to point out (what appears to be the fact) that the most material indisposition, or at least that which is felt most sensibly, does not arise primarily from the first action of the virus on the constitution, but that it often comes on, if the pustule is left to chance, as a secondary disease. this leads me to conjecture, what experiment must finally determine, that they who have had the smallpox are not afterwards susceptible of the primary action of the cow-pox virus; for seeing that the simple virus itself, when it has not passed beyond the boundary of a vesicle, excites in the system so little commotion, is it not probable the trifling illness, thus induced may be lost in that which so quickly, and oftentimes so severely, follows in the casual cowpox from the presence of corroding ulcers? this consideration induces me to suppose that i may have been mistaken in my former observation on this subject. in this respect, as well as many others, a parallel may be drawn between this disease and the smallpox. in the latter, the patient first feels the effect of what is called the absorption of the virus. the symptoms then often nearly retire, when a fresh attack commences, different from the first, and the illness keeps pace with the progress of the pustules through their different stages of maturation, ulceration, etc. although the application i have mentioned in the case of mary hearn proved sufficient to check the progress of ulceration and prevent any secondary symptoms, yet, after the pustule has duly exerted its influence, i should prefer the destroying it quickly and effectually to any other mode. the term caustic to a tender ear (and i conceive none feel more interested in this inquiry than the anxious guardians of a nursery) may sound harsh and unpleasing, but every solicitude that may arise on this account will no longer exist when it is understood that the pustule, in a state fit to be acted upon, is then quite superficial, and that it does not occupy the space of a silver penny. [footnote: i mention escharotics for stopping the progress of the pustule because i am acquainted with their efficacy; probably more simple means might answer the purpose quite as well, such as might be found among the mineral and vegetable astringents.] as a proof of the efficacy of this practice, even before the virus has fully exerted itself on the system, i shall lay before my reader the following history: by a reference to the treatise on the variolae vaccinae it will be seen that, in the month of april, 1798, four children were inoculated with the matter of cow-pox, and that in two of these cases the virus on the arm was destroyed soon after it had produced a perceptible sickening. mary james, aged seven years, one of the children alluded to, was inoculated in the month of december following with fresh variolous matter, and at the same time was exposed to the effluvia of a patient affected with the smallpox. the appearance and progress of the infected arm was, in every respect similar to that which we generally observe when variolous matter has been inserted into the skin of a person who has not previously undergone either the cow-pox or the smallpox. on the eighth day, conceiving there was infection in it, she was removed from her residence among those who had not had the smallpox. i was now anxiously waiting the result, conceiving, from the state of the girl's arm, she would fall sick about this time. on visiting her on the evening of the following day (the ninth) all i could learn from the woman who attended her was that she felt somewhat hotter than usual during the night, but was not restless; and that in the morning there was the faint appearance of a rash about her wrists. this went off in a few hours, and was not at all perceptible to me on my visit in the evening. not a single eruption appeared, the skin having been repeatedly and carefully examined. the inoculated arm continued to make the usual progress to the end, through all the stages of inflammation, maturation, and scabbing. on the eighth day matter was taken from the arm of this girl (mary james) and inserted into the arms of her mother and brother (neither of whom had had either the smallpox or the cow-pox), the former about fifty years of age, the latter six. on the eighth day after the insertion the boy felt indisposed, and continued unwell two days, when a measles-like rash appeared on his hands and wrists, and was thinly scattered over his arms. the day following his body was marbled over with an appearance somewhat similar, but he did not complain, nor did he appear indisposed. a few pustules now appeared, the greater part of which went away without maturating. on the ninth day the mother began to complain. she was a little chilly and had a headache for two days, but no pustule appeared on the skin, nor had she any appearance of a rash. the family was attended by an elderly woman as a nurse, who in her infancy had been exposed to the contagion of the smallpox, but had resisted it. this woman was now infected, but had the disease in the slightest manner, a very few eruptions appearing, two or three of which only maturated. from a solitary instance like that adduced of mary james, whose constitution appears to have resisted the action of the variolous virus, after the influence of the cow-pox virus had been so soon arrested in its progress, no positive conclusion can be fairly drawn; nor from the history of the three other patients who were subsequently infected, but, nevertheless, the facts collectively may be deemed interesting. that one mild variety of the smallpox has appeared i have already plainly shewn; [footnote: see inquiry into the causes and effects of the variolae vaccinae, p. 54 (of original article)], and by the means now mentioned we probably have it in our power to produce at will another. at the time when the pustule was destroyed in the arm of mary james i was informed she had been indisposed about twelve hours; but i am now assured by those who were with her that the space of time was much less. be that as it may, in cases of cow-pox inoculation i would not recommend any application to subdue the action of the pustule until convincing proofs had appeared of the patient's having felt its effects at least twelve hours. no harm, indeed, could ensue were a longer period to elapse before the application was made use of. in short, it should be suffered to have as full an effect as it could, consistently with the state of the arm. as the cases of inoculation multiply, i am more and more convinced of the extreme mildness of the symptoms arising merely from the primary action of the virus on the constitution, and that those symptoms which, as in the accidental cow-pox, affect the patient with severity, are entirely secondary, excited by the irritating processes of inflammation and ulceration; and it appears to me that this singular virus possesses an irritating quality of a peculiar kind, but as a single cow-pox pustule is all that is necessary to render the variolous virus ineffectual, and as we possess the means of allaying the irritation, should any arise, it becomes of little or no consequence. it appears then, as far as an inference can be drawn from the present progress of cow-pox inoculation, that it is an accidental circumstance only which can render this a violent disease, and a circumstance of that nature which, fortunately, it is in the power of almost every one to avoid. i allude to the communication of the disease from cows. in this case, should the hands of the milker be affected with little accidental sores to any extent, every sore would become the nidus of infection and feel the influence of the virus; and the degree of violence in the constitutional symptoms would be in proportion to the number and to the state of these local affections. hence it follows that a person, either by accident or design, might be so filled with these wounds from contact with the virus that the constitution might sink under the pressure. seeing that we possess the means of rendering the action of the sores mild, which, when left to chance, are capable of producing violent effects; and seeing, too, that these sores bear a resemblance to the smallpox, especially the confluent, should it not encourage the hope that some topical application might be used with advantage to counteract the fatal tendency of that disease, when it appears in this terrific form? at what stage or stages of the disease this may be done with the most promising expectation of success i will not pretend now to determine. i only throw out this idea as the basis of further reasoning and experiment. i have often been foiled in my endeavours to communicate the cowpox by inoculation. an inflammation will sometimes succeed the scratch or puncture, and in a few days disappear without producing any further effect. sometimes it will even produce an ichorous fluid, and yet the system will not be affected. the same thing we know happens with the smallpox virus. four or five servants were inoculated at a farm contiguous to this place, last summer, with matter just taken from an infected cow. a little inflammation appeared on all their arms, but died away without producing a pustule; yet all these servants caught the disease within a month afterwards from milking the infected cows, and some of them had it severely. at present no other mode than that commonly practiced for inoculating the smallpox has been used for giving the cow-pox; but it is probable this might be varied with advantage. we should imitate the casual communication more clearly were we first, by making the smallest superficial incision or puncture on the skin, to produce a little scab, and then, removing it, to touch the abraded part with the virus. a small portion of a thread imbrued in the virus (as in the old method of inoculating the smallpox) and laid upon the slightly incised skin might probably prove a successful way of giving the disease; or the cutis might be exposed in a minute point by an atom of blistering plaster, and the virus brought in contact with it. in the cases just alluded to, where i did not succeed in giving the disease constitutionally, the experiment was made with matter taken in a purulent state from a pustule on the nipple of a cow. is pure pus, though contained in a smallpox pustule, ever capable of producing the smallpox perfectly? i suspect it is not. let us consider that it is always preceded by the limpid fluid, which, in constitutions susceptible of variolous contagion, is always infectious; and though, on opening a pustule, its contents may appear perfectly purulent, yet a given quantity of the limpid fluid may, at the same time, be blended with it, though it would be imperceptible to the only test of our senses, the eye. the presence, then, of this fluid, or its mechanical diffusion through pus, may at all times render active what is apparently mere pus, while its total absence (as in stale pustules) may be attended with the imperfect effects we have seen. it would be digressing too widely to go far into the doctrine of secretion, but as it will not be quite extraneous, i shall just observe that i consider both the pus and the limpid fluid of the pustule as secretions, but that the organs established by nature to perform the office of secreting these fluids may differ essentially in their mechanical structure. what but a difference in the organization of glandular bodies constitutes the difference in the qualities of the fluids secreted? from some peculiar derangement in the structure or, in other words, some deviation in the natural action of a gland destined to create a mild, innoxious fluid, a poison of the most deadly nature may be created; for example: that gland, which in its sound state secretes pure saliva, may, from being thrown into diseased action, produce a poison of the most destructive quality. nature appears to have no more difficulty in forming minute glands among the vascular parts of the body than she has in forming blood vessels, and millions of these can be called into existence, when inflammation is excited, in a few hours. [footnote: mr. home, in his excellent dissertation on pus and mucus, justifies this assertion.] in the present early stage of the inquiry (for early it certainly must be deemed), before we know for an absolute certainty how soon the virus of the cow-pox may suffer a change in its specific properties, after it has quitted the limpid state it possesses when farming a pustule, it would be prudent for those who have been inoculated with it to submit to variolous inoculation. no injury or inconvenience can accrue from this; and were the same method practiced among those who, from inoculation, have felt the smallpox in an unsatisfactory manner at any period of their lives, it might appear that i had not been too officious in offering a cautionary, hint in recommending a second inoculation with matter in its most perfect state. and here let me suppose, for argument's sake (not from conviction), that one person in an hundred after having had the cow-pox should be found susceptible of the smallpox, would this invalidate the utility of the practice? for, waiving all other considerations, who will deny that the inoculated smallpox, although abstractedly it may be considered as harmless, does not involve in itself something that in numberless instances proves baneful to the human frame. that in delicate constitutions it sometimes excites scrofula is a fact that must generally be subscribed to, as it is so obvious to common observation. this consideration is important. as the effects of the smallpox inoculation on those who have had the cow-pox will be watched with the most scrupulous eye by those who prosecute this inquiry, it may be proper to bring to their recollection some facts relative to the smallpox, which i must consider here as of consequence, but which hitherto seem not to have made a due impression. it should be remembered that the constitution cannot, by previous infection, be rendered totally unsusceptible of the variolous poison; neither the casual nor the inoculated smallpox, whether it produces the disease in a mild or in a violent way, can perfectly extinguish the susceptibility. the skin, we know, is ever ready to exhibit, though often in a very limited degree, the effects of the poison when inserted there; and how frequently do we see, among nurses, when much exposed to the contagion, eruptions, and these sometimes preceded by sensible illness! yet should any thing like an eruption appear, or the smallest degree of indisposition, upon the insertion of the variolous matter on those who have gone through the cow-pox, my assertions respecting the peculiarities of the disease might be unjustly discredited. i know a gentleman who, many years ago, was inoculated for the smallpox, but having no pustules, or scarcely any constitutional affection that was perceptible, he was dissatisfied, and has since been repeatedly inoculated. a vesicle has always been produced in the arm in consequence, with axillary swelling and a slight indisposition; this is by no means a rare occurrence. it is probable that fluid thus excited upon the skin would always produce the smallpox. on the arm of a person who had gone through the cow-pox many years before i once produced a vesication by the insertion of variolous matter, and, with a little of the fluid, inoculated a young woman who had a mild, but very efficacious, smallpox in consequence, although no constitutional effect was produced on the patient from whom the matter was taken. the following communication from mr. fewster affords a still clearer elucidation of this fact. mr. fewster says: "on the 3d of april, 1797, i inoculated master h--, aged fourteen months, for the smallpox. at the usual time he sickened, had a plentiful eruption, particularly on his face, and got well. his nursemaid, aged twenty-four, had many years before gone through the smallpox, in the natural way, which was evident from her being much pitted with it. she had used the child to sleep on her left arm, with her left cheek in contact with his face, and during his inoculation he had mostly slept in that manner. about a week after the child got well she (the nurse) desired me to look at her face, which she said was very painful. there was a plentiful eruption on the left cheek, but not on any other part of the body, which went on to maturation. "on enquiry i found that three days before the appearance of the eruption she was taken with slight chilly fits, pain in her head and limbs, and some fever. on the appearance of the eruption these pains went off, and now, the second day of the eruption, she complains of a little sore throat. whether the above symptoms are the effects of the smallpox or a recent cold i do not know. on the fifth day of the eruption i charged a lancet from two of the pustules, and on the next day i inoculated two children, one two years, the other four months old, with the matter. at the same time i inoculated the mother and eldest sister with variolous matter taken from master h--. on the fifth day of their inoculation all their arms were inflamed alike; and on the eighth day the eldest of those inoculated from the nurse sickened, and the youngest on the eleventh. they had both a plentiful eruption, from which i inoculated several others, who had the disease very favourably. the mother and the other child sickened about the same time, and likewise had a plentiful eruption. "soon after, a man in the village sickened with the smallpox and had a confluent kind. to be convinced that the children had had the disease effectually i took them to his house and inoculated them in both arms with matter taken from him, but without effect." these are not brought forward as uncommon occurrences, but as exemplifications of the human system's susceptibility of the variolous contagion, although it has been previously sensible of its action. happy is it for mankind that the appearance of the small-pox a second time on the same person, beyond a trivial extent, is so extremely rare that it is looked upon as a phaenomenon! indeed, since the publication of dr. heberden's paper on the varicellae, or chicken-pox, the idea of such an occurrence, in deference to authority so truly respectable, has been generally relinquished. this i conceive has been without just reason; for after we have seen, among many others, so strong a case as that recorded by mr. edward withers, surgeon, of newbury, berks, in the fourth volume of the memoirs of the medical society of london (from which i take the following extracts), no one, i think, will again doubt the fact. "mr. richard langford, a farmer of west shefford, in this county (berks), about fifty years of age, when about a month old had the smallpox at a time when three others of the family had the same disease, one of whom, a servant man, died of it. mr. langford's countenance was strongly indicative of the malignity of the distemper, his face being so remarkably pitted and seamed as to attract the notice of all who saw him, so that no one could entertain a doubt of his having had that disease in a most inveterate manner." mr. withers proceeds to state that mr. langford was seized a second time, had a bad confluent smallpox, and died on the twenty-first day from the seizure; and that four of the family, as also a sister of the patient's, to whom the disease was conveyed by her son's visiting his uncle, falling down with the smallpox, fully satisfied the country with regard to the nature of the disease, which nothing short of this would have done; the sister died. "this case was thought so extraordinary a one as to induce the rector of the parish to record the particulars in the parish register." it is singular that in most cases of this kind the disease in the first instance has been confluent; so that the extent of the ulceration on the skin (as in the cow-pox) is not the process in nature which affords security to the constitution. as the subject of the smallpox is so interwoven with that which is the more immediate object of my present concern, it must plead my excuse for so often introducing it. at present it must be considered is a distemper not well understood. the inquiry i have instituted into the nature of the cow-pox will probably promote its more perfect investigation. the inquiry of dr. pearson into the history of the cow-pox having produced so great a number of attestations in favour of my assertion that it proves a protection to the human body from the smallpox, i have not been assiduous in seeking for more; but as some of my friends have been so good as to communicate the following, i shall conclude these observations with their insertion. extract of a letter from mr. drake, surgeon, at stroud, in this county, and late surgeon to the north gloucester regiment of militia: "in the spring of the year 1796 i inoculated men, women, and children to the amount of about seventy. many of the men did not receive the infection, although inoculated at least three times and kept in the same room with those who actually underwent the disease during the whole time occupied by them in passing through it. being anxious they should, in future, be secure against it, i was very particular in my inquiries to find out whether they ever had previously had it, or at any time been in the neighbourhood of people labouring under it. but, after all, the only satisfactory information i could obtain was that they had had the cow-pox. as i was then ignorant of such a disease affecting the human subject, i flattered myself what they imagined to be the cow-pox was in reality the smallpox in a very slight degree. i mentioned the circumstance in the presence of the officers, at the time expressing my doubts if it were not smallpox, and was not a little surprised when i was told by the colonel that he had frequently heard you mention the cow-pox as a disease endemial to gloucestershire, and that if a person were ever affected by it, you supposed him afterwards secure from the smallpox. this excited my curiosity, and when i visited gloucestershire i was very inquisitive concerning the subject, and from the information i have since received, both from your publication and from conversation with medical men of the greatest accuracy in their observations, i am fully convinced that what the men supposed to be cow-pox was actually so, and i can safely affirm that they effectually resisted the smallpox." mr. fry, surgeon, at dursley in this county, favours me with the following communication: "during the spring of the year 1797 i inoculated fourteen hundred and seventy-five patients, of all ages, from a fortnight old to seventy years; amongst whom there were many who had previously gone through the cow-pox. the exact number i cannot state; but if i say there were nearly thirty, i am certainly within the number. there was not a single instance of the variolous matter producing any constitutional effect on these people, nor any greater degree of local inflammation than it would have done in the arm of a person who had before gone through the smallpox, notwithstanding it was invariably inserted four, five, and sometimes six different times, to satisfy the minds of the patients. in the common course of inoculation previous to the general one scarcely a year passed without my meeting with one or two instances of persons who had gone through the cow-pox, resisting the action of the variolous contagion. i may fairly say that the number of people i have seen inoculated with the smallpox who, at former periods, had gone through the cow-pox, are not less than forty; and in no one instance have i known a patient receive the smallpox, notwithstanding they invariably continued to associate with other inoculated patients during the progress of the disease, and many of them purposely exposed themselves to the contagion of the natural smallpox; whence i am fully convinced that a person who had fairly had the cow-pox is no longer capable of being acted upon by the variolous matter. "i also inoculated a very considerable number of those who had had a disease which ran through the neighbourhood a few years ago, and was called by the common people the swine-pox, not one of whom received the smallpox. [footnote: this was that mild variety of the smallpox which i have noticed in the late treatise on the cow-pox (p. 233).] "there were about half a dozen instances of people who never had either the cow-or swine-pox, yet did not receive the smallpox, the system not being in the least deranged, or the arms inflamed, although they were repeatedly inoculated, and associated with others who were labouring under the disease; one of them was the son of a farrier." mr. tierny, assistant surgeon of the south gloucester regiment of militia, has obliged me with the following information: "that in the summer of the year of 1798 he inoculated a great number of the men belonging to the regiment, and that among them he found eleven who, from having lived in dairies, had gone through the cow-pox. that all of them resisted the smallpox except one, but that on making the most rigid and scrupulous enquiry at the farm in gloucestershire, where the man said he lived when he had the disease, and among those with whom, at the same time, he declared he had associated, and particularly of a person in the parish, whom he said had dressed his fingers, it most clearly appeared that he aimed at an imposition, and that he never had been affected with the cow-pox." [footnote: the public cannot be too much upon their guard respecting persons of this description.] mr. tierny remarks that the arms of many who were inoculated after having had the cow-pox inflamed very quickly, and that in several a little ichorous fluid was formed. mr. cline, who in july last was so obliging at my request as to try the efficacy of the cow-pox virus, was kind enough to give me a letter on the result of it, from which the following is an extract: "my dear sir: "the cow-pox experiment has succeeded admirably. the child sickened on the seventh day, and the fever, which was moderate, subsided on the eleventh. the inflammation arising from the insertion of the virus extended to about four inches in diameter, and then gradually subsided, without having been attended with pain or other inconvenience. there were no eruptions. "i have since inoculated him with smallpox matter in three places, which were slightly inflamed on the third day, and then subsided. "dr. lister, who was formerly physician to the smallpox hospital, attended the child with me, and he is convinced that it is not possible to give him the smallpox. i think the substituting the cow-pox poison for the smallpox promises to be one of the greatest improvements that has ever been made in medicine; and the more i think on the subject, the more i am impressed with its importance. "with great esteem "i am, etc., "henry cline. "lincoln's inn fields, august 2, 1798." from communications, with which i have been favoured from dr. pearson, who has occasionally reported to me the result of his private practice with the vaccine virus in london, and from dr. woodville, who also has favoured me with an account of his more extensive inoculation with the same virus at the smallpox hospital, it appears that many of their patients have been affected with eruptions, and that these eruptions have maturated in a manner very similar to the variolous. the matter they made use of was taken in the first instance from a cow belonging to one of the great milk farms in london. having never seen maturated pustules produced either in my own practice among those who were casually infected by cows, or those to whom the disease had been communicated by inoculation, i was desirous of seeing the effect of the matter generated in london, on subjects living in the country. a thread imbrued in some of this matter was sent to me, and with it two children were inoculated, whose cases i shall transcribe from my notes. stephen jenner, three years and a half old. 3d day: the arm shewed a proper and decisive inflammation. 6th: a vesicle arising. 7th: the pustule of a cherry colour. 8th: increasing in elevation. a few spots now appear on each arm near the insertion of the inferior tendons of the biceps muscles. they are very small and of a vivid red colour. the pulse natural; tongue of its natural hue; no loss of appetite or any symptom of indisposition. 9th: the inoculated pustule on the arm this evening began to inflame, and gave the child uneasiness; he cried and pointed to the seat of it, and was immediately afterwards affected with febrile symptoms. at the expiration of two hours after the seizure a plaster of ung. hydrarg. fort, was applied, and its effect was very quickly perceptible, for in ten minutes he resumed his usual looks and playfulness. on examining the arm about three hours after the application of the plaster its effects in subduing the inflammation were very manifest. 10th: the spots on the arms have disappeared, but there are three visible in the face. 11th: two spots on the face are gone; the other barely perceptible. 13th: the pustule delineated in the second plate in the treatise on the variolae vaccinae is a correct representation of that on the child's arm as it appears at this time. 14th: two fresh spots appear on the face. the pustule on the arm nearly converted into a scab. as long as any fluid remained in it it was limpid. james hill, four years old, was inoculated on the same day, and with part of the same matter which infected stephen jenner. it did not appear to have taken effect till the fifth day. 7th: a perceptible vesicle: this evening the patient became a little chilly; no pain or tumour discoverable in the axilla. 8th: perfectly well. 9th: the same. 10th: the vesicle more elevated than i have been accustomed to see it, and assuming more perfectly the variolous character than is common with the cow-pox at this stage. 11th: surrounded by an inflammatory redness, about the size of a shilling, studded over with minute vesicles. the pustule contained a limpid fluid till the fourteenth day, after which it was incrusted over in the usual manner; but this incrustation or scab being accidentally rubbed off, it was slow in healing. these children were afterwards fully exposed to the smallpox contagion without effect. having been requested by my friend, mr. henry hicks, of eastington, in this county, to inoculate two of his children, and at the same time some of his servants and the people employed in his manufactory, matter was taken from the arm of this boy for the purpose. the numbers inoculated were eighteen. they all took the infection, and either on the fifth or sixth day a vesicle was perceptible on the punctured part. some of them began to feel a little unwell on the eighth day, but the greater number on the ninth. their illness, as in the former cases described, was of short duration, and not sufficient to interrupt, but at very short intervals, the children from their amusements, or the servants and manufacturers from following their ordinary business. three of the children whose employment in the manufactory was in some degree laborious had an inflammation on their arms beyond the common boundary about the eleventh or twelfth day, when the feverish symptoms, which before were nearly gone off, again returned, accompanied with increase of axillary tumour. in these cases (clearly perceiving that the symptoms were governed by the state of the arms) i applied on the inoculated pustules, and renewed the application three or four times within an hour, a pledget of lint, previously soaked in aqua lythargyri acetati [footnote: goulard's extract of saturn.] and covered the hot efflorescence surrounding them with cloths dipped in cold water. the next day i found this simple mode of treatment had succeeded perfectly. the inflammation was nearly gone off, and with it the symptoms which it had produced. some of these patients have since been inoculated with variolous matter, without any effect beyond a little inflammation on the part where it was inserted. why the arms of those inoculated with the vaccine matter in the country should be more disposed to inflame than those inoculated in london it may be difficult to determine. from comparing my own cases with some transmitted to me by dr. pearson and dr. woodville, this appears to be the fact; and what strikes me as still more extraordinary with respect to those inoculated in london is the appearance of maturating eruptions, in the two instances only which i have mentioned (the one from the inoculated, the other from the casual, cow-pox) a few red spots appeared, which quickly went off without maturating. the case of the rev. mr. moore's servant may, indeed, seem like a deviation from the common appearances in the country, but the nature of these eruptions was not ascertained beyond their not possessing the property of communicating the disease by their effluvia. perhaps the difference we perceive may be owing to some variety in the mode of action of the virus upon the skin of those who breathe the air of london and those who live in the country. that the erysipelas assumes a different form in london from what we see it put on in this country is a fact very generally acknowledged. in calling the inflammation that is excited by the cow-pox virus erysipelatous, perhaps i may not be critically exact, but it certainly approaches near to it. now, as the diseased action going forward in the part infected with the virus may undergo different modifications according to the peculiarities of the constitution on which it is to produce its effect, may it not account for the variation which has been observed? to this it may probably be objected that some of the patients inoculated, and who had pustules in consequence, were newly come from the country; but i conceive that the changes wrought in the human body through the medium of the lungs may be extremely rapid. yet, after all, further experiments made in london with vaccine virus generated in the country must finally throw a light on what now certainly appears obscure and mysterious. the principal variation perceptible to me in the action of the vaccine virus generated in london from that produced in the country was its proving more certainly infectious and giving a less disposition in the arm to inflame. there appears also a greater elevation of the pustule above the surrounding skin. in my former cases the pustule produced by the insertion of the virus was more like one of those which are so thickly spread over the body in a bad kind of confluent smallpox. this was more like a pustule of the distinct smallpox, except that i saw no instance of pus being formed in it, the matter remaining limpid till the period of scabbing. wishing to see the effects of the disease on an infant newly born, my nephew, mr. henry jenner, at my request, inserted the vaccine virus into the arm of a child about twenty hours old. his report to me is that the child went through the disease without apparent illness, yet that it was found effectually to resist the action of variolous matter with which it was subsequently inoculated. i have had an opportunity of trying the effects of the cow-pox matter on a boy, who, the day preceding its insertion, sickened with the measles. the eruption of the measles, attended with cough, a little pain in the chest; and the usual symptoms accompanying the disease, appeared on the third day and spread all over him. the disease went through its course without any deviation from its usual habits; and, notwithstanding this, the cow-pox virus excited its common appearances, both on the arm and on the constitution, without any febrile interruption; on the sixth day there was a vesicle. 8th: pain in the axilla, chilly, and affected with headache. 9th: nearly well. 12th: the pustule spread to the size of a large split-pea, but without any surrounding efflorescence. it soon afterwards scabbed, and the boy recovered his general health rapidly. but it should be observed that before it scabbed the efflorescence which had suffered a temporary suspension advanced in the usual manner. here we see a deflation from the ordinary habits of the smallpox, as it has been observed that the presence of the measles suspends the action of the variolous matter. the very general investigation that is now taking place, chiefly through inoculation (and i again repeat my earnest hope that it may be conducted with that calmness and moderation which should ever accompany a philosophical research), must soon place the vaccine disease in its just point of view. the result of all my trials with the virus on the human subject has been uniform. in every instance the patient who has felt its influence, has completely lost the susceptibility for the variolous contagion; and as these instances are now become numerous, i conceive that, joined to the observations in the former part of this paper, they sufficiently preclude me from the necessity of entering into controversies with those who have circulated reports adverse to my assertions, on no other evidence than what has been casually collected. iii a continuation of facts and observations relative to the various vaccines, or cow-pox. 1800 since my former publications on the vaccine inoculation i have had the satisfaction of seeing it extend very widely. not only in this country is the subject pursued with ardour, but from my correspondence with many respectable medical gentlemen on the continent (among whom are dr. de carro, of vienna, and dr. ballhorn, of hanover) i find it is as warmly adopted abroad, where it has afforded the greatest satisfaction. i have the pleasure, too, of seeing that the feeble efforts of a few individuals to depreciate the new practice are sinking fast into contempt beneath the immense mass of evidence which has arisen up in support of it. upwards of six thousand persons have now been inoculated with the virus of cow-pox, and the far greater part of them have since been inoculated with that of smallpox, and exposed to its infection in every rational way that could be devised, without effect. it was very improbable that the investigation of a disease so analogous to the smallpox should go forward without engaging the attention of the physician of the smallpox hospital in london. accordingly, dr. woodville, who fills that department with so much respectability, took an early opportunity of instituting an inquiry into the nature of the cow-pox. this inquiry was begun in the early part of the present year, and in may, dr. woodville published the result, which differs essentially from mine in a point of much importance. it appears that three-fifths of the patients inoculated were affected with eruptions, for the most part so perfectly resembling the smallpox as not to be distinguished from them. on this subject it is necessary that i should make some comments. when i consider that out of the great number of cases of casual inoculation immediately from cows which from time to time presented themselves to my observation, and the many similar instances which have been communicated to me by medical gentlemen in this neighbourhood; when i consider, too, that the matter with which my inoculations were conducted in the years 1797, '98, and '99, was taken from some different cows, and that in no instance any thing like a variolous pustule appeared, i cannot feel disposed to imagine that eruptions, similar to those described by dr. woodville, have ever been produced by the pure uncontaminated cow-pock virus; on the contrary, i do suppose that those which the doctor speaks of originated in the action of variolous matter which crept into the constitution with the vaccine. and this i presume happened from the inoculation of a great number of the patients with variolous matter (some on the third, others on the fifth, day) after the vaccine had been applied; and it should be observed that the matter thus propagated became the source of future inoculations in the hands of many medical gentlemen who appeared to have been previously unacquainted with the nature of the cow-pox. another circumstance strongly, in my opinion, supporting this supposition is the following: the cow-pox has been known among our dairies time immemorial. if pustules, then, like the variolous, were to follow the communication of it from the cow to the milker, would not such a fact have been known and recorded at our farms? yet neither our farmers nor the medical people of the neighbourhood have noticed such an occurrence. a few scattered pimples i have sometimes, though very rarely, seen, the greater part of which have generally disappeared quickly, but some have remained long enough to suppurate at their apex. that local cuticular inflammation, whether springing up spontaneously or arising from the application of acrid substances, such for instance, as cantharides, pix burgundica, antimonium tartarizatum, etc., will often produce cutaneous affections, not only near the seat of the inflammation, but on some parts of the skin far beyond its boundary, is a well-known fact. it is, doubtless, on this principle that the inoculated cow-pock pustule and its concomitant efflorescence may, in very irritable constitutions, produce this affection. the eruption i allude to has commonly appeared some time in the third week after inoculation. but this appearance is too trivial to excite the least regard. the change which took place in the general appearance during the progress of the vaccine inoculation at the smallpox hospital should likewise be considered. although at first it took on so much of the variolous character as to produce pustules in three cases out of five, yet in dr. woodville's last report, published in june, he says: "since the publication of my reports of inoculations for the cow-pox, upwards of three hundred cases have been under my care; and out of this number only thirty-nine had pustules that suppurated; viz., out of the first hundred, nineteen had pustules; out of the second, thirteen; and out of the last hundred and ten, only seven had pustules. thus it appears that the disease has become considerably milder; which i am inclined to attribute to a greater caution used in the choice of the matter, with which the infection was communicated; for, lately, that which has been employed for this purpose has been taken only from those patients in whom the cow-pox proved very mild and well characterized." [footnote: in a few weeks after the cow-pox inoculation was introduced at the smallpox hospital i was favoured with some virus from this stock. in the first instance it produced a few pustules, which did not maturate; but in the subsequent cases none appeared.--e. j.] the inference i am induced to draw from these premises is very different. the decline, and, finally, the total extinction nearly, of these pustules, in my opinion, are more fairly attributable to the cow-pox virus, assimilating the variolous, [footnote: in my first publication on this subject i expressed an opinion that the smallpox and the cow-pox were the same diseases under different modifications. in this opinion dr. woodville has concurred the axiom of the immortal hauter, that two diseased actions cannot take place at the same time in one and the same part, will not be injured by the admission of this theory.] the former probably being the original, the latter the same disease under a peculiar, and at present an inexplicable, modification. one experiment tending to elucidate the point under discussion i had myself an opportunity of instituting. on the supposition of its being possible that the cow which ranges over the fertile meadows in the vale of gloucester might generate a virus differing in some respects in its qualities from that produced by the animal artificially pampered for the production of milk for the metropolis, i procured, during my residence there in the spring, some cow pock virus from a cow at one of the london milkfarms. [footnote: it was taken by mr. tanner, then a student at the veterinary college, from a cow at mr. clark's farm at kentish town.] it was immediately conveyed into gloucestershire to dr. marshall, who was then extensively engaged in the inoculation of the cow-pox, the general result of which, and of the inoculation in particular with this matter, i shall lay before my reader in the following communication from the doctor: "dear sir: "my neighbour, mr. hicks, having mentioned your wish to be informed of the progress of the inoculation here for the cow-pox, and he also having taken the trouble to transmit to you my minutes of the cases which have fallen under my care, i hope you will pardon the further trouble i now give you in stating the observations i have made upon the subject. when first informed of it, having two children who had not had the smallpox, i determined to inoculate them for the cow-pox whenever i should be so fortunate as to procure matter proper for the purpose. i was, therefore, particularly happy when i was informed that i could procure matter from some of those whom you had inoculated. in the first instance i had no intention of extending the disease further than my own family, but the very extensive influence which the conviction of its efficacy in resisting the smallpox has had upon the minds of the people in general has rendered that intention nugatory, as you will perceive, by the continuation of my cases enclosed in this letter, [footnote: doctor marshall has detailed these cases with great accuracy, but their publication would now be deemed superfluous.--e.j.] by which it will appear that since the 22d of march i have inoculated an hundred and seven persons; which, considering the retired situation i resided in, is a very great number. there are also other considerations which, besides that of its influence in resisting the smallpox, appear to have had their weight; the peculiar mildness of the disease, the known safety of it, and its not having in any instance prevented the patient from following his ordinary business. in all the cases under my care there have only occurred two or three which required any application, owing to erysipelatous inflammation on the arm, and they immediately yielded to it. in the remainder the constitutional illness has been slight but sufficiently marked, and considerably less than i ever observed in the same number inoculated with the smallpox. in only one or two of the cases have any other eruptions appeared than those around the spot where the matter was inserted, and those near the infected part. neither does there appear in the cow-pox to be the least exciting cause to any other disease, which in the smallpox has been frequently observed, the constitution remaining in as full health and vigour after the termination of the disease as before the infection. another important consideration appears to be the impossibility of the disease being communicated except by the actual contact of the matter of the pustule, and consequently the perfect safety of the remaining part of the family, supposing only one or two should wish to be inoculated at the same time. "upon the whole, it appears evident to me that the cow-pox is a pleasanter, shorter, and infinitely more safe disease than the inoculated smallpox when conducted in the most careful and approved manner; neither is the local affection of the inoculated part, or the constitutional illness, near so violent. i speak with confidence on the subject, having had an opportunity of observing its effects upon a variety of constitutions, from three months old to sixty years; and to which i have paid particular attention. in the cases alluded to here you will observe that the removal from the original source of the matter had made no alteration or change in the nature or appearance of the disease, and that it may be continued, ad infinitum (i imagine), from one person to another (if care be observed in taking the matter at a proper period) without any necessity of recurring to the original matter of the cow. "i should be happy if any endeavours of mine could tend further to elucidate the subject, and shall be much gratified is sending you any further observations i may be enabled to make. "i have the pleasure to subscribe myself, "dear sir, etc., "joseph h. marshall "eastington, gloucestershire, april 26, 1799." the gentleman who favoured me with the above account has continued to prosecute his inquiries with unremitting industry, and has communicated the result in another letter, which at his request i lay before the public without abbreviation. dr. marshall's second letter: "dear sir: "since the date of my former letter i have continued to inoculate with the cow-pox virus. including the cases before enumerated, the number now amounts to four hundred and twenty-three. it would be tedious and useless to detail the progress of the disease in each individual--it is sufficient to observe that i noticed no deviation in any respect from the cases i formerly adduced. the general appearances of the arm exactly corresponded with the account given in your first publication. when they were disposed to become troublesome by erysipelatous inflammation, an application of equal parts of vinegar and water always answered the desired intention. i must not omit to inform you that when the disease had duly acted upon the constitution i have frequently used the vitriolic acid. a portion of a drop applied with the head of a probe or any convenient utensil upon the pustule, suffered to remain about forty seconds, and afterwards washed off with sponge and water, never failed to stop its progress and expedite the formation of a scab. "i have already subjected two hundred and eleven of my patients to the action of variolous matter, but every one resisted it. "the result of my experiments (which were made with every requisite caution) has fully convinced me that the true cow-pox is a safe and infallible preventive from the smallpox; that in no case which has fallen under my observation has it been in any considerable degree troublesome, much less have i seen any thing like danger; for in no instance were the patients prevented from following their ordinary employments. "in dr. woodville's publication on the cow-pox i notice an extraordinary fact. he says that the generality of his patients had pustules. it certainly appears extremely extraordinary that in all my cases there never was but one pustule, which appeared on a patient's elbow on the inoculated arm, and maturated. it appeared exactly like that on the incised part. "the whole of my observations, founded as it appears on an extensive experience, leads me to these obvious conclusions; that those cases which have been or may be adduced against the preventive powers of the cow-pox could not have been those of the true kind, since it must appear to be absolutely impossible that i should have succeeded in such a number of cases without a single exception if such a preventive power did not exist. i cannot entertain a doubt that the inoculated cow-pox must quickly supersede that of the smallpox. if the many important advantages which must result from the new practice are duly considered, we may reasonably infer that public benefit, the sure test of the real merit of discoveries, will render it generally extensive. "to you, sir, as the discoverer of this highly beneficial practice, mankind are under the highest obligations. as a private individual i participate in the general feeling; more particularly as you have afforded me an opportunity of noticing the effects of a singular disease, and of viewing the progress of the most curious experiment that ever was recorded in the history of physiology. "i remain, dear sir, etc., "joseph h. marshall." "p.s. i should have observed that, of the patients i inoculated and enumerated in my letter, one hundred and twenty-seven were infected with the matter you sent me from the london cow. i discovered no dissimilarity of symptoms in these cases from those which i inoculated from matter procured in this country. no pustules have occurred, except in one or two cases, where a single one appeared on the inoculated arm. no difference was apparent in the local inflammation. there was no suspension of ordinary employment among the labouring people, nor was any medicine required. "i have frequently inoculated one or two in a family, and the remaining part of it some weeks afterwards. the uninfected have slept with the infected during the whole course of the disease without being affected; so that i am fully convinced that the disease cannot be taken but by actual contact with the matter. "a curious fact has lately fallen under my observation, on which i leave you to comment. "i visited a patient with the confluent smallpox and charged a lancet with some of the matter. two days afterwards i was desired to inoculate a woman and four children with the cow-pox, and i inadvertently took the vaccine matter on the same lancet which was before charged with that of smallpox. in three days i discovered the mistake, and fully expected that my five patients would be infected with smallpox; but i was agreeably surprised to find the disease to be genuine cow-pox, which proceeded without deviating in any particular from my former cases. i afterwards inoculated these patients with variolous matter, but all of them resisted its action. "i omitted mentioning another great advantage that now occurs to me in the inoculated cow-pox; i mean, the safety with which pregnant women may have the disease communicated to them. i have inoculated a great number of females in that situation, and never observed their cases to differ in any respect from those of my other patients. indeed, the disease is so mild that it seems as if it might at all times be communicated with the most perfect safety." i shall here take the opportunity of thanking dr. marshall and those other gentlemen who have obligingly presented me with the result of their inoculations; but, as they all agree in the same point as that given in the above communication, namely, the security of the patient from the effects of the smallpox after the cow-pox, their perusal, i presume, would afford us no satisfaction that has not been amply given already. particular occurrences i shall, of course, detail. some of my correspondents have mentioned the appearance of smallpox-like eruptions at the commencement of their inoculations; but in these cases the matter was derived from the original stock at the smallpox hospital. i have myself inoculated a very considerable number from the matter produced by dr. marshall's patients, originating in the london cow, without observing pustules of any kind, and have dispersed it among others who have used it with a similar effect. from this source mr. h. jenner informs me he has inoculated above an hundred patients without observing eruptions. whether the nature of the virus will undergo any change from being farther removed from its original source in passing successively from one person to another time alone can determine. that which i am now employing has been in use near eight months, and not the least change is perceptible in its mode of action either locally or constitutionally. there is, therefore, every reason to expect that its effects will remain unaltered and that we shall not be under the necessity of seeking fresh supplies from the cow. the following observations were obligingly sent me by mr. tierny, assistant surgeon to the south gloucester regiment of militia, to whom i am indebted for a former report on this subject: "i inoculated with the cow-pox matter from the eleventh to the latter part of april, twenty-five persons, including women and children. some on the eleventh were inoculated with the matter mr. shrapnell (surgeon to the regiment) had from you, the others with matter taken from these. the progress of the puncture was accurately observed, and its appearance seemed to differ from the smallpox in having less inflammation around its basis on the first days--that is, from the third to the seventh; but after this the inflammation increased, extending on the tenth or eleventh day to a circle of an inch and a half from its centre, and threatening very sore arms; but this i am happy to say was not the case; for, by applying mercurial ointment to the inflamed part, which was repeated daily until the inflammation went off, the arm got well without any further application or trouble. the constitutional symptoms which appeared on the eighth or ninth day after inoculation scarcely deserved the name of disease, as they were so slight as to be scarcely perceptible, except that i could connect a slight headache and languor, with a stiffness and rather painful sensation in the axilla. this latter symptom was the most striking--it remained from twelve to forty-eight hours. in no case did i observe the smallest pustule, or even discolouration of the skin, like an incipient pustule, except about the part where the virus has been applied. "after all these symptoms had subsided and the arms were well, i inoculated four of this number with variolous matter, taken from a patient in another regiment. in each of these it was inserted several times under the cuticle, producing slight inflammation on the second or third day, and always disappearing before the fifth or sixth, except in one who had the cow-pox in gloucestershire before he joined us, and who also received it at this time by inoculation. in this man the puncture inflamed and his arm was much sorer than from the insertion of the cow-pox virus; but there was no pain in the axilla, nor could any constitutional affection be observed. "i have only to add that i am now fully satisfied of the efficacy of the cow-pox in preventing the appearance of the smallpox, and that it is a most happy and salutary substitute for it. i remain, etc., "m. j. tierny." although the susceptibility of the virus of the cow-pox is, for the most part, lost in those who have had the smallpox, yet in some constitutions it is only partially destroyed, and in others it does not appear to be in the least diminished. by far the greater number on whom trials were made resisted it entirely; yet i found some on whose arm the pustule from inoculation was formed completely, but without producing the common efflorescent blush around it, or any constitutional illness, while others have had the disease in the most perfect manner. a case of the latter kind having been presented to me by mr. fewster, surgeon, of thornbury, i shall insert it: "three children were inoculated with the vaccine matter you obligingly sent me. on calling to look at their arms three days after i was told that john hodges, one of the three, had been inoculated with the smallpox when a year old, and that he had a full burthen, of which his face produced plentiful marks, a circumstance i was not before made acquainted with. on the sixth day the arm of the boy appeared as if inoculated with variolous matter, but the pustule was rather more elevated. on the ninth day he complained of violent pain in his head and back, accompanied with vomiting and much fever. the next day he was very well and went to work as usual. the punctured part began to spread, and there was the areola around the inoculated part to a considerable extent. "as this is contrary to an assertion made in the medical and physical journal, no. 8, i thought it right to give you this information, and remain, "dear sir, etc., "j. fewster." it appears, then, that the animal economy with regard to the action of this virus is under the same laws as it is with respect to the variolous virus, after previously feeling its influence, as far as comparisons can be made between the two diseases. some striking instances of the power of the cow-pox in suspending the progress of the smallpox after the patients had been several days casually exposed to the infection have been laid before me by mr. lyford, surgeon, of winchester, and my nephew, the rev. g. c jenner. mr. lyford, after giving an account of his extensive and successful practice in the vaccine inoculation in hampshire, writes as follows: "the following case occurred to me a short time since, and may probably be worth your notice. i was sent for to a patient with the smallpox, and on inquiry found that five days previous to my seeing him the eruption began to appear. during the whole of this time two children who had not had the smallpox, were constantly in the room with their father, and frequently on the bed with him. the mother consulted me on the propriety of inoculating them, but objected to my taking the matter from their father, as he was subject to erysipelas. i advised her by all means to have them inoculated at that time, as i could not procure any variolous matter elsewhere. however, they were inoculated with vaccine matter, but i cannot say i flattered myself with its proving successful, as they had previously been so long and still continued to be exposed to the variolous infection. notwithstanding this i was agreeably surprised to find the vaccine disease advance and go through its regular course; and, if i may be allowed the expression, to the total extinction of the smallpox." mr. jenner's cases were not less satisfactory. he writes as follows: "a son of thomas stinchcomb, of woodford, near berkeley, was infected with the natural smallpox at bristol, and came home to his father's cottage. four days after the eruptions had appeared upon the boy, the family (none of which had ever had the smallpox), consisting of the father, mother, and five children, was inoculated with vaccine virus. on the arm of the mother it failed to produce the least effect, and she, of course, had the smallpox, [footnote: under similar circumstances i think it would be advisable to insert the matter into each arm, which would be more likely to insure the success of the operation.--e. j.] but the rest of the family had the cow-pox in the usual way, and were not affected with the smallpox, although they were in the same room, and the children slept in the same bed with their brother who was confined to it with the natural smallpox; and subsequently with their mother. "i attended this family with my brother, mr. h. jenner." the following cases are of too singular a nature to remain unnoticed. miss r--, a young lady about five years old, was seized on the evening of the eighth day after inoculation with vaccine virus, with such symptoms as commonly denote the accession of violent fever. her throat was also a little sore, and there were some uneasy sensations about the muscles of the neck. the day following a rash was perceptible on her face and neck, so much resembling the efflorescence of the scarlatina anginosa that i was induced to ask whether miss r--had been exposed to the contagion of that disease. an answer in the affirmative, and the rapid spreading of the redness over the skin, at once relieved me from much anxiety respecting the nature of the malady, which went through its course in the ordinary way, but not without symptoms which were alarming both to myself and mr. lyford, who attended with me. there was no apparent deviation in the ordinary progress of the pustule to a state of maturity from what we see in general; yet there was a total suspension of the areola or florid discolouration around it, until the scarlatina had retired from the constitution. as soon as the patient was freed from this disease this appearance advanced in the usual way. [footnote: i witnessed a similar fact in a case of measles. the pustule from the cow-pock virus advanced to maturity, while the measles existed in the constitution, but no efflorescence appeared around it until the measles had ceased to exert its influence.] the case of miss h--r--is not less interesting than that of her sister, above related. she was exposed to the contagion of the scarlatina at the same time, and sickened almost at the same hour. the symptoms continued severe about twelve hours, when the scarlatina-rash shewed itself faintly upon her face, and partly upon her neck. after remaining two or three hours it suddenly disappeared, and she became perfectly free from every complaint. my surprise at this sudden transition from extreme sickness to health in great measure ceased when i observed that the inoculated pustule had occasioned, in this case, the common efflorescent appearance around it, and that as it approached the centre it was nearly in an erysipelatous state. but the most remarkable part of this history is that, on the fourth day afterwards, so soon as the efflorescence began to die away upon the arm and the pustule to dry up, the scarlatina again appeared, her throat became sore, the rash spread all over her. she went fairly through the disease with its common symptoms. that these were actually cases of scarlatina was rendered certain by two servants in the family falling ill at the same time with the distemper, who had been exposed to the infection with the young ladies. some there are who suppose the security from the smallpox obtained through the cow-pox will be of a temporary nature only. this supposition is refuted not only by analogy with respect to the habits of diseases of a similar nature, but by incontrovertible facts, which appear in great numbers against it. to those already adduced in the former part of my first treatise [footnote: see pages 217, 218, 219, 221, 223, etc.] many more might be adduced were it deemed necessary; but among the cases i refer to, one will be found of a person who had the cow-pox fifty-three years before the effect of the smallpox was tried upon him. as he completely resisted it, the intervening period i conceive must necessarily satisfy any reasonable mind. should further evidence be thought necessary, i shall observe that, among the cases presented to me by mr. fry, mr. darke, mr. tierny, mr. h. jenner, and others, there were many whom they inoculated ineffectually with variolous matter, who had gone through the cow-pox many years before this trial was made. it has been imagined that the cow-pox is capable of being communicated from one person to another by effluvia without the intervention of inoculation. my experiments, made with the design of ascertaining this important point, all tend to establish my original position, that it is not infectious except by contact, i have never hesitated to suffer those on whose arms there were pustules exhaling the effluvia from associating or even sleeping with others who never had experienced either the cow-pox or the smallpox. and, further, i have repeatedly, among children, caused the uninfected to breathe over the inoculated vaccine 'pustules during their whole progress, yet these experiments were tried without the least effect. however, to submit a matter so important to a still further scrutiny, i desired mr. h. jenner to make any further experiments which might strike him as most likely to establish or refute what had been advanced on this subject. he has since informed me "that he inoculated children at the breast, whose mothers had not gone through either the smallpox or the cow-pox; that he had inoculated mothers whose sucking infants had never undergone either of these diseases; that the effluvia from the inoculated pustules, in either case, had been inhaled from day to day during the whole progress of their maturation, and that there was not the least perceptible effect from these exposures." one woman he inoculated about a week previous to her accouchement, that her infant might be the more fully and conveniently exposed to the pustule; but, as in the former instances, no infection was given, although the child frequently slept on the arm of its mother with its nostrils and mouth exposed to the pustule in the fullest state of maturity. in a word, is it not impossible for the cow-pox, whose only manifestation appears to consist in the pustules created by contact, to produce itself by effluvia? in the course of a late inoculation i observed an appearance which it may be proper here to relate. the punctured part on a boy's arm (who was inoculated with fresh limpid virus) on the sixth day, instead of shewing a beginning vesicle, which is usual in the cow-pox at that period, was encrusted over with a rugged, amber-coloured scab. the scab continued to spread and increase in thickness for some days, when, at its edges, a vesicated ring appeared, and the disease went through its ordinary course, the boy having had soreness in the axilla and some slight indisposition. with the fluid matter taken from his arm five persons were inoculated. in one it took no effect. in another it produced a perfect pustule without any deviation from the common appearance; but in the other three the progress of the inflammation was exactly similar to the instance which afforded the virus for their inoculation; there was a creeping scab of a loose texture, and subsequently the formation of limpid fluid at its edges. as these people were all employed in laborious exercises, it is possible that these anomalous appearances might owe their origin to the friction of the clothes on the newly inflamed part of the arm. i have not yet had an opportunity of exposing them to the smallpox. in the early part of this inquiry i felt far more anxious respecting the inflammation of the inoculated arm than at present; yet that this affection will go on to a greater extent than could be wished is a circumstance sometimes to be expected. as this can be checked, or even entirely subdued, by very simple means, i see no reason why the patient should feel an uneasy hour because an application may not be absolutely necessary. about the tenth or eleventh day, if the pustule has proceeded regularly, the appearance of the arm will almost to a certainty indicate whether this is to be expected or not. should it happen, nothing more need be done than to apply a single drop of the aqua lythargyri acetati [footnote: extract of saturn.] upon the pustule, and, having suffered it to remain two or three minutes, to cover the efflorescence surrounding the pustule with a piece of linen dipped in the aqua lythargyri compos. [footnote: goulard water. for further information on this subject see the first treatise on the var. vac., dr. marshall's letters, etc.] the former may be repeated twice or thrice during the day, the latter as often as it may feel agreeable to the patient. when the scab is prematurely rubbed off (a circumstance not unfrequent among children and working people), the application of a little aqua lythargyri acet. to the part immediately coagulates the surface, which supplies its place, and prevents a sore. in my former treatises on this subject i have remarked that the human constitution frequently retains its susceptibility to the smallpox contagion (both from effluvia and contact) after previously feeling its influence. in further corroboration of this declaration many facts have been communicated to me by various correspondents. i shall select one of them. "dear sir: "society at large must, i think, feel much indebted to you for your inquiries and observations on the nature and effects of the variolae vaccinae, etc., etc. as i conceive what i am now about to communicate to be of some importance, i imagine it cannot be uninteresting to you, especially as it will serve to corroborate your assertion of the susceptibility of the human system of the variolous contagion, although it has previously been made sensible of its action. in november, 1793, i was desired to inoculate a person with the smallpox. i took the variolous matter from a child under the disease in the natural way, who had a large burthen of distinct pustules. the mother of the child being desirous of seeing my method of communicating the disease by inoculation, after having opened a pustule, i introduced the point of my lancet in the usual way on the back part of my own hand, and thought no more of it until i felt a sensation in the part which reminded me of the transaction. this happened upon the third day; on the fourth there were all the appearances common to inoculation, at which i was not at all surprised, nor did i feel myself uneasy upon perceiving the inflammation continue to increase to the sixth and seventh day, accompanied with a very small quantity of fluid, repeated experiments having taught me it might happen so with persons who had undergone the disease, and yet would escape any constitutional affection; but i was not so fortunate; for on the eighth day i was seized with all the symptoms of the eruptive fever, but in a much more violent degree than when i was before inoculated, which was about eighteen years previous to this, when i had a considerable number of pustules. i must confess i was now greatly alarmed, although i had been much engaged in the smallpox, having at different times inoculated not less than two thousand persons. i was convinced my present indisposition proceeded from the insertion of the variolous matter, and, therefore, anxiously looked for an eruption. on the tenth day i felt a very unpleasant sensation of stillness and heat on each side of my face near my ear, and the fever began to decline. the affection in my face soon terminated in three or four pustules attended with inflammation, but which did not maturate, and i was presently well. "i remain, dear sir, etc., "thomas miles." this inquiry is not now so much in its infancy as to restrain me from speaking more positively than formerly on the important point of scrophula as connected with the smallpox. every practitioner in medicine who has extensively inoculated with the smallpox, or has attended many of those who have had the distemper in the natural way, must acknowledge that he has frequently seen scrophulous affections, in some form or another, sometimes rather quickly shewing themselves after the recovery of the patients. conceiving this fact to be admitted, as i presume it must be by all who have carefully attended to the subject, may i not ask whether it does not appear probable that the general introduction of the smallpox into europe has not been among the most conductive means in exciting that formidable foe to health? having attentively watched the effects of the cow-pox in this respect, i am happy in being able to declare that the disease does not appear to have the least tendency to produce this destructive malady. the scepticism that appeared, even among the most enlightened of medical men when my sentiments on the important subject of the cow-pox were first promulgated, was highly laudable. to have admitted the truth of a doctrine, at once so novel and so unlike any thing that ever had appeared in the annals of medicine, without the test of the most rigid scrutiny, would have bordered upon temerity; but now, when that scrutiny has taken place, not only among ourselves, but in the first professional circles in europe, and when it has been uniformly found in such abundant instances that the human frame, when once it has felt the influence of the genuine cow-pox in the way that has been described, is never afterwards at any period of its existence assailable by the smallpox, may i not with perfect confidence congratulate my country and society at large on their beholding, in the mild form of the cow-pox, an antidote that is capable of extirpating from the earth a disease which is every hour devouring its victims; a disease that has ever been considered as the severest scourge of the human race! the contagiousness of puerperal fever by oliver wendell holmes introductory note oliver wendell holmes was born in cambridge, massachusetts, august 29, 1809, and educated at phillips academy, andover, and harvard college. after graduation, he entered the law school, but soon gave up law for medicine. he studied first in boston, and later spent two years in medical schools in europe, mainly in paris. on his return he began to practise in boston, but in two years he was appointed professor of anatomy at dartmouth college, a position which he held from 1838 to 1840, when he again took up his boston practise. it was soon after this, in 1843, that he published his essay on the "contagiousness of puerperal fever," his only contribution of high distinction to medical science. from 1847 to 1882 he was parkman professor of anatomy and physiology in the harvard medical school. he died in boston, october 7, 1894. in spite of the importance of the paper here printed, holmes's reputation as a scientist was overshadowed by that won by him as a wit and a man of letters. when he was only twenty-one his "old ironsides" brought him into notice; and through his poetry and fiction, and the sparkling talk of the "breakfast table" series, he took a high place among the most distinguished group of writers that america has yet produced. the contagiousness of puerperal fever note.--this essay appeared first in 1843, in the new england quarterly journal of medicine, and was reprinted in the "medical essays" in 1855. in collecting, enforcing and adding to the evidence accumulated upon this most serious subject, i would not be understood to imply that there exists a doubt in the mind of any well-informed member of the medical profession as to the fact that puerperal fever is sometimes communicated from one person to another, both directly and indirectly. in the present state of our knowledge upon this point i should consider such doubts merely as a proof that the sceptic had either not examined the evidence, or, having examined it, refused to accept its plain and unavoidable consequences. i should be sorry to think, with dr. rigby, that it was a case of "oblique vision"; i should be unwilling to force home the argumentum ad hominem of dr. blundell, but i would not consent to make a question of a momentous fact which is no longer to be considered as a subject for trivial discussions, but to be acted upon with silent promptitude. it signifies nothing that wise and experienced practitioners have sometimes doubted the reality of the danger in question; no man has the right to doubt it any longer. no negative facts, no opposing opinions, be they what they may, or whose they may, can form any answer to the series of cases now within the reach of all who choose to explore the records of medical science. if there are some who conceive that any important end would be answered by recording such opinions, or by collecting the history of all the cases they could find in which no evidence of the influence of contagion existed, i believe they are in error. suppose a few writers of authority can be found to profess a disbelief in contagion,--and they are very few compared with those who think differently,--is it quite clear that they formed their opinions on a view of all the facts, or is it not apparent that they relied mostly on their own solitary experience? still further, of those whose names are quoted, is it not true that scarcely a single one could, by any possibility, have known the half or the tenth of the facts bearing on the subject which have reached such a frightful amount within the last few years? again, as to the utility of negative facts, as we may briefly call them,--instances, namely, in which exposure has not been followed by disease,--although, like other truths, they may be worth knowing, i do not see that they are like to shed any important light upon the subject before us. every such instance requires a good deal of circumstantial explanation before it can be accepted. it is not enough that a practitioner should have had a single case of puerperal fever not followed by others. it must be known whether he attended others while this case was in progress, whether he went directly from one chamber to others, whether he took any, and what, precautions. it is important to know that several women were exposed to infection derived from the patient, so that allowance may be made for want of predisposition. now, if of negative facts so sifted there could be accumulated a hundred for every one plain instance of communication here recorded, i trust it need not be said that we are bound to guard and watch over the hundredth tenant of our fold, though the ninety and nine may be sure of escaping the wolf at its entrance. if any one is disposed, then, to take a hundred instances of lives, endangered or sacrificed out of those i have mentioned, and make it reasonably clear that within a similar time and compass ten thousand escaped the same exposure, i shall, thank him for his industry, but i must be permitted to hold to my own practical conclusions, and beg him to adopt or at least to examine them also. children that walk in calico before open fires are not always burned to death; the instances to the contrary may be worth recording; but by no means if they are to be used as arguments against woollen frocks and high fenders. i am not sure that this paper will escape another remark which it might be wished were founded in justice. it may be said that the facts are too generally known and acknowledged to require any formal argument or exposition, that there is nothing new in the positions advanced, and no need of laying additional statements before the profession. but on turning to two works, one almost universally, and the other extensively, appealed to as authority in this country, i see ample reason to overlook this objection. in the last edition of dewees's treatise on the "diseases of females" it is expressly said, "in this country, under no circumstance that puerperal fever has appeared hitherto, does it afford the slightest ground for the belief that it is contagious." in the "philadelphia practice of midwifery" not one word can be found in the chapter devoted to this disease which would lead the reader to suspect that the idea of contagion had ever been entertained. it seems proper, therefore, to remind those who are in the habit of referring to the works for guidance that there may possibly be some sources of danger they have slighted or omitted, quite as important as a trifling irregularity of diet, or a confined state of the bowels, and that whatever confidence a physician may have in his own mode of treatment, his services are of questionable value whenever he carries the bane as well as the antidote about his person. the practical point to be illustrated is the following: the disease known as puerperal fever is so far contagious as to be frequently carried from patient to patient by physicians and nurses. let me begin by throwing out certain incidental questions, which, without being absolutely essential, would render the subject more complicated, and by making such concessions and assumptions as may be fairly supposed to be without the pale of discussion. 1. it is granted that all the forms of what is called puerperal fever may not be, and probably are not, equally contagious or infectious. i do not enter into the distinctions which have been drawn by authors, because the facts do not appear to me sufficient to establish any absolute line of demarcation between such forms as may be propagated by contagion and those which are never so propagated. this general result i shall only support by the authority of dr. ramsbotham, who gives, as the result of his experience, that the same symptoms belong to what he calls the infectious and the sporadic forms of the disease, and the opinion of armstrong in his original essay. if others can show any such distinction, i leave it to them to do it. but there are cases enough that show the prevalence of the disease among the patients of a single practitioner when it was in no degree epidemic; in the proper sense of the term. i may refer to those of mr. roberton and of dr. peirson, hereafter to be cited, as examples. 2. i shall not enter into any dispute about the particular mode of infection, whether it be by the atmosphere the physician carries about him into the sick-chamber, or by the direct application of the virus to the absorbing surfaces with which his hand comes in contact. many facts and opinions are in favour of each of these modes of transmission. but it is obvious that, in the majority of cases, it must be impossible to decide by which of these channels the disease is conveyed, from the nature of the intercourse between the physician and the patient. 3. it is not pretended that the contagion of puerperal fever must always be followed by the disease. it is true of all contagious diseases that they frequently spare those who appear to be fully submitted to their influence. even the vaccine virus, fresh from the subject, fails every day to produce its legitimate effect, though every precaution is taken to insure its action. this is still more remarkably the case with scarlet fever and some other diseases. 4. it is granted that the disease may be produced and variously modified by many causes besides contagion, and more especially by epidemic and endemic influences. but this is not peculiar to the disease in question. there is no doubt that smallpox is propagated to a great extent by contagion, yet it goes through the same records of periodical increase and diminution which have been remarked in puerperal fever. if the question is asked how we are to reconcile the great variations in the mortality of puerperal fever in different seasons and places with the supposition of contagion, i will answer it by another question from mr. farr's letter to the registrar-general. he makes the statement that "five die weekly of smallpox in the metropolis when the disease is not epidemic," and adds, "the problem for solution is, why do the five deaths become 10, 15, 20, 31, 58, 88, weekly, and then progressively fall through the same measured steps?" 5. i take it for granted that if it can be shown that great numbers of lives have been and are sacrificed to ignorance or blindness on this point, no other error of which physicians or nurses may be occasionally suspected will be alleged in palliation of this; but that whenever and wherever they can be shown to carry disease and death instead of health and safety, the common instincts of humanity will silence every attempt to explain away their responsibility. the treatise of dr. gordon, of aberdeen, was published in the year 1795, being among the earlier special works upon the disease. a part of his testimony has been occasionally copied into other works, but his expressions are so clear, his experience is given with such manly distinctness and disinterested honesty, that it may be quoted as a model which might have been often followed with advantage. "this disease seized such women only as were visited or delivered by a practitioner, or taken care of by a nurse, who had previously attended patients affected with the disease." "i had evident proofs of its infectious nature, and that the infection was as readily communicated as that of the smallpox or measles, and operated more speedily than any other infection with which i am acquainted." "i had evident proofs that every person who had been with a patient in the puerperal fever became charged with an atmosphere of infection, which was communicated to every pregnant woman who happened to come within its sphere. this is not an assertion, but a fact, admitting of demonstration, as may be seen by a perusal of the foregoing table"--referring to a table of seventy-seven cases, in many of which the channel of propagation was evident. he adds: "it is a disagreeable declaration for me to mention, that i myself was the means of carrying the infection to a great number of women." he then enumerates a number of instances in which the disease was conveyed by midwives and others to the neighboring villages, and declares that "these facts fully prove that the cause of the puerperal fever, of which i treat, was a specific contagion, or infection, altogether unconnected with a noxious constitution of the atmosphere." but his most terrible evidence is given in these words: "i arrived at that certainty in the matter that i could venture to foretell what women would be affected with the disease, upon hearing by what midwife they were to be delivered, or by what nurse they were to be attended, during their lying-in: and almost in every instance my prediction was verified." even previously to gordon, mr. white, of manchester, had said: "i am acquainted with two gentlemen in another town, where the whole business of midwifery is divided betwixt them, and it is very remarkable that one of them loses several patients every year of the puerperal fever, and the other never so much as meets with the disorder"--a difference which he seems to attribute to their various modes of treatment. [footnote: on the management of lying-in women. p. 120.] dr. armstrong has given a number of instances in his essay on puerperal fever of the prevalence of the disease among the patients of a single practitioner. at sunderland, "in all, fortythree cases occurred from the 1st of january to the 1st of october, when the disease ceased; and of this number, forty were witnessed by mr. gregson and his assistant, mr. gregory, the remainder having been separately seen by three accoucheurs." there is appended to the london edition of this essay a letter from mr. gregson, in which that gentleman says, in reference to the great number of cases occurring in his practice, "the cause of this i cannot pretend fully to explain, but i should be wanting in common liberality if i were to make any hesitation in asserting that the disease which appeared in my practice was highly contagious, and communicable from one puerperal woman to another." "it is customary among the lower and middle ranks of people to make frequent personal visits to puerperal women resident in the same neighborhood, and i have ample evidence for affirming that the infection of the disease was often carried about in that manner; and, however painful to my feelings, i must in candour declare that it is very probable the contagion was conveyed, in some instances, by myself, though i took every possible care to prevent such a thing from happening the moment that i ascertained that the distemper was infectious." dr. armstrong goes on to mention six other instances within his knowledge, in which the disease had at different times and places been limited, in the same singular manner, to the practice of individuals, while it existed scarcely, if at all, among the patients of others around them. two of the gentlemen became so convinced of their conveying the contagion that they withdrew for a time from practice. i find a brief notice, in an american journal, of another series of cases, first mentioned by mr. davies, in the "medical repository." this gentleman stated his conviction that the disease is contagious. "in the autumn of 1822 he met with twelve cases, while his medical friends in the neighbourhood did not meet with any, 'or at least very few.' he could attribute this circumstance to no other cause than his having been present at the examination after death, of two cases, some time previous, and of his having imparted the disease to his patients, notwithstanding every precaution." [footnote: philad. med. journal for 1825, p. 408.] dr. gooch says: "it is not uncommon for the greater number of cases to occur in the practice of one man, whilst the other practitioners of the neighborhood, who are not more skilful or more busy, meet with few or none. a practitioner opened the body of a woman who had died of puerperal fever, and continued to wear the same clothes. a lady whom he delivered a few days afterwards was attacked with and died of a similar disease; two more of his lying-in patients, in rapid succession, met with the same fate; struck by the thought that he might have carried contagion in his clothes, he instantly changed them, and met with no more cases of the kind. [footnote: a similar anecdote is related by sir benjamin brodie, of the late dr. john clark, lancet, may 2, 1840.] a woman in the country who was employed as washerwoman and nurse washed the linen of one who had died of puerperal fever; the next lying-in patient she nursed died of the same disease; a third nursed by her met the same fate, till the neighbourhood, getting afraid of her, ceased to employ her." [footnote: an account of some of the most important diseases peculiar to women, p. 4]. in the winter of the year 1824, "several instances occurred of its prevalence among the patients of particular practitioners, whilst others who were equally busy met with few or none. one instance of this kind was very remarkable. a general practitioner, in large midwifery practice, lost so many patients from puerperal fever that he determined to deliver no more for some time, but that his partner should attend in his place. this plan was pursued for one month, during which not a case of the disease occurred in their practice. the elder practitioner, being then sufficiently recovered, returned to his practice, but the first patient he attended was attacked by the disease and died. a physician who met him in consultation soon afterwards, about a case of a different kind, and who knew nothing of his misfortune, asked him whether puerperal fever was at all prevalent in his neighbourhood, on which he burst into tears, and related the above circumstances. "among the cases which i saw this season in consultation, four occurred in one month in the practice of one medical man, and all of them terminated fatally." [footnote: gooch, op. cit., p. 71.] dr. ramsbotham asserted, in a lecture at the london hospital, that he had known the disease spread through a particular district, or be confined to the practice of a particular person, almost every patient being attacked with it, while others had not a single case. it seemed capable, he thought, of conveyance, not only by common modes, but through the dress of the attendants upon the patient. [footnote: lond. med. gaz., may 2, 1835.] in a letter to be found in the "london medical gazette" for january, 1840, mr. roberton, of manchester, makes the statement which i here give in a somewhat condensed form. a midwife delivered a woman on the 4th of december, 1830, who died soon after with the symptoms of puerperal fever. in one month from this date the same midwife delivered thirty women, residing in different parts of an extensive suburb, of which number sixteen caught the disease and all died. these were the only cases which had occurred for a considerable time in manchester. the other midwives connected with the same charitable institution as the woman already mentioned are twenty-five in number, and deliver, on an average, ninety women a week, or about three hundred and eighty a month. none of these women had a case of puerperal fever. "yet all this time this woman was crossing the other midwives in every direction, scores of the patients of the charity being delivered by them in the very same quarters where her cases of fever were happening." mr. roberton remarks that little more than half the women she delivered during this month took the fever; that on some days all escaped, on others only one or more out of three or four; a circumstance similar to what is seen in other infectious maladies. dr. blundell says: "those who have never made the experiment can have but a faint conception how difficult it is to obtain the exact truth respecting any occurrence in which feelings and interests are concerned. omitting particulars, then, i content myself with remarking, generally, that from more than one district i have received accounts of the prevalence of puerperal fever in the practice of some individuals, while its occurrence in that of others, in the same neighborhood, was not observed. some, as i have been told, have lost ten, twelve, or a greater number of patients, in scarcely broken succession; like their evil genius, the puerperal fever has seemed to stalk behind them wherever they went. some have deemed it prudent to retire for a time from practice. in fine, that this fever may occur spontaneously, i admit; that its infectious nature may be plausibly disputed, i do not deny; but i add, considerately, that in my own family i had rather that those i esteemed the most should be delivered, unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease. gossiping friends, wet-nurses, monthly nurses, the practitioner himself, these are the channels by which, as i suspect, the infection is principally conveyed." [footnote: lect. on midwifery, p. 395.] at a meeting of the royal medical and chirurgical society dr. king. mentioned that some years since a practitioner at woolwich lost sixteen patients from puerperal fever in the same year. he was compelled to give up practice for one or two years, his business being divided among the neighboring practitioners. no case of puerperal fever occurred afterwards, neither had any of the neighboring surgeons any cases of this disease. at the same meeting mr. hutchinson mentioned the occurrence of three consecutive cases of puerperal fever, followed subsequently by two others, all in the practice of one accoucheur. [footnote: lancet, may 3, 1840.] dr. lee makes the following statement: "in the last two weeks of september, 1827, five fatal cases of uterine inflammation came under our observation. all the individuals so attacked had been attended in labor by the same midwife, and no example of a febrile or inflammatory disease of a serious nature occurred during that period among the other patients of the westminster general dispensary, who had been attended by the other midwives belonging to that institution." [footnote: lond. cyc. of pract. med., art., "fever, puerperal"] the recurrence of long series of cases like those i have cited, reported by those most interested to disbelieve in contagion, scattered along through an interval of half a century, might have been thought sufficient to satisfy the minds of all inquirers that here was something more than a singular coincidence. but if, on a more extended observation, it should be found that the same ominous groups of cases clusterings about individual practitioners were observed in a remote country, at different times, and in widely separated regions, it would seem incredible that any should be found too prejudiced or indolent to accept the solemn truth knelled into their ears by the funeral bells from both sides of the ocean--the plain conclusion that the physician and the disease entered, hand in hand, into the chamber of the unsuspecting patient. that such series of cases have been observed in this country, and in this neighborhood, i proceed to show. in dr. francis's "notes to denman's midwifery" a passage is cited from dr. hosack in which he refers to certain puerperal cases which proved fatal to several lying-in women, and in some of which the disease was supposed to be conveyed by the accoucheurs themselves. [footnote: denman's midwifery, p. 673, third am. ed.] a writer in the "new york medical and physical journal" for october, 1829, in speaking of the occurrence of puerperal fever confined to one man's practice, remarks: "we have known cases of this kind occur, though rarely, in new york." i mention these little hints about the occurrence of such cases partly because they are the first i have met with in american medical literature, but more especially because they serve to remind us that behind the fearful array of published facts there lies a dark list of similar events, unwritten in the records of science, but long remembered by many a desolated fireside. certainly nothing can be more open and explicit than the account given by dr. peirson, of salem, of the cases seen by him. in the first nineteen days of january, 1829, he had five consecutive cases of puerperal fever, every patient he attended being attacked, and the three first cases proving fatal. in march of the same year he had two moderate cases, in june, another case, and in july, another, which proved fatal. "up to this period," he remarks, "i am not informed that a single case had occurred in the practice of any other physician. since that period i have had no fatal case in my practice, although i have had several dangerous cases. i have attended in all twenty cases of this disease, of which four have been fatal. i am not aware that there has been any other case in the town of distinct puerperal peritonitis, although i am willing to admit my information may be very defective on this point. i have been told of some 'mixed cases,' and 'morbid affections after delivery.'" [footnote: remarks on puerperal fever, pp. 12 and 13.] in the "quarterly summary of the transactions of the college of physicians of philadelphia" [footnote: for may, june, and july, 1842.] may be found some most extraordinary developments respecting a series of cases occurring in the practice of a member of that body. dr. condie called the attention of the society to the prevalence, at the present time, of puerperal fever of a peculiarly insidious and malignant character. "in the practice of one gentleman extensively engaged as an obstetrician nearly every female he has attended in confinement, during several weeks past, within the above limits" (the southern sections and neighboring districts), "had been attacked by the fever." "an important query presents itself, the doctor observed, in reference to the particular form of fever now prevalent. is it, namely, capable of being propagated by contagion, and is a physician who has been in attendance upon a case of the disease warranted in continuing, without interruption, his practice as an obstetrician? dr. c., although not a believer in the contagious character of many of those affections generally supposed to be propagated in this manner, has, nevertheless, become convinced by the facts that have fallen under his notice that the puerperal fever now prevailing is capable of being communicated by contagion. how, otherwise, can be explained the very curious circumstance of the disease in one district being exclusively confined to the practice of a single physician, a fellow of this college, extensively engaged in obstetrical practice, while no instance of the disease has occurred in the patients under the care of any other accoucheur practising within the same district; scarcely a female that has been delivered for weeks past has escaped an attack?" dr. rutter, the practitioner referred to, "observed that, after the occurrence of a number of cases of the disease in his practice, he had left the city and remained absent for a week, but, on returning, no article of clothing he then wore having been used by him before, one of the very first cases of parturition he attended was followed by an attack of the fever and terminated fatally; he cannot readily, therefore, believe in the transmission of the disease from female to female in the person or clothes of the physician." the meeting at which these remarks were made was held on the 3d of may, 1842. in a letter dated december 20, 1842, addressed to dr. meigs, and to be found in the "medical examiner," [footnote: for january 21, 1843.] he speaks of "those horrible cases of puerperal fever, some of which you did me the favor to see with me during the past summer," and talks of his experience in the disease, "now numbering nearly seventy cases, all of which have occurred within less than a twelve-month past." and dr. meigs asserts, on the same page, "indeed, i believe that his practice in that department of the profession was greater than that of any other gentleman, which was probably the cause of his seeing a greater number of the cases." this from a professor of midwifery, who some time ago assured a gentleman whom he met in consultation that the night on which they met was the eighteenth in succession that he himself had been summoned from his repose, [footnote: medical examiner for december 10, 1842.] seems hardly satisfactory. i must call the attention of the inquirer most particularly to the quarterly report above referred to, and the letters of dr. meigs and dr. rutter, to be found in the "medical examiner." whatever impression they may produce upon his mind, i trust they will at least convince him that there is some reason for looking into this apparently uninviting subject. at a meeting of the college of physicians just mentioned dr. warrington stated that a few days after assisting at an autopsy of puerperal peritonitis, in which he laded out the contents of the abdominal cavity with his hands, he was called upon to deliver three women in rapid succession. all of these women were attacked with different forms of what is commonly called puerperal fever. soon after these he saw two other patients, both on the same day, with the same disease. of these five patients, two died. at the same meeting dr. west mentioned a fact related to him by dr. samuel jackson, of northumberland. seven females, delivered by dr. jackson in rapid succession, while practising in northumberland county, were all attacked with puerperal fever, and five of them died. "women," he said, "who had expected me to attend upon them, now becoming alarmed, removed out of my reach, and others sent for a physician residing several miles distant. these women, as well as those attended by midwives, all did well; nor did we hear of any deaths in child-bed within a radius of fifty miles, excepting two, and these i afterwards ascertained to have been caused by other diseases." he underwent, as he thought, a thorough purification, and still his next patient was attacked with the disease and died. he was led to suspect that the contagion might have been carried in the gloves which he had worn in attendance upon the previous cases. two months or more after this he had two other cases. he could find nothing to account for these unless it were the instruments for giving enemata, which had been used in two of the former cases and were employed by these patients. when the first case occurred, he was attending and dressing a limb extensively mortified from erysipelas, and went immediately to the accouchement with his clothes and gloves most thoroughly imbued with its effluvia. and here i may mention that this very dr. samael jackson, of northumberland, is one of dr. dewees's authorities against contagion. the three following statements are now for the first time given to the public. all of the cases referred to occurred within this state, and two of the three series in boston and its immediate vicinity. i. the first is a series of cases which took place during the last spring in a town at some distance from this neighborhood. a physician of that town, dr. c, had the following consecutive cases: no. 1, delivered march 20, died march 24. " 2, " april 9, " april 14. " 3, " " 10, " " 14. " 4, " " 11, " " 18. " 5, " " 27, " may 3. " 6, " " 28, had some symptoms, recovered. " 7, " may 8, had some symptoms, also recovered. these were the only cases attended by this physician during the period referred to, "they were all attended by him until their termination, with the exception of the patient no. 6, who fell into the hands of another physician on the 2d of may." (dr. c. left town for a few days at this time.) dr. c. attended cases immediately before and after the above-named periods, none of which, however, presented any peculiar symptoms of the disease. about the 1st of july he attended another patient in a neighboring village, who died two or three days after delivery. the first patient, it is stated, was delivered on the 20th of march. "on the 19th dr. c. made the autopsy of a man who had died suddenly, sick only forty-eight hours; had oedema of the thigh and gangrene extending from a little above the ankle into the cavity of the abdomen." dr. c. wounded himself very slightly in the right hand during the autopsy. the hand was quite painful the night following, during his attendance on the patient no. 1. he did not see this patient after the 20th, being confined to the house, and very sick from the wound just mentioned, from this time until the 3d of april. several cases of erysipelas occurred in the house where the autopsy mentioned above took place, soon after the examination. there were also many cases of erysipelas in town at the time of the fatal puerperal cases which have been mentioned. the nurse who laid out the body of the patient no. 3 was taken on the evening of the same day with sore throat and erysipelas, and died in ten days from the first attack. the nurse who laid out the body of the patient no. 4 was taken on the day following with symptoms like those of this patient, and died in a week, without any external marks of erysipelas. "no other cases of similar character with those of dr. c. occurred in the practice of any of the physicians in the town or vicinity at the time. deaths following confinement have occurred in the practice of other physicians during the past year, but they were not cases of puerperal fever. no post-mortem examinations were held in any of these puerperal cases." some additional statements in this letter are deserving of insertion: "a physician attended a woman in the immediate neighborhood of the cases numbered 2, 3, and 4. this patient was confined the morning of march 1st, and died on the night of match 7th. it is doubtful whether this should be considered a case of puerperal fever. she had suffered from canker, indigestion, and diarrhoea for a year previous to her delivery. her complaints were much aggravated for two or three months previous to delivery; she had become greatly emaciated, and weakened to such an extent that it had not been expected that she would long survive her confinement, if indeed she reached that period. her labor was easy enough; she flowed a good deal, seemed exceedingly prostrated, had ringing in her ears, and other symptoms of exhaustion; the pulse was quick and small. on the second and third day there was some tenderness and tumefaction of the abdomen, which increased somewhat on the fourth and fifth. he had cases in midwifery before and after this, which presented nothing peculiar. it is also mentioned in the same letter that another physician had a case during the last summer and another last fall, both of which recovered. another gentleman reports a case last december, a second case five weeks, and another three weeks, since. all these recovered, a case also occurred very recently in the practice of a physician in the village where the eighth patient of dr. c. resides, which proved fatal "this patient had some patches of erysipelas on the legs and arms. the same physician has delivered three cases since, which have all done well. there have been no other cases in this town or its vicinity recently. there have been some few cases of erysipelas." it deserves notice that the partner of dr. c, who attended the autopsy of the man above mentioned and took an active part in it, who also suffered very slightly from a prick under the thumb-nail received during the examination, had twelve cases of midwifery between march 26th and april 12th, all of which did well, and presented no peculiar symptoms. it should also be stated that during these seventeen days he was in attendance on all the cases of erysipelas in the house where the autopsy had been performed. i owe these facts to the prompt kindness of a gentleman whose intelligence and character are sufficient guaranty for their accuracy. the two following letters were addressed to my friend dr. storer by the gentleman in whose practice the cases of puerperal fever occurred. his name renders it unnecessary to refer more particularly to these gentlemen, who on their part have manifested the most perfect freedom and courtesy in affording these accounts of their painful experience. "january 38, 1843. ii ... "the time to which you allude was in 1830. the first case was in february, during a very cold time. she was confined the 4th, and died the 12th. between the 10th and 28th of this month i attended six women in labor, all of whom did well except the last, as also two who were confined march 1st and 5th. mrs. e., confined february 28th, sickened, and died march 8th. the next day, 9th, i inspected the body, and the night after attended a lady, mrs. b., who sickened, and died 16th. the 10th, i attended another, mrs. g., who sickened, but recovered. march 16th i went from mrs. g.'s room to attend a mrs. h., who sickened, and died 21st. the 17th, i inspected mrs. b. on the 19th, i went directly from mrs. h.'s room to attend another lady, mrs. g., who also sickened, and died 22d. while mrs. b. was sick, on 15th, i went directly from her room a few rods, and attended another woman, who was not sick. up to 20th of this month i wore the same clothes. i now refused to attend any labor, and did not till april 21st, when, having thoroughly cleansed myself, i resumed my practice, and had no more puerperal fever. "the cases were not confined to a narrow space. the two nearest were half a mile from each other, and half that distance from my residence. the others were from two to three miles apart, and nearly that distance from my residence. there were no other cases in their immediate vicinity which came to my knowledge. the general health of all the women was pretty good, and all the labors as good as common, except the first. this woman, in consequence of my not arriving in season, and the child being half-born at some time before i arrived, was very much exposed to the cold at the time of confinement, and afterwards, being confined in a very open, cold room. of the six cases, you perceive only one recovered. "in the winter of 1817 two of my patients had puerperal fever, one very badly, the other not so badly. both recovered. one other had swelled leg or phlegmasia dolens, and one or two others did not recover as well as usual. "in the summer of 1835 another disastrous period occurred in my practice. july 1st i attended a lady in labor, who was afterwards quite ill and feverish; but at the time i did not consider her case a decided puerperal fever. on the 8th i attended one who did well. on the 12th, one who was seriously sick. this was also an equivocal case, apparently arising from constipation and irritation of the rectum. these women were ten miles apart and five from my residence. on 15th and 2oth two who did well. on 25th i attended another. this was a severe labor, and followed by unequivocal puerperal fever, or peritonitis. she recovered. august 2nd and 3rd, in about twenty-four hours, i attended four persons. two of them did very well; one was attacked with some of the common symptoms, which, however, subsided in a day or two, and the other had decided puerperal fever, but recovered. this woman resided five miles from me. up to this time i wore the same coat. all my other clothes had frequently been changed. on 6th, i attended two women, one of whom was not sick at all; but the other, mrs. l., was afterwards taken ill. on 10th, i attended a lady, who did very well. i had previously changed all my clothes, and had no garment on which had been in a puerperal room. on 12th, i was called to mrs. s., in labor. while she was ill, i left her to visit mrs. l., one of the ladies who was confined on 6th. mrs. l. had been more unwell than usual, but i had not considered her case anything more than common till this visit. i had on a surtout at this visit, which, on my return to mrs. s., i left in another room. mrs. s. was delivered on 13th with forceps. these women both died of decided puerperal fever. "while i attended these women in their fevers i changed my clothes, and washed my hands in a solution of chloride of lime after each visit. i attended seven women in labor during this period, all of whom recovered without sickness. "in my practice i have had several single cases of puerperal fever, some of whom have died and some have recovered. until the year 1830 i had no suspicion that the disease could be communicated from one patient to another by a nurse or midwife; but i now think the foregoing facts strongly favor that idea. i was so much convinced of this fact that i adopted the plan before related. "i believe my own health was as good as usual at each of the above periods. i have no recollection to the contrary. "i believe i have answered all your questions. i have been more particular on some points perhaps than necessary; but i thought you could form your own opinion better than to take mine. in 1830 i wrote to dr. channing a more particular statement of my cases. if i have not answered your questions sufficiently, perhaps dr. c. may have my letter to him, and you can find your answer there." [footnote: in a letter to myself this gentleman also stated," i do not recollect that there was any erysipelas or any other disease particularly prevalent at the time."] "boston, february 3, 1843. iii. "my dear sir: i received a note from you last evening requesting me to answer certain questions therein proposed, touching the cases of puerperal fever which came under my observation the past summer. it gives me pleasure to comply with your request, so far as it is in my power so to do, but, owing to the hurry in preparing for a journey, the notes of the cases i had then taken were lost or mislaid. the principal facts, however, are too vivid upon my recollection to be soon forgotten. i think, therefore, that i shall be able to give you all the information you may require. "all the cases that occurred in my practice took place between the 7th of may and the 17th of june, 1842. they were not confined to any particular part of the city. the first two cases were patients residing at the south end, the next was at the extreme north end, one living in sea street and the other in roxbury. the following is the order in which they occurred: "case 1.--mrs.-was confined on the 7th of may, at 5 o'clock, p. m., after a natural labor of six hours. at 12 o'clock at night, on the 9th (thirty-one hours after confinement), she was taken with severe chill, previous to which she was as comfortable as women usually are under the circumstances. she died on the 10th. "case 2.--mrs.-was confined on the 10th of june (four weeks after mrs. c), at 11 a. m., after a natural, but somewhat severe, labor of five hours. at 7 o'clock, on the morning of the 11th, she had a chill. died on the 12th. "case 3.--mrs.--, confined on the 14th of june, was comfortable until the 18th, when symptoms of puerperal fever were manifest. she died on the 20th. "case 4.--mrs.--, confined june 17th, at 5 o'clock, a. m., was doing well until the morning of the 19th. she died on the evening of the 21st. "case 5.--mrs.--was confined with her fifth child on the 17th of june, at 6 o'clock in the evening. this patient had been attacked with puerperal fever, at three of her previous confinements, but the disease yielded to depletion and other remedies without difficulty. this time, i regret to say, i was not so fortunate. she was not attacked, as were the other patients, with a chill, but complained of extreme pain in the abdomen, and tenderness on pressure, almost from the moment of her confinement. in this, as in the other cases, the disease resisted all remedies, and she died in great distress on the 22d of the same month. owing to the extreme heat of the season and my own indisposition, none of the subjects were examined after death. dr. channing, who was in attendance with me on the three last cases, proposed to have a post-mortem examination of the subject of case no. 5, but from some cause which i do not now recollect it was not obtained. "you wish to know whether i wore the same clothes when attending the different cases. i cannot positively say, but i should think i did not, as the weather became warmer after, the first two cases; i therefore think it probable that i made a change of at least a part of my dress. i have had no other case of puerperal fever in my own practice for three years, save those above related, and i do not remember to have lost a patient before with this disease. while absent, last july, i visited two patients sick with puerperal fever, with a friend of mine in the country. both of them recovered. "the cases that i have recorded were not confined to any particular constitution or temperament, but it seized upon the strong and the weak, the old and the young--one being over forty years, and the youngest under eighteen years of age... if the disease is of an erysipelatous nature, as many suppose, contagionists may perhaps find some ground for their belief in the fact that, for two weeks previous to my first case of puerperal fever, i had been attending a severe case of erysipelas, and the infection may have been conveyed through me to the patient; but, on the other hand, why is not this the case with other physicians, or with the same physician at all times, for since my return from the country i have had a more inveterate case of erysipelas than ever before, and no difficulty whatever has attended any of my midwifery cases?" i am assured, on unquestionable authority, that "about three years since a gentleman in extensive midwifery business, in a neighboring state, lost in the course of a few weeks eight patients in child-bed, seven of them being undoubted cases of puerperal fever. no other physician of the town lost a single patient of this disease during the same period." and from what i have heard in conversation with some of our most experienced practitioners, i am inclined to think many cases of the kind might be brought to light by extensive inquiry. this long catalogue of melancholy histories assumes a still darker aspect when we remember how kindly nature deals with the parturient female, when she is not immersed in the virulent atmosphere of an impure lying-in hospital, or poisoned in her chamber by the unsuspected breath of contagion. from all causes together not more than four deaths in a thousand births and miscarriages happened in england and wales during the period embraced by the first report of the registrar-general. [footnote: first report, p. 105.] in the second report the mortality was shown to be about five in one thousand. [footnote: second report, p. 73.] in the dublin lying-in hospital, during the seven years of dr. collins's mastership, there was one case of puerperal fever to 178 deliveries, or less than six to the thousand, and one death from this disease in 278 cases, or between three and four to the thousand. [footnote: collins's treatise on midwifery, p. 228, etc.] yet during this period the disease was endemic in the hospital, and might have gone on to rival the horrors of the pestilence of the maternite, had not the poison been destroyed by a thorough purification. in private practice, leaving out of view the cases that are to be ascribed to the self-acting system of propagation, it would seem that the disease must be far from common. mr. white, of manchester, says: "out of the whole number of lying-in patients whom i have delivered (and i may safely call it a great one), i have never lost one, nor to the best of my recollection has one been greatly endangered, by the puerperal, miliary, low nervous, putrid malignant, or milk fever." [footnote: op. cit., p. 115.] dr. joseph clarke informed dr. collins that in the course of forty-five years' most extensive practice he lost but four patients from this disease. [footnote: op. cit., p.228.] one of the most eminent practitioners of glasgow who has been engaged in very extensive practice for upwards of a quarter of a century testifies that he never saw more than twelve cases of real puerperal fever. [footnote: lancet, may 4, 1833.] i have myself been told by two gentlemen practicing in this city, and having for many years a large midwifery business, that they had neither of them lost a patient from this disease, and by one of them that he had only seen it in consultation with other physicians. in five hundred cases of midwifery, of which dr. storer has given an abstract in the first number of this journal, there was only one instance of fatal puerperal peritonitis. in the view of these facts it does appear a singular coincidence that one man or woman should have ten, twenty, thirty, or seventy cases of this rare disease following his or her footsteps with the keenness of a beagle, through the streets and lanes of a crowded city, while the scores that cross the same paths on the same errands know it only by name. it is a series of similar coincidences which has led us to consider the dagger, the musket, and certain innocent-looking white powders as having some little claim to be regarded as dangerous. it is the practical inattention to similar coincidences which has given rise to the unpleasant but often necessary documents called indictments, which has sharpened a form of the cephalotome sometimes employed in the case of adults, and adjusted that modification of the fillet which delivers the world of those who happen to be too much in the way while such striking coincidences are taking place. i shall now mention a few instances in which the disease appears to have been conveyed by the process of direct inoculation. dr. campbell, of edinburgh, states that in october, 1821, he assisted at the post-mortem examination of a patient who died with puerperal fever. he carried the pelvic viscera in his pocket to the class-room. the same evening he attended a woman in labor without previously changing his clothes; this patient died. the next morning he delivered a woman with the forceps; she died also, and of many others who were seized with the disease within a few weeks, three shared the same fate in succession. in june, 1823, he assisted some of his pupils at the autopsy of a case of puerperal fever. he was unable to wash his hands with proper care, for want of the necessary accommodations. on getting home he found that two patients required his assistance. he went without further ablution or changing his clothes; both these patients died with puerperal fever. [footnote: lond. med. gazette, december 10, 1831.] this same dr. campbell is one of dr. churchill's authorities against contagion. mr. roberton says that in one instance within his knowledge a practitioner passed the catheter for a patient with puerperal fever late in the evening; the same night he attended a lady who had the symptoms of the disease on the second day. in another instance a surgeon was called while in the act of inspecting the body of a woman who had died of this fever, to attend a labor; within forty-eight hours this patient was seized with the fever [footnote: ibid. for january 1832]. on the 16th of march, 1831, a medical practitioner examined the body of a woman who had died a few days after delivery, from puerperal peritonitis. on the evening of the 17th he delivered a patient, who was seized with puerperal fever on the 19th, and died on the 24th. between this period and the 6th of april the same practitioner attended two other patients, both of whom were attacked with the same disease and died. [footnote: london cyc. of pract. med., art., "fever, puerperal."] in the autumn of 1829 a physician was present at the examination of a case of puerperal fever, dissected out the organs, and assisted in sewing up the body. he had scarcely reached home when he was summoned to attend a young lady in labor. in sixteen hours she was attacked with the symptoms of puerperal fever, and narrowly escaped with her life. [footnote: ibid.] in december, 1830, a midwife, who had attended two fatal cases of puerperal fever at the british lying-in hospital, examined a patient who had just been admitted, to ascertain if labor had commenced. this patient remained two days in the expectation that labor would come on, when she returned home and was then suddenly taken in labor and delivered before she could set out for the hospital. she went on favorably for two days, and was then taken with puerperal fever and died in thirty-six hours. [footnote: ibid.] a young practitioner, contrary to advice, examined the body of a patient who had died from puerperal fever; there was no epidemic at the time; the case appeared to be purely sporadic. he delivered three other women shortly afterwards; they all died with puerperal fever, the symptoms of which broke out very soon after labor. the patients of his colleague did well, except one, where he assisted to remove some coagula from the uterus; she was attacked in the same manner as those whom he had attended, and died also." the writer in the "british and foreign medical review," from whom i quote this statement,--and who is no other than dr. rigby,--adds: "we trust that this fact alone will forever silence such doubts, and stamp the well-merited epithet of 'criminal,' as above quoted, upon such attempts [footnote: brit. and for. medical review for january, 1842, p. 112.] from the cases given by mr. ingleby i select the following: two gentlemen, after having been engaged in conducting the postmortem examination of a case of puerperal fever, went in the same dress, each respectively, to a case of midwifery. "the one patient was seized with the rigor about thirty hours afterwards. the other patient was seized with a rigor the third morning after delivery. one recovered, one died." [footnote: edin. med. and surg. journal, april 1838.] one of these same gentlemen attended another woman in the same clothes two days after the autopsy referred to. "the rigor did not take place until the evening of the fifth day from the first visit. result fatal." these cases belonged to a series of seven, the first of which was thought to have originated in a case of erysipelas. "several cases of a mild character followed the foregoing seven, and their nature being now most unequivocal, my friend declined visiting all midwifery cases for a time, and there was no recurrence of the disease." these cases occurred in 1833. five of them proved fatal. mr. ingleby gives another series of seven cases which occurred to a practitioner in 1836, the first of which was also attributed to his having opened several erysipelatous abscesses a short time previously. i need not refer to the case lately read before this society, in which a physician went, soon after performing an autopsy of a case of puerperal fever, to a woman in labor, who was seized with the same disease and perished. the forfeit of that error has been already paid. at a meeting of the medical and chirurgical society before referred to, dr. merriman related an instance occurring in his own practice, which excites a reasonable suspicion that two lives were sacrificed to a still less dangerous experiment. he was at the examination of a case of puerperal fever at two o'clock in the afternoon. he took care not to touch the body. at nine o'clock the same evening he attended a woman in labor; she was so nearly delivered that he had scarcely anything to do. the next morning she had severe rigors, and in forty-eight hours she was a corpse. her infant had erysipelas and died in two days. [footnote: lancet, may 2, 1840.] in connection with the facts which have been stated it seems proper to allude to the dangerous and often fatal effects which have followed from wounds received in the post-mortem examination of patients who have died of puerperal fever. the fact that such wounds are attended with peculiar risk has been long noticed. i find that chaussier was in the habit of cautioning his students against the danger to which they were exposed in these dissections. [footnote: stein, l'art d'accoucher, 1794; dict. des sciences medicales, art., "puerperal."] the head pharmacien of the hotel dieu, in his analysis of the fluid effused in puerperal peritonitis, says that practitioners are convinced of its deleterious qualities, and that it is very dangerous to apply it to the denuded skin. [footnote: journal de pharmacie, january 1836.] sir benjamin brodie speaks of it as being well known that the inoculation of lymph or pus from the peritoneum of a puerperal patient is often attended with dangerous and even fatal symptoms. three cases in confirmation of this statement, two of them fatal, have been reported to this society within a few months. of about fifty cases of injuries of this kind, of various degrees of severity, which i have collected from different sources, at least twelve were instances of infection from puerperal peritonitis. some of the others are so stated as to render it probable that they may have been of the same nature. five other cases were of peritoneal inflammation; three in males. three were what was called enteritis, in one instance complicated with erysipelas; but it is well known that this term has been often used to signify inflammation of the peritoneum covering the intestines. on the other hand, no case of typhus or typhoid fever is mentioned as giving rise to dangerous consequences, with the exception of the single instance of an undertaker mentioned by mr. travers, who seems to have been poisoned by a fluid which exuded from the body. the other accidents were produced by dissection, or some other mode of contact with bodies of patients who had died of various affections. they also differed much in severity, the cases of puerperal origin being among the most formidable and fatal. now a moment's reflection will show that the number of cases of serious consequences ensuing from the dissection of the bodies of those who had perished of puerperal fever is so vastly disproportioned to the relatively small number of autopsies made in this complaint as compared with typhus or pneumonia (from which last disease not one case of poisoning happened), and still more from all diseases put together, that the conclusion is irresistible that a most fearful morbid poison is often generated in the course of this disease. whether or not it is sui generis confined to this disease, or produced in some others, as, for instance, erysipelas, i need not stop to inquire. in connection with this may be taken the following statement of dr. rigby: "that the discharges from a patient under puerperal fever are in the highest degree contagious we have abundant evidence in the history of lying-in hospitals. the puerperal abscesses are also contagious, and may be communicated to healthy lying-in women by washing with the same sponge; this fact has been repeatedly proved in the vienna hospital; but they are equally communicable to women not pregnant; on more than one occasion the women engaged in washing the soiled bed-linen of the general lying-in hospital have been attacked with abscesses in the fingers or hands, attended with rapidly spreading inflammation of the cellular tissue."[footnote: system of midwifery, p. 292] now add to all this the undisputed fact that within the walls of lying-in hospitals there is often generated a miasm, palpable as the chlorine used to destroy it, tenacious so as in some cases almost to defy extirpation, deadly in some institutions as the plague; which has killed women in a private hospital of london so fast that they were buried two in one coffin to conceal its horrors; which enabled tonnelle to record two hundred and twentytwo autopsies at the maternite of paris; which has led dr. lee to express his deliberate conviction that the loss of life occasioned by these institutions completely defeats the objects of their founders; and out of this train of cumulative evidence, the multiplied groups of cases clustering about individuals, the deadly results of autopsies, the inoculation by fluids from the living patient, the murderous poison of hospitals--does there not result a conclusion that laughs all sophistry to scorn, and renders all argument an insult? i have had occasion to mention some instances in which there was an apparent relation between puerperal fever and erysipelas. the length to which this paper has extended does not allow me to enter into the consideration of this most important subject. i will only say that the evidence appears to me altogether satisfactory that some most fatal series of puerperal fever have been produced by an infection originating in the matter or effluvia of erysipelas. in evidence of some connection between the two diseases, i need not go back to the older authors, as pouteau or gordon, but will content myself with giving the following references, with their dates; from which it will be seen that the testimony has been constantly coming before the profession for the last few years: "london cyclopaedia of practical medicine," article "puerperal fever," 1833. mr. ceeley's account of the puerperal fever at aylesbury, "lancet," 1835. dr. ramsbotham's lecture, "london medical gazette," 1835. mr. yates ackerly's letter in the same journal, 1838. mr. ingleby on epidemic puerperal fever, "edinburgh medical and surgical journal," 1838. mr. paley's letter, "london medical gazette," 1839. remarks at the medical and chirurgical society, "lancet," 1840. dr. rigby's "system of midwifery," 1841. "nunneley on erysipelas," a work which contains a large number of references on the subject, 1841. "british and foreign quarterly review," 1842. dr. s. jackson, of northumberland, as already quoted from the summary of the college of physicians, 1842. and, lastly, a startling series of cases by mr. storrs, of doncaster, to be found in the "american journal of the medical sciences" for january, 1843. the relation of puerperal fever with other continued fevers would seem to be remote and rarely obvious. hey refers to two cases of synochus occurring in the royal infirmary of edinburgh, in women who had attended upon puerperal patients. dr. collins refers to several instances in which puerperal fever has appeared to originate from a continued proximity to patients suffering with typhus. [footnote: treatise on midwifery, p. 228.] such occurrences as those just mentioned, though most important to be remembered and guarded against, hardly attract our notice in the midst of the gloomy facts by which they are surrounded. of these facts, at the risk of fatiguing repetitions, i have summoned a sufficient number, as i believe, to convince the most incredulous that every attempt to disguise the truth which underlies them all is useless. it is true that some of the historians of the disease, especially hulme, hull, and leake, in england; tonnelle, duges, and baudelocque, in france, profess not to have found puerperal fever contagious. at the most they give us mere negative facts, worthless against an extent of evidence which now overlaps the widest range of doubt, and doubles upon itself in the redundancy of superfluous demonstration. examined in detail, this and much of the show of testimony brought up to stare the daylight of conviction out of countenance, proves to be in a great measure unmeaning and inapplicable, as might be easily shown were it necessary. nor do i feel the necessity of enforcing the conclusion which arises spontaneously from the facts which have been enumerated by formally citing the opinions of those grave authorities who have for the last half-century been sounding the unwelcome truth it has cost so many lives to establish. "it is to the british practitioner," says dr. rigby, "that we are indebted for strongly insisting upon this important and dangerous character of puerperal fever." [footnote: british and foreign med. rev. for january, 1842.] the names of gordon, john clarke, denman, burns, young, [footnote: encyc. britannica, xiii, 467, art., "medicine."] hamilton,[footnote: outlines of midwifery, p. 109.] haighton, [footnote: oral lectures, etc.] good, [footnote: study of medicine, ii, 195.] waller, [footnote: medical and physical journal, july, 1830.] blundell, gooch, ramsbotham, douglas, [footnote: dublin hospital reports for 1822.] lee, ingleby, locock, [footnote: library of practical medicine, i. 373], abercrombie [footnote: researches on diseases of the stomach, etc. p. 1841], alison [footnote: library of practical medicine, i, 95.], travers, [footnote: further researches on constitutional irritation, p. 128], rigby, and watson [footnote: london medical gazette, february, 1842] many of whose writings i have already referred to, may have some influence with those who prefer the weight of authorities to the simple deductions of their own reason from the facts aid before them. a few continental writers have adopted similar conclusions [footnote: see british and foreign medical review, vol. iil, p. 525, and vol. iv, p. 517. also ed. med. and surg. journal for july 1824, and american journal of med. sciences for january, 1841.] it gives me pleasure to remember that, while the doctrine has been unceremoniously discredited in one of the leading journals [footnote: pisid. med. journal, vol. xii, p. 364], and made very light of by teachers in two of the principal medical schools of this country, dr. channing has for many years inculcated, and enforced by examples, the danger to be apprehended and the precautions to be taken in the disease under consideration. i have no wish to express any harsh feeling with regard to the painful subject which has come before us. if there are any so far excited by the story of these dreadful events that they ask for some word of indignant remonstrance to show that science does not turn the hearts of its followers into ice or stone, let me remind them that such words have been uttered by those who speak with an authority i could not claim [footnote: dr. blundell and dr. bigby in the works already cited.] it is as a lesson rather than as a reproach that i call up the memory of these irreparable errors and wrongs. no tongue can tell the heart-breaking calamity they have caused; they have closed the eyes just opened upon a new world of love and happiness; they have bowed the strength of manhood into the dust; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. there is no tone deep enough for regret, and no voice loud enough for warning. the woman about to become a mother. or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. the very outcast of the streets has pity upon her sister in degradation when the seal of promised maternity is impressed upon her. the remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. the solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. god forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly! there may be some among those whom i address who are disposed to ask the question, what course are we to follow in relation to this matter? the facts are before them, and the answer must be left to their own judgment and conscience. if any should care to know my own conclusions, they are the following; and in taking the liberty to state them very freely and broadly, i would ask the inquirer to examine them as freely in the light of the evidence which has been laid before him. 1. a physician holding himself in readiness to attend cases of midwifery should never take any active part in the post-mortem examination of cases of puerperal fever. 2. if a physician is present at such autopsies, he should use thorough ablution, change every article of dress, and allow twenty-four hours or more to elapse before attending to any case of midwifery. it may be well to extend the same caution to cases of simple peritonitis. 3. similar precautions should be taken after the autopsy or surgical treatment of cases of erysipelas, if the physician is obliged to unite such offices with his obstetrical duties, which is in the highest degree inexpedient. 4. on the occurrence of a single case of puerperal fever in his practice, the physician is bound to consider the next female he attends in labor, unless some weeks at least have elapsed, as in danger of being infected by him, and it is his duty to take every precaution to diminish her risk of disease and death. 5. if within a short period two cases of puerperal fever happen close to each other, in the practice of the same physician, the disease not existing or prevailing in the neighborhood, he would do wisely to relinquish his obstetrical practice for at least one month, and endeavor to free himself by every available means from any noxious influence he may carry about with him. 6. the occurrence of three or more closely connected cases, in the practice of one individual, no others existing in the neighborhood, and no other sufficient cause being alleged for the coincidence, is prima facie evidence that he is the vehicle of contagion. 7. it is the duty of the physician to take every precaution that the disease shall not be introduced by nurses or other assistants, by making proper inquiries concerning them, and giving timely warning of every suspected source of danger. 8. whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery, the time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon, not as a misfortune, but a crime; and in the knowledge of such occurrences the duties of the practitioner to his profession should give way to his paramount obligations to society. additional references and cases. fifth annual report of the registrar-general of england, 1843, appendix. letter from william fair, esq.--several new series of cases are given in the letter of mr. storrs, contained in the appendix to this report. mr. storrs suggests precautions similar to those i have laid down, and these precautions are strongly enforced by mr. farr, who is, therefore, obnoxious to the same criticisms as myself. hall and dexter, in am. journal of med. sc. for january, 1844.-cases of puerperal fever seeming to originate in erysipelas. elkington, of birmingham, in provincial med. journal, cited in am. journ. med. sc. for april, 1844.--six cases in less than a fortnight, seeming to originate in a case of erysipelas. west's reports, in brit. and for. med. review for october, 1845, and january, 1847.--affection of the arm, resembling malignant pustule, after removing the placenta of a patient who died from puerperal fever. reference to cases at wurzburg, as proving contagion, and to keiller's cases in the monthly journal for february, 1846, as showing connection of puerperal fever and erysipelas. kneeland.--contagiousness of puerperal fever. am. jour. med. sc., january, 1846. also, connection between puerperal fever epidemic erysipelas. ibid., april, 1846. robert storrs.-contagious effects of puerperal fever on the male subject; or on persons not child-bearing. (from provincial med. and surg. journal.) am. jour. med. sc., january, 1846. numerous cases. see also dr. reid's case in same journal for april, 1846. routh's paper in proc. of royal med. chir. soc., am. jour. med. sc., april, 1849, also in b. and f. med. chir. review, april, 1850. hill, of leuchars.--a series of cases illustrating the contagious nature of erysipelas and puerperal fever, and their intimate pathological connection. (from monthly journal of med. sc.) am. jour. med. sc., july, 1850. skoda on the causes of puerperal fever. (peritonitis in rabbits, from inoculation with different morbid secretions.) am. jour. med. sc., october, 1850. arneth.--paper read before the national academy of medicine. annales d'hygiene, tome lxv. 2e partie. ("means of disinfection proposed by m. semmelweis." semmelweiss.) lotions of chloride of lime and use of nail-brush before admission to lying-in wards, alleged sudden and great decrease of mortality from puerperal fever. cause of disease attributed to inoculation with cadaveric matters.) see also routh's paper, mentioned above. moir.--remarks at a meeting of the edinburgh medico-chirurgical society. refers to cases of dr. kellie, of leith. sixteen in succession, all fatal. also to several instances of individual pupils having had a succession of cases in various quarters of the town, while others, practising as extensively in the same localities, had none. also to several special cases not mentioned elsewhere. am. jour. med. sc. for october, 1851. (from new monthly journal of med. science.) simpson.--observations at a meeting of the edinburgh obstetrical society. (an "eminent gentleman," according to dr. meigs, whose "name is as well known in america as in (his) native land," obstetrics, phil., 1852, pp. 368, 375.) the student is referred to this paper for a valuable resume of many of the facts, and the necessary inferences, relating to this subject. also for another series of cases, mr. sidey's, five or six in rapid succession. dr. simpson attended the dissection of two of dr. sidey's cases, and freely handled the diseased parts. his next four child-bed patients were affected with puerperal fever, and it was the first time he had seen it in practice. as dr. simpson is a gentleman (dr. meigs, as above), and as "a gentleman's hands are clean" (dr. meigs' sixth letter), it follows that a gentleman with clean hands may carry the disease. am. jour. med. sc., october, 1851. peddie.--the five or six cases of dr. sidey, followed by the four of dr. simpson, did not end the series. a practitioner in leith having examined in dr. simpson's house, a portion of the uterus obtained from one of the patients, had immediately afterwards three fatal cases of puerperal fever. dr. peddie referred to two distinct series of consecutive cases in his own practice. he had since taken precautions, and not met with any such cases. am. jour. med october, 1851. copland.--considers it proved that puerperal fever may be propagated by the hands and the clothes, or either, of a third person, the bed-clothes or body-clothes of a patient. mentions a new series of cases, one of which he saw, with the practitioner who had attended them. she was the sixth he had had within a few days. all died. dr. copland insisted that contagion had caused these cases; advised precautionary measures, and the practitioner had no other cases for a considerable time. considers it criminal, after the evidence adduced,--which be could have quadrupled,--and the weight of authority brought forward, for a practitioner to be the medium of transmitting contagion and death to his patients. dr. copland lays down rules similar to those suggested by myself, and is therefore entitled to the same epithet for so doing. medical dictionary, new york, 1853. article, puerperal states and diseases. if there is any appetite for facts so craving as to be yet unappeased,--lassata, necdum satiata,--more can be obtained. dr. hodge remarks that "the frequency and importance of this singular circumstance that the disease is occasionally more prevalent with one practitioner than another, has been exceedingly overrated." more than thirty strings of cases, more than two hundred and fifty sufferers from puerperal fever, more than one hundred and thirty deaths, appear as the results of a sparing estimate of such among the facts i have gleaned as could be numerically valued. these facts constitute, we may take it for granted, but a small fraction of those that have actually occurred. the number of them might be greater, but "'t is enough, 't will serve," in mercutio's modest phrase, so far as frequency is concerned. for a just estimate of the importance of the singular circumstance, it might be proper to consult the languid survivors, the widowed husbands, and the motherless children, as well as "the unfortunate accoucheur." on the antiseptic principle of the practice of surgery by joseph lister introductory note joseph lister was born at upton, essex, england, in 1827, and received aw general education at the university of london. after graduation he studied medicine in london and edinburgh, and became lecturer in surgery at the university in the latter city. later he was professor of surgery at glasgow, at edinburgh, and at king's college hospital, london, and surgeon to queen victoria. he was made a baronet in 1883; retired from teaching in 1893; and was raised to the peerage in 1897, with the title of baron lister. even before the work of pasteur on fermentation and putrefaction, lister had been convinced of the importance of scrupulous cleanliness and the usefulness of deodorants in the operating room; and when, through pasteur's researches, he realised that the formation of pus was due to bacteria, he proceeded to develop his antiseptic surgical methods. the immediate success of the new treatment led to its general adoption, with results of such beneficence as to make it rank as one of the great discoveries of the age. on the antiseptic principle of the practice of surgery (1867) in the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it, i arrived several years ago at the conclusion that the essential cause of suppuration in wounds is decomposition brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury. to prevent the occurrence of suppuration with all its attendant risks was an object manifestly desirable, but till lately apparently unattainable, since it seemed hopeless to attempt to exclude the oxygen which was universally regarded as the agent by which putrefaction was effected. but when it had been shown by the researches of pasteur that the septic properties of the atmosphere depended not on the oxygen, or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, it occurred to me that decomposition in the injured part might be avoided without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles. upon this principle i have based a practice of which i will now attempt to give a short account. the material which i have employed is carbolic or phenic acid, a volatile organic compound, which appears to exercise a peculiarly destructive influence upon low forms of life, and hence is the most powerful antiseptic with which we are at present acquainted. the first class of cases to which i applied it was that of compound fractures, in which the effects of decomposition in the injured part were especially striking and pernicious. the results have been such as to establish conclusively the great principle that all local inflammatory mischief and general febrile disturbances which follow severe injuries are due to the irritating and poisonous influence of decomposing blood or sloughs. for these evils are entirely avoided by the antiseptic treatment, so that limbs which would otherwise be unhesitatingly condemned to amputation may be retained, with confidence of the best results. in conducting the treatment, the first object must be the destruction of any septic germs which may have been introduced into the wounds, either at the moment of the accident or during the time which has since elapsed. this is done by introducing the acid of full strength into all accessible recesses of the wound by means of a piece of rag held in dressing forceps and dipped into the liquid. [footnote: the addition of a few drops of water to a considerable quantity of the acid, induces it to assume permanently the liquid form.] this i did not venture to do in the earlier cases; but experience has shown that the compound which carbolic acid forms with the blood, and also any portions of tissue killed by its caustic action, including even parts of the bone, are disposed of by absorption and organisation, provided they are afterwards kept from decomposing. we are thus enabled to employ the antiseptic treatment efficiently at a period after the occurrence of the injury at which it would otherwise probably fail. thus i have now under my care, in glasgow infirmary, a boy who was admitted with compound fracture of the leg as late as eight and one-half hours after the accident, in whom, nevertheless, all local and constitutional disturbance was avoided by means of carbolic acid, and the bones were soundly united five weeks after his admission. the next object to be kept in view is to guard effectually against the spreading of decomposition into the wound along the stream of blood and serum which oozes out during the first few days after the accident, when the acid originally applied has been washed out or dissipated by absorption and evaporation. this part of the treatment has been greatly improved during the past few weeks. the method which i have hitherto published (see lancet for mar. 16th, 23rd, 30th, and april 27th of the present year) consisted in the application of a piece of lint dipped in the acid, overlapping the sound skin to some extent and covered with a tin cap, which was daily raised in order to touch the surface of the lint with the antiseptic. this method certainly succeeded well with wounds of moderate size; and indeed i may say that in all the many cases of this kind which have been so treated by myself or my house-surgeons, not a single failure has occurred. when, however, the wound is very large, the flow of blood and serum is so profuse, especially during the first twenty-four hours, that the antiseptic application cannot prevent the spread of decomposition into the interior unless it overlaps the sound skin for a very considerable distance, and this was inadmissible by the method described above, on account of the extensive sloughing of the surface of the cutis which it would involve. this difficulty has, however, been overcome by employing a paste composed of common whiting (carbonate of lime), mixed with a solution of one part of carbolic acid in four parts of boiled linseed oil so as to form a firm putty. this application contains the acid in too dilute a form to excoriate the skin, which it may be made to cover to any extent that may be thought desirable, while its substance serves as a reservoir of the antiseptic material. so long as any discharge continues, the paste should be changed daily, and, in order to prevent the chance of mischief occurring during the process, a piece of rag dipped in the solution of carbolic acid in oil is put on next the skin, and maintained there permanently, care being taken to avoid raising it along with the putty. this rag is always kept in an antiseptic condition from contact with the paste above it, and destroys any germs which may fall upon it during the short time that should alone be allowed to pass in the changing of the dressing. the putty should be in a layer about a quarter of an inch thick, and may be advantageously applied rolled out between two pieces of thin calico, which maintain it in the form of a continuous sheet, which may be wrapped in a moment round the whole circumference of a limb if this be thought desirable, while the putty is prevented by the calico from sticking to the rag which is next the skin.[footnote: in order to prevent evaporation of the acid, which passes readily through any organic tissue, such as oiled silk or gutta percha, it is well to cover the paste with a sheet of block tin. or tinfoil strengthened with adhesive plaster. the tin sheet lead used for lining tea chests will also answer the purpose, and may be obtained from any wholesale grocer.] when all discharge has ceased, the use of the paste is discontinued, but the original rag is left adhering to the skin till healing by scabbing is supposed to be complete. i have at present in the hospital a man with severe compound fracture of both bones of the left leg, caused by direct violence, who, after the cessation of the sanibus discharge under the use of the paste, without a drop of pus appearing, has been treated for the last two weeks exactly as if the fracture was a simple one. during this time the rag, adhering by means of a crust of inspissated blood collected beneath it, has continued perfectly dry, and it will be left untouched till the usual period for removing the splints in a simple fracture, when we may fairly expect to find a sound cicatrix beneath it. we cannot, however, always calculate on so perfect a result as this. more or less pus may appear after the lapse of the first week, and the larger the wound, the more likely this is to happen. and here i would desire earnestly to enforce the necessity of persevering with the antiseptic application in spite of the appearance of suppuration, so long as other symptoms are favorable. the surgeon is extremely apt to suppose that any suppuration is an indication that the antiseptic treatment has failed, and that poulticing or water dressing should be resorted to. but such a course would in many cases sacrifice a limb or a life. i cannot, however, expect my professional brethren to follow my advice blindly in such a matter, and therefore i feel it necessary to place before them, as shortly as i can, some pathological principles intimately connected, not only with the point we are immediately considering, but with the whole subject of this paper. if a perfectly healthy granulating sore be well washed and covered with a plate of clean metal, such as block tin, fitting its surface pretty accurately, and overlapping the surrounding skin an inch or so in every direction and retained in position by adhesive plaster and a bandage, it will be found, on removing it after twenty-four or forty-eight hours, that little or nothing that can be called pus is present, merely a little transparent fluid, while at the same time there is an entire absence of the unpleasant odour invariably perceived when water dressing is changed. here the clean metallic surface presents no recesses like those of porous lint for the septic germs to develope in, the fluid exuding from the surface of the granulations has flowed away undecomposed, and the result is the absence of suppuration. this simple experiment illustrates the important fact that granulations have no inherent tendency to form pus, but do so only when subjected to preternatural stimulus. further, it shows that the mere contact of a foreign body does not of itself stimulate granulations to suppurate; whereas the presence of decomposing organic matter does. these truths are even more strikingly exemplified by the fact that i have elsewhere recorded (lancet, march 23rd, 1867), that a piece of dead bone free from decomposition may not only fail to induce the granulations around it to suppurate, but may actually be absorbed by them; whereas a bit of dead bone soaked with putrid pus infallibly induces suppuration in its vicinity. another instructive experiment is, to dress a granulating sore with some of the putty above described, overlapping the sound skin extensively; when we find, in the course of twenty-four hours, that pus has been produced by the sore, although the application has been perfectly antiseptic; and, indeed, the larger the amount of carbolic acid in the paste, the greater is the quantity of pus formed, provided we avoid such a proportion as would act as a caustic. the carbolic acid, though it prevents decomposition, induces suppuration--obviously by acting as a chemical stimulus; and we may safely infer that putrescent organic materials (which we know to be chemically acrid) operate in the same way. in so far, then, carbolic acid and decomposing substances are alike; viz., that they induce suppuration by chemical stimulation, as distinguished from what may be termed simple inflammatory suppuration, such as that in which ordinary abscesses originate--where the pus appears to be formed in consequence of an excited action of the nerves, independently of any other stimulus. there is, however, this enormous difference between the effects of carbolic acid and those of decomposition; viz., that carbolic acid stimulates only the surface to which it is at first applied, and every drop of discharge that forms weakens the stimulant by diluting it; but decomposition is a self-propagating and self-aggravating poison, and, if it occur at the surface of a severely injured limb, it will spread into all its recesses so far as any extravasated blood or shreds of dead tissue may extend, and lying in those recesses, it will become from hour to hour more acrid, till it requires the energy of a caustic sufficient to destroy the vitality of any tissues naturally weak from inferior vascular supply, or weakened by the injury they sustained in the accident. hence it is easy to understand how, when a wound is very large, the crust beneath the rag may prove here and there insufficient to protect the raw surface from the stimulating influence of the carbolic acid in the putty; and the result will be first the conversion of the tissues so acted on into granulations, and subsequently the formation of more or less pus. this, however, will be merely superficial, and will not interfere with the absorption and organisation of extravasated blood or dead tissues in the interior. but, on the other hand, should decomposition set in before the internal parts have become securely consolidated, the most disastrous results may ensue. i left behind me in glasgow a boy, thirteen years of age, who, between three and four weeks previously, met with a most severe injury to the left arm, which he got entangled in a machine at a fair. there was a wound six inches long and three inches broad, and the skin was very extensively undermined beyond its limits, while the soft parts were generally so much lacerated that a pair of dressing forceps introduced at the wound and pushed directly inwards appeared beneath the skin at the opposite aspect of the limb. from this wound several tags of muscle were hanging, and among them was one consisting of about three inches of the triceps in almost its entire thickness; while the lower fragment of the bone, which was broken high up, was protruding four inches and a half, stripped of muscle, the skin being tucked in under it. without the assistance of the antiseptic treatment, i should certainly have thought of nothing else but amputation at the shoulder-joint; but, as the radial pulse could be felt and the fingers had sensation, i did not hesitate to try to save the limb and adopted the plan of treatment above described, wrapping the arm from the shoulder to below the elbow in the antiseptic application, the whole interior of the wound, together with the protruding bone, having previously been freely treated with strong carbolic acid. about the tenth day, the discharge, which up to that time had been only sanious and serous, showed a slight admixture of slimy pus; and this increased till (a few days before i left) it amounted to about three drachms in twenty-four hours. but the boy continued as he had been after the second day, free from unfavorable symptoms, with pulse, tongue, appetite, and sleep natural and strength increasing, while the limb remained as it had been from the first, free from swelling, redness, or pain. i. therefore, persevered with the antiseptic dressing; and, before i left, the discharge was already somewhat less, while the bone was becoming firm. i think it likely that, in that boy's case, i should have found merely a superficial sore had i taken off all the dressings at the end of the three weeks; though, considering the extent of the injury, i thought it prudent to let the month expire before disturbing the rag next the skin. but i feel sure that, if i had resorted to ordinary dressing when the pus first appeared, the progress of the case would have been exceedingly different. the next class of cases to which i have applied the antiseptic treatment is that of abscesses. here also the results have been extremely satisfactory, and in beautiful harmony with the pathological principles indicated above. the pyogenic membrane, like the granulations of a sore, which it resembles in nature, forms pus, not from any inherent disposition to do so, but only because it is subjected to some preternatural stimulation. in an ordinary abscess, whether acute or chronic, before it is opened the stimulus which maintains the suppuration is derived from the presence of pus pent up within the cavity. when a free opening is made in the ordinary way, this stimulus is got rid of, but the atmosphere gaining access to the contents, the potent stimulus of decomposition comes into operation, and pus is generated in greater abundance than before. but when the evacuation is effected on the antiseptic principle, the pyogenic membrane, freed from the influence of the former stimulus without the substitution of a new one, ceases to suppurate (like the granulations of a sore under metallic dressing), furnishing merely a trifling amount of clear serum, and, whether the opening be dependent or not, rapidly contracts and coalesces. at the same time any constitutional symptoms previously occasioned by the accumulation of the matter are got rid of without the slightest risk of the irritative fever or hectic hitherto so justly dreaded in dealing with large abscesses. in order that the treatment may be satisfactory, the abscess must be seen before it is opened. then, except in very rare and peculiar cases [footnote: as an instance of one of these exceptional cases, i may mention that of an abscess in the vicinity of the colon, and afterwords proved by post-mortem examination to have once communicated with it. here the pus was extremely offensive when evacuated, and exhibited vibros under the microscope.], there are no septic organisms in the contents, so that it is needless to introduce carbolic acid into the interior. indeed, such a procedure would be objectionable, as it would stimulate the pyogenic membrane to unnecessary suppuration. all that is requisite is to guard against the introduction of living atmospheric germs from without, at the same time that free opportunity is afforded for the escape of the discharge from within. i have so lately given elsewhere a detailed account of the method by which this is effected (lancet, july 27th, 1867), that i shall not enter into it at present further than to say that the means employed are the same as those described above for the superficial dressing of compound fractures; viz., a piece of rag dipped into the solution of carbolic add in oil to serve as an antiseptic curtain, under cover of which the abscess is evacuated by free incision, and the antiseptic paste to guard against decomposition occurring in the stream of pus that flows out beneath it; the dressing being changed daily until the sinus is closed. the most remarkable results of this practice in a pathological point of view have been afforded by cases where the formation of pus depended on disease of bone. here the abscesses, instead of forming exceptions to the general class in the obstinacy of the suppuration, have resembled the rest in yielding in a few days only a trifling discharge, and frequently the production of pus has ceased from the moment of the evacuation of the original contents. hence it appears that caries, when no longer labouring as heretofore under the irritation of decomposing matter, ceases to be an opprobrium of surgery, and recovers like other inflammatory affections. in the publication before alluded to, i have mentioned the case of a middle-aged man with a psoas abscess depending in diseased bone, in whom the sinus finally closed after months of patient perseverance with the antiseptic treatment. since that article was written i have had another instance of abscess equally gratifying, but the differing in the circumstance that the disease and the recovery were more rapid in their course. the patient was a blacksmith, who had suffered four and a half months before i saw him from symptoms of ulceration of cartilage in the left elbow. these had latterly increased in severity so as to deprive him entirely of his night's rest and of appetite. i found the region of the elbow greatly swollen, and on careful examination found a fluctuating point at the outer aspect of the articulation. i opened it on the antiseptic principle, the incision evidently penetrating to the joint, giving exit to a few drachms of pus. the medical gentleman under whose care he was (dr. macgregor, of glasgow) supervised the daily dressing with the carbolic acid paste till the patient went to spend two or three weeks at the coast, when his wife was entrusted with it. just two months after i opened the abscess, he called to show me the limb, stating that the discharge had been, for at least two weeks, as little as it was then, a trifling moisture upon the paste, such as might be accounted for by the little sore caused by the incision. on applying a probe guarded with an antiseptic rag, i found that the sinus was soundly closed, while the limb was free from swelling or tenderness; and, although he had not attempted to exercise it much, the joint could already be moved through a considerable angle. here the antiseptic principle had effected the restoration of a joint, which, on any other known system of treatment, must have been excised. ordinary contused wounds are, of course, amenable to the same treatment as compound fractures, which are a complicated variety of them. i will content myself with mentioning a single instance of this class of cases. in april last, a volunteer was discharging a rifle when it burst, and blew back the thumb with its metacarpal bone, so that it could be bent back as on a hinge at the trapezial joint, which had evidently been opened, while all the soft parts between the metacarpal bones of the thumb and forefinger were torn through. i need not insist before my present audience on the ugly character of such an injury. my housesurgeon, mr. hector cameron, applied carbolic acid to the whole raw surface, and completed the dressing as if for compound fracture. the hand remained free from pain, redness or swelling, and with the exception of a shallow groove, all the wound consolidated without a drop of matter, so that if it had been a clean cut, it would have been regarded as a good example of primary union. the small granulating surface soon healed, and at present a linear cicatrix alone tells of the injury he has sustained, while his thumb has all its movements and his hand a fine grasp. if the severest forms of contused and lacerated wounds heal thus kindly under the antiseptic treatment, it is obvious that its application to simple incised wounds must be merely a matter of detail. i have devoted a good deal of attention to this class, but i have not as yet pleased myself altogether with any of the methods i have employed. i am, however, prepared to go so far as to say that a solution of carbolic acid in twenty parts of water, while a mild and cleanly application, may be relied on for destroying any septic germs that may fall upon the wound during the performance of an operation; and also that, for preventing the subsequent introduction of others, the paste above described, applied as for compound fractures, gives excellent results. thus i have had a case of strangulated inguinal hernia in which it was necessary to take away half a pound of thickened omentum, heal without any deep-seated suppuration or any tenderness of the sac or any fever; and amputations, including one immediately below the knee, have remained absolutely free from constitutional symptoms. further, i have found that when the antiseptic treatment is efficiently conducted, ligatures may be safely cut short and left to be disposed of by absorption or otherwise. should this particular branch of the subject yield all that it promises, should it turn out on further trial that when the knot is applied on the antiseptic principle, we may calculate as securely as if it were absent on the occurrence of healing without any deepseated suppuration, the deligation of main arteries in their continuity will be deprived of the two dangers that now attend it, viz., those of secondary haemorrhage and an unhealthy state of the wound. further, it seems not unlikely that the present objection to tying an artery in the immediate vicinity of a large branch may be done away with; and that even the innominate, which has lately been the subject of an ingenious experiment by one of the dublin surgeons, on account of its well-known fatality under the ligature for secondary haemorrhage, may cease to have this unhappy character when the tissues in the vicinity of the thread, instead of becoming softened through the influence of an irritating decomposing substance, are left at liberty to consolidate firmly near an unoffending though foreign body. it would carry me far beyond the limited time which, by the rules of the association, is alone at my disposal, were i to enter into the various applications of the antiseptic principle in the several special departments of surgery. there is, however, one point more that i cannot but advert to, viz., the influence of this mode of treatment upon the general healthiness of an hospital. previously to its introduction the two large wards in which most of my cases of accident and of operation are treated were among the unhealthiest in the whole surgical division of the glasgow royal infirmary, in consequence apparently of those wards being unfavorably placed with reference to the supply of fresh air; and i have felt ashamed when recording the results of my practice, to have so often to allude to hospital gangrene or pyaemia. it was interesting, though melancholy, to observe that whenever all or nearly all the beds contained cases with open sores, these grievous complications were pretty sure to show themselves; so that i came to welcome simple fractures, though in themselves of little interest either for myself or the students, because their presence diminished the proportion of open sores among the patients. but since the antiseptic treatment has been brought into full operation, and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their character; so that during the last nine months not a single instance of pysemia, hospital gangrene, or erysipelas has occurred in them. as there appears to be no doubt regarding the cause of this change, the importance of the fact can hardly be exaggerated. the physiological theory of fermentation by louis pasteur translated by f. faulkner and d. c. robb and revised the germ theory and its applications to medicine and surgery by mm. pasteur, jourbert, and chamberland translated by h. c. ernst, m. d. professor of bacteriology in the harvard medical school on the extension of the germ theory to the etiology of certain common diseases by louis pasteur translated by h. c. ernst, m. d. introductory note louis pasteur was born at dole, jura, france, december 27, 1822, and died near saint-cloud, september 28, 1895. his interest in science, and especially in chemistry, developed early, and by the time he was twenty-six he was professor of the physical sciences at dijon. the most important academic positions held by him later were those as professor of chemistry at strasburg, 1849; dean of the faculty of sciences at lille, 1854; science director of the ecole normale superieure, paris, 1857; professor of geology, physics, and chemistry at the ecole des beaux arts; professor of chemistry at the sorbonne, 1867. after 1875 he carried on his researches at the pasteur institute. he was a member of the institute, and received many honors from learned societies at home and abroad. in respect of the number and importance, practical as well as scientific, of his discoveries, pasteur has hardly a rival in the history of science. he may be regarded as the founder of modern stereo-chemistry; and his discovery that living organisms are the cause of fermentation is the basis of the whole modern germtheory of disease and of the antiseptic method of treatment. his investigations of the diseases of beer and wine; of pebrine, a disease affecting silk-worms; of anthrax, and of fowl cholera, were of immense commercial importance and led to conclusions which have revolutionised physiology, pathology, and therapeutics. by his studies in the culture of bacteria of attenuated virulence he extended widely the practise of inoculation with a milder form of various diseases, with a view to producing immunity. the following papers present some of the most important of his contributions, and exemplify his extraordinary powers of lucid exposition and argument. to the memory of my father formerly a soldier under the first empire chevalier of the legion of honor the longer i live, the better i understand the kindness of thy heart and the high quality of thy mind. the efforts which i have devoted to these studies, as well as those which preceded them, are the fruit of thy counsel and example. desiring to honor these filial remembrances, i dedicate this work to thy memory. l. pasteur. author's preface our misfortunes inspired me with the idea of these researches. i undertook them immediately after the war of 1870, and have since continued them without interruption, with the determination of perfecting them, and thereby benefiting a branch of industry wherein we are undoubtedly surpassed by germany. i am convinced that i have found a precise, practical solution of the arduous problem which i proposed to myself--that of a process of manufacture, independent of season and locality, which should obviate the necessity of having recourse to the costly methods of cooling employed in existing processes, and at the same time secure the preservation of its products for any length of time. these new studies are based on the same principles which guided me in my researches on wine, vinegar, and the silkworm disease-principles, the applications of which are practically unlimited. the etiology of contagious diseases may, perhaps, receive from them an unexpected light. i need not hazard any prediction concerning the advantages likely to accrue to the brewing industry from the adoption of such a process of brewing as my study of the subject has enabled me to devise, and from an application of the novel facts upon which this process is founded. time is the best appraiser of scientific work, and i am not unaware that an industrial discovery rarely produces all its fruit in the hands of its first inventor. i began my researches at clermont-ferrand, in the laboratory, and with the help, of my friend m. duclaux, professor of chemistry at the faculty of sciences of that town. i continued them in paris, and afterwards at the great brewery of tourtel brothers, of tantonville, which is admitted to be the first in france. i heartily thank these gentlemen for their extreme kindness. i owe also a public tribute of gratitude to m. kuhn, a skillful brewer of chamalieres, near clermont-ferrand, as well as to m. velten of marseilles, and to mm. de tassigny, of reims, who have placed at my disposal their establishments and their products, with the most praiseworthy eagerness. l. pasteur. paris, june 1, 1879. the physiological theory of fermentation i. on the relations existing between oxygen and yeast it is characteristic of science to reduce incessantly the number of unexplained phenomena. it is observed, for instance, that fleshy fruits are not liable to fermentation so long as their epidermis remains uninjured. on the other hand, they ferment very readily when they are piled up in heaps more or less open, and immersed in their saccharine juice. the mass becomes heated and swells; carbonic acid gas is disengaged, and the sugar disappears and is replaced by alcohol. now, as to the question of the origin of these spontaneous phenomena, so remarkable in character as well as usefulness for man's service, modern knowledge has taught us that fermentation is the consequence of a development of vegetable cells the germs of which do not exist in the saccharine juices within fruits; that many varieties of these cellular plants exist, each giving rise to its own particular fermentation. the principal products of these various fermentations, although resembling each other in their nature, differ in their relative proportions and in the accessory substances that accompany them, a fact which alone is sufficient to account for wide differences in the quality and commercial value of alcoholic beverages. now that the discovery of ferments and their living nature, and our knowledge of their origin, may have solved the mystery of the spontaneous appearance of fermentations in natural saccharine juices, we may ask whether we must still regard the reactions that occur in these fermentations as phenomena inexplicable by the ordinary laws of chemistry. we can readily see that fermentations occupy a special place in the series of chemical and biological phenomena. what gives to fermentations certain exceptional characters of which we are only now beginning to suspect the causes, is the mode of life in the minute plants designated under the generic name of ferments, a mode of life which is essentially different from that in other vegetables, and from which result phenomena equally exceptional throughout the whole range of the chemistry of living beings. the least reflection will suffice to convince us that the alcoholic ferments must possess the faculty of vegetating and performing their functions out of contact with air. let us consider, for instance, the method of vintage practised in the jura. the bunches are laid at the foot of the vine in a large tub, and the grapes there stripped from them. when the grapes, some of which are uninjured, others bruised, and all moistened by the juice issuing from the latter, fill the tub--where they form what is called the vintage--they are conveyed in barrels to large vessels fixed in cellars of a considerable depth. these vessels are not filled to more than three-quarters of their capacity. fermentation soon takes place in them, and the carbonic acid gas finds escape through the bunghole, the diameter of which, in the case of the largest vessels, is not more than ten or twelve centimetres (about four inches). the wine is not drawn off before the end of two or three months. in this way it seems highly probable that the yeast which produces the wine under such conditions must have developed, to a great extent at least, out of contact with oxygen. no doubt oxygen is not entirely absent from the first; nay, its limited presence is even a necessity to the manifestation of the phenomena which follow. the grapes are stripped from the bunch in contact with air, and the must which drops from the wounded fruit takes a little of this gas into solution. this small quantity of air so introduced into the must, at the commencement of operations, plays a most indispensable part, it being from the presence of this that the spores of ferments which are spread over the surface of the grapes and the woody part of the bunches derive the power of starting their vital phenomena [footnote: it has been marked in practice that fermentation is facilitated by leaving the grapes on the bunches. the reason of this has not yet been discovered. still we have no doubt that it may be attributed, principally, to the fact that the interatices between the grapes, and the spaces between the bunch leaves throughout, considerably increase the volume of air placed at the service of the germs of ferment.]. this air, however, especially when the grapes have been stripped from the bunches, is in such small proportion, and that which is in contact with the liquid mass is so promptly expelled by the carbonic acid gas, which is evolved as soon as a little yeast has formed, that it will readily be admitted that most of the yeast is produced apart from the influence of oxygen, whether free or in solution. we shall revert to this fact, which is of great importance. at present we are only concerned in pointing out that, from the mere knowledge of the practices of certain localities, we are induced to believe that the cells of yeast, after they have developed from their spores, continue to live and multiply without the intervention of oxygen, and that the alcoholic ferments have a mode of life which is probably quite exceptional, since it is not generally met with in other species, vegetable or animal. another equally exceptional characteristic of yeast and fermentation in general consists in the small proportion which the yeast that forms bears to the sugar that decomposes. in all other known beings the weight of nutritive matter assimilated corresponds with the weight of food used up, any difference that may exist being comparatively small. the life of yeast is entirely different. for a certain weight of yeast formed, we may have ten times, twenty times, a hundred times as much sugar, or even more decomposed, as we shall experimentally prove by-andbye; that is to say, that whilst the proportion varies in a precise manner, according to conditions which we shall have occasion to specify, it is also greatly out of proportion to the weight of the yeast. we repeat, the life of no other being, under its normal physiological conditions, can show anything similar. the alcoholic ferments, therefore, present themselves to us as plants which possess at least two singular properties: they can live without air, that is without oxygen, and they can cause decomposition to an amount which, though variable, yet, as estimated by weight of product formed, is out of all proportion to the weight of their own substance. these are facts of so great importance, and so intimately connected with the theory of fermentation, that it is indispensable to endeavour to establish them experimentally, with all the exactness of which they will admit. the question before us is whether yeast is in reality an anaerobian [footnote: capable of living without free oxygen--a term invented by pasteur.--en.] plant, and what quantities of sugar it may cause to ferment, under the various conditions under which we cause it to act. the following experiments were undertaken to solve this double problem:--we took a double-necked flask, of three litres (five pints) capacity, one of the tubes being curved and forming an escape for the gas; the other one, on the right hand side (fig. 1), being furnished with a glass tap. we filled this flask with pure yeast water, sweetened with 5 per cent, of sugar candy, the flask being so full that there was not the least trace of air remaining above the tap or in the escape tube; this artificial wort had, however, been itself aerated. the curved tube was plunged in a porcelain vessel full of mercury, resting on a firm support. in the small cylindrical funnel above the tap, the capacity of which was from 10 cc. to 15 cc. (about half a fluid ounce) we caused to ferment, at a temperature of 20 degrees or 25 degrees c. (about 75 degrees f.), five or six cubic centimetres of the saccharine liquid, by means of a trace of yeast, which multiplied rapidly, causing fermentation, and forming a slight deposit of yeast at the bottom of the funnel above the tap. we then opened the tap, and some of the liquid in the funnel entered the flask, carrying with it the small deposit of yeast, which was sufficient to impregnate the saccharine liquid contained in the flask. in this manner it is possible to introduce as small a quantity of yeast as we wish, a quantity the weight of which, we may say, is hardly appreciable. the yeast sown multiplies rapidly and produces fermentation, the carbonic gas from which is expelled into the mercury. in less than twelve days all the sugar had disappeared, and the fermentation had finished. there was a sensible deposit of yeast adhering to the sides of the flask; collected and dried it weighed 2.25 grammes (34 grains). it is evident that in this experiment the total amount of yeast formed, if it required oxygen to enable it to live, could not have absorbed, at most, more than the volume which was originally held in solution in the saccharine liquid, when that was exposed to the air before being introduced into the flask. [illustration with caption: fig. 1] some exact experiments conducted by m. raulin in our laboratory have established the fact that saccharine worts, like water, soon become saturated when shaken briskly with an excess of air, and also that they always take into solution a little less air than saturated pure water contains under the same conditions of temperature and pressure. at a temperature of 25 degrees c. (77 degrees f.), therefore, if we adopt the coefficient of the solubility of oxygen in water given in bunsen's tables, we find that 1 litre (1 3/4 pints) of water saturated with air contains 5.5 cc. (0.3 cubic inch) of oxygen. the three litres of yeastwater in the flask, supposing it to have been saturated, contains less than 16.5 cc. (1 cubic inch) of oxygen, or, in weight, less than 23 milligrammes (0.35 grains). this was the maximum amount of oxygen, supposing the greatest possible quantity to have been absorbed, that was required by the yeast formed in the fermentation of 150 grammes (4.8 troy ounces) of sugar. we shall better understand the significance of this result later on. let us repeat the foregoing experiment, but under altered conditions. let us fill, as before, our flask with sweetened yeast-water, but let this first be boiled, so as to expel all the air it contains. to effect this we arrange our apparatus as represented in the accompanying sketch. (fig 2.) we place our flask, a, on a tripod above a gas flame, and in place of the vessel of mercury substitute a porcelain dish, under which we can put a gas flame, and which contains some fermentable, saccharine liquid, similar to that with which the flask is filled. we boil the liquid in the flask and that in the basin simultaneously, and then let them cool down together, so that as the liquid in the flask cools some of the liquid is sucked from the basin into the flask. from a trial experiment which we conducted, determining the quantity of oxygen that remained in solution in the liquid after cooling, according to m. schutzenberger's valuable method, by means of hydrosulphite of soda [footnote: nahso2, now called sodium hyposulphite.--d.c.r.], we found that the three litres in the flask, treated as we have described, contained less than one milligramme (0.015 grain) of oxygen. at the same time we conducted another experiment, by way of comparison (fig. 3). we took a flask, b, of larger capacity than the former one, which we filled about half with the same volume as before of a saccharine liquid of identically the same composition. this liquid had been previously freed from alterative germs by boiling. in the funnel surmounting a, we put a few cubic centimetres of saccharine liquid in a state of fermentation, and when this small quantity of liquid was in full fermentation, and the yeast in it was young and vigorous, we opened the tap, closing it again immediately, so that a little of the liquid and yeast still remained in the funnel. by this means we caused the liquid in a to ferment. we also impregnated the liquid in b with some yeast taken from the funnel of a. we then replaced the porcelain dish in which the curved escape tube of a had been plunged, by a vessel filled with mercury. the following is a description of two of these comparative fermentations and the results they gave. [illustration with caption: fig 2] [illustration with caption: fig. 3] the fermentable liquid was composed of yeast-water sweetened with 5 per cent, of sugar--candy; the ferment employed was sacchormyces pastorianus. the impregnation took place on january 20th. the flasks were placed in an oven at 25 degrees (77 degrees f.). flask a, without air. january 21st.--fermentation commenced; a little frothy liquid issued from the escape tube and covered the mercury. the following days, fermentation was active. examining the yeast mixed with the froth that was expelled into the mercury by the evolution of carbonic acid gas, we find that it was very fine, young, and actively budding. february 3rd.--fermentation still continued, showing itself by a number of little bubbles rising from the bottom of the liquid, which had settled bright. the yeast was at the bottom in the form of a deposit. february 7th.--fermentation still continued, but very languidly. february 9th.--a very languid fermentation still went on, discernible in little bubbles rising from the bottom of the flask. flask b, with air. january 21st.--a sensible development of yeast. the following days, fermentation was active, and there was an abundant froth on the surface of the liquid. february 1st.--all symptoms of fermentation had ceased. as the fermentation in a would have continued a long time, being so very languid, and as that in b had been finished for several days, we brought to a close our two experiments on february 9th. to do this we poured off the liquids in a and b, collecting the yeasts on tared filters. filtration was an easy matter, more especially in the case of a. examining the yeasts under the microscope, immediately after decantation, we found that both of them remained very pure. the yeast in a was in little clusters, the globules of which were collected together, and appeared by their well-defined borders to be ready for an easy revival in contact with air. as might have been expected, the liquid in flask b did not contain the least trace of sugar; that in the flask a still contained some, as was evident from the non-completion of fermentation, but not more than 4.6 grammes (71 grains). now, as each flask originally contained three litres of liquid holding in solution 5 per cent of sugar, it follows that 150 grammes (2,310 grains) of sugar had fermented in the flask b, and 145.4 grammes (2,239.2 grains) in the flask a. the weights of yeast after drying at 100 degrees c. (212 degrees f.) were-for the flask b, with air. ... ..1,970 grammes (30.4 grains). for the flask a, without air ... 1,368 grammes [footnote: this appears to be a misprint for 1.638 grammes=25.3 grains.--d. c. r.]. the proportions were 1 of yeast to 76 of fermented sugar in the first case, and 1 of yeast to 89 of fermented sugar in the second. from these facts the following consequences may be deduced: 1. the fermentable liquid (flask b), which since it had been in contact with air, necessarily held air in solution, although not to the point of saturation, inasmuch as it had been once boiled to free it from all foreign germs, furnished a weight of yeast sensibly greater than that yielded by the liquid which contained no air at all (flask a) or, at least, which could only have contained an exceedingly minute quantity. 2. this same slightly aerated fermentable liquid fermented much more rapidly than the other. in eight or ten days it contained no more sugar; while the other, after twenty days, still contained an appreciable quantity. is this last fact to be explained by the greater quantity of yeast formed in b? by no means. at first, when the air has access to the liquid, much yeast is formed and little sugar disappears, as we shall prove immediately; nevertheless the yeast formed in contact with the air is more active than the other. fermentation is correlative first to the development of the globules, and then to the continued life of those globules once formed. the more oxygen these last globules have at their disposal during their formation, the more vigorous, transparent, and turgescent, and, as a consequence of this last quality, the more active they are in decomposing sugar. we shall hereafter revert to these facts. 3. in the airless flask the proportion of yeast to sugar was 1/59; it was only 1/79 in the flask which had air at first. the proportion that the weight of yeast bears to the weight of the sugar is, therefore, variable, and this variation depends, to a certain extent, upon the presence of air and the possibility of oxygen being absorbed by the yeast. we shall presently show that yeast possesses the power of absorbing that gas and emitting carbonic acid, like ordinary fungi, that even oxygen may be reckoned amongst the number of food-stuffs that may be assimilated by this plant, and that this fixation of oxygen in yeast, as well as the oxidations resulting from it, have the most marked effect on the life of yeast, on the multiplication of its cells, and on their activity as ferments acting upon sugar, whether immediately or afterwards, apart from supplies of oxygen or air. in the preceding experiment, conducted without the presence of air, there is one circumstance particularly worthy of notice. this experiment succeeds, that is to say, the yeast sown in the medium deprived of oxygen develops, only when this yeast is in a state of great vigour. we have already explained the meaning of this last expression. but we wish now to call attention to a very evident fact in connection with this point. we impregnate a fermentable liquid; yeast develops and fermentation appears. this lasts for several days and then ceases. let us suppose that, from the day when fermentation first appears in the production of a minute froth, which gradually increases until it whitens the surface of the liquid, we take, every twenty-four hours, or at longer intervals, a trace of the yeast deposited on the bottom of the vessel and use it for starting fresh fermentations. conducting these fermentations all under precisely the same conditions of temperature, character and volume of liquid, let us continue this for a prolonged time, even after the original fermentation is finished. we shall have no difficulty in seeing that the first signs of action in each of our series of second fermentations appear always later and later in proportion to the length of time that has elapsed from the commencement of the original fermentation. in other words, the time necessary for the development of the germs and the production of that amount of yeast sufficient to cause the first appearance of fermentation varies with the state of the impregnating cells, and is longer in proportion as the cells are further removed from the period of their formation. it is essential, in experiments of this kind, that the quantities of yeast successively taken should be as nearly as possible equal in weight or volume, since, celeris paribus, fermentations manifest themselves more quickly the larger the quantity of yeast employed in impregnation. if we compare under the microscope the appearance and character of the successive quantities of yeast taken, we shall see plainly that the structure of the cells undergoes a progressive change. the first sample which we take, quite at the beginning of the original fermentation, generally gives us cells rather larger than those later on, and possessing a remarkable tenderness. their walls are exceedingly thin, the consistency and softness of their protoplasm is akin to fluidity, and their granular contents appear in the form of scarcely visible spots. the borders of the cells soon become more marked, a proof that their walls undergo a thickening; their protoplasm also becomes denser, and the granulations more distinct. cells of the same organ, in the states of infancy and old age, should not differ more than the cells of which we are speaking, taken in their extreme states. the progressive changes in the cells, after they have acquired their normal form and volume, clearly demonstrate the existence of a chemical work of a remarkable intensity, during which their weight increases, although in volume they undergo no sensible change, a fact that we have often characterized as "the continued life of cells already formed." we may call this work a process of maturation on the part of the cells, almost the same that we see going on in the case of adult beings in general, which continue to live for a long time, even after they have become incapable of reproduction, and long after their volume has become permanently fixed. this being so, it is evident, we repeat, that, to multiply in a fermentable medium, quite out of contact with oxygen, the cells of yeast must be extremely young, full of life and health, and still under the influence of the vital activity which they owe to the free oxygen which has served to form them, and which they have perhaps stored up for a time. when older, they reproduce themselves with much difficulty when deprived of air, and gradually become more languid; and if they do multiply, it is in strange and monstrous forms. a little older still, they remain absolutely inert in a medium deprived of free oxygen. this is not because they are dead; for in general they may be revived in a marvellous manner in the same liquid if it has been first aerated before they are sown. it would not surprise us to learn that at this point certain preconceived ideas suggest themselves to the mind of an attentive reader on the subject of the causes that may serve to account for such strange phenomena in the life of these beings which our ignorance hides under the expressions of youth and age; this, however, is a subject which we cannot pause to consider here. at this point we must observe--for it is a matter of great importance--that in the operations of the brewer there is always a time when the yeasts are in this state of vigorous youth of which we have been speaking, acquired under the influence of free oxygen, since all the worts and the yeasts of commerce are necessarily manipulated in contact with air, and so impregnated more or less with oxygen. the yeast immediately seizes upon this gas and acquires a state of freshness and activity, which permits it to live afterwards out of contact with air, and to act as a ferment. thus, in ordinary brewery practice, we find the yeast already formed in abundance even before the earliest external signs of fermentation have made their appearance. in this first phase of its existence, yeast lives chiefly like an ordinary fungus. from the same circumstances it is clear that the brewer's fermentations may, speaking quite strictly, last for an indefinite time, in consequence of the unceasing supply of fresh wort, and from the fact, moreover, that the exterior air is constantly being introduced during the work, and that the air contained in the fresh worts keeps up the vital activity of the yeast, as the act of breathing keeps up the vigour and life of cells in all living beings. if the air could not renew itself in any way, the vital activity which the cells originally received, under its influence, would become more and more exhausted, and the fermentation eventually come to an end. we may recount one of the results obtained in other experiments similar to the last, in which, however, we employed yeast which was still older than that used for our experiment with flask a (fig. 2), and moreover took still greater precautions to prevent the presence of air. instead of leaving the flask, as well as the dish, to cool slowly, after having expelled all air by boiling, we permitted the liquid in the dish to continue boiling whilst the flask was being cooled by artificial means; the end of the escape tube was then taken out of the still boiling dish and plunged into the mercury trough. in impregnating the liquid, instead of employing the contents of the small cylindrical funnel whilst still in a state of fermentation, we waited until this was finished. under these conditions, fermentation was still going on in our flask, after a lapse of three months. we stopped it and found that 0.255 gramme (3.9 grains) of yeast had been formed, and that 45 grammes (693 grains) of sugar had fermented, the ratio between the weights of yeast and sugar being thus 0.255 divided by 45 = 1 divided by 176. in this experiment the yeast developed with much difficulty, by reason of the conditions to which it had been subjected. in appearance the cells varied much, some were to be found large, elongated, and of tubular aspect, some seemed very old and were extremely granular, whilst others were more transparent. all of them might be considered abnormal cells. in such experiments we encounter another difficulty. if the yeast sown in the non-aerated fermentable liquid is in the least degree impure, especially if we use sweetened yeast-water, we may be sure that alcoholic fermentation will soon cease, if, indeed, it ever commences, and that accessory fermentations will go on. the vibrios of butyric fermentation, for instance, will propagate with remarkable facility under these circumstances. clearly then, the purity of the yeast at the moment of impregnation, and the purity of the liquid in the funnel, are conditions indispensable to success. to secure the latter of these conditions, we close the funnel, as shown in fig. 2, by means of a cork pierced with two holes, through one of which a short tube passes, to which a short length of india-rubber tubing provided with a glass stopper is attached; through the other hole a thin curved tube is passed. thus fitted, the funnel can answer the same purposes as our double-necked flasks. a few cubic centimetres of sweetened yeast-water are put in it and boiled, so that the steam may destroy any germs adhering to the sides; and when cold the liquid is impregnated by means of a trace of pure yeast, introduced through the glassstoppered tube. if these precautions are neglected, it is scarcely possible to secure a successful fermentation in our flasks, because the yeast sown is immediately held in check by a development of anaerobian vibrios. for greater security, we may add to the fermentable liquid, at the moment when it is prepared, a very small quantity of tartaric acid, which will prevent the development of butyric vibrios. [illustration with caption: fig. 4.] the variation of the ratio between the weight of the yeast and that of the sugar decomposed by it now claims special attention. side by side with the experiments which we have just described, we conducted a third lot by means of the flask c (fig. 4), holding 4.7 litres (8 1/2 pints), and fitted up like the usual two-necked flasks, with the object of freeing the fermentable liquid from foreign germs, by boiling it to begin with, so that we might carry on our work under conditions of purity. the volume of yeast-water (containing 5 per cent. of sugar) was only 200 cc. (7 fl. oz.), and consequently, taking into account the capacity of the flask, it formed but a very thin layer at the bottom. on the day after impregnation the deposit of yeast was already considerable, and forty-eight hours afterwards the fermentation was completed. on the third day we collected the yeast after having analyzed the gas contained in the flask. this analysis was easily accomplished by placing the flask in a hot-water bath, whilst the end of the curved tube was plunged under a cylinder of mercury. the gas contained 41.4 per cent. of carbonic acid, and, after the absorption, the remaining air contained:-oxygen . ... . ... . ... . ... . ... . ... . ... ... 19.7 nitrogen . ... . ... . ... . ... . ... . ... . ... . 80.3 100.0 taking into consideration the volume of this flask, this shows a minimum of 50 cc. (3.05 cub. in.) of oxygen to have been absorbed by the yeast. the liquid contained no more sugar, and the weight of the yeast, dried at a temperature of 100 degrees c (212 degrees f.), was 0.44 grammes. the ratio between the weights of yeast and sugar is 0.44/10=1/22.7 [footnote: 200 cc. of liquid were used, which, as containing 3 per cent., had in solution 10 grammes of sugar.--d.c.r.]. on this occasion, where we had increased the quantity of oxygen held in solution, so as to yield itself for assimilation at the beginning and during the earlier developments of the yeast, we found instead of the previous ratio of 1/76 that of 1/23. [illustration with caption: fig. 5] the next experiment was to increase the proportion of oxygen to a still greater extent, by rendering the diffusion of gas a more easy matter than in a flask, the air in which is in a state of perfect quiescence. such a state of matters hinders the supply of oxygen, inasmuch as the carbonic acid, as soon as it is liberated, at once forms an immovable layer on the surface of the liquid, and so separates off the oxygen. to effect the purpose of our present experiment, we used flat basins having glass bottoms and low sides, also of glass, in which the depth of the liquid is not more than a few millimetres (less than 1/4 inch) (fig. 5). the following is one of our experiments so conducted:--on april 16th, 1860, we sowed a trace of beer yeast ("high" yeast) in 200 cc. (7 fl. oz.) of a saccharine liquid containing 1.720 grammes (26.2 grains) of sugar-candy. from april 18th our yeast was in good condition and well developed. we collected it, after having added to the liquid a few drops of concentrated sulphuric acid, with the object of checking the fermentation to a great extent, and facilitating filtration. the sugar remaining in the filtered liquid, determined by fehling's solution, showed that 1.04 grammes (16 grains) of sugar had disappeared. the weight of the yeast, dried at 100 degrees c. (212 degrees f.), was 0.127 gramme (2 grains), which gives us the ratio between the weight of the yeast and that of the fermented sugar 0.123/1.04=1/8.1, which is considerably higher than the preceding ones. we may still further increase this ratio by making our estimation as soon as possible after the impregnation, or the addition of the ferment. it will be readily understood why yeast, which is composed of cells that bud and subsequently detach themselves from one another, soon forms a deposit at the bottom of the vessels. in consequence of this habit of growth, the cells constantly covering each other prevents the lower layers from having access to the oxygen held in solution in the liquid, which is absorbed by the upper ones. hence, these which are covered and deprived of this gas act on the sugar without deriving any vital benefit from the oxygen--a circumstance which must tend to diminish the ratio of which we are speaking. once more repeating the preceding experiment, but stopping it as soon as we think that the weight of yeast formed may be determined by the balance (we find that this may be done twenty-four hours after impregnation with an inappreciable quantity of yeast), in this case the ratio between the weights of yeast and sugar is gr/024 yeast/0 gr. 09 sugar=1/4. this is the highest ratio we have been able to obtain. under these conditions the fermentation of sugar is extremely languid: the ratio obtained is very nearly the same that ordinary fungoid growths would give. the carbonic acid evolved is principally formed by the decompositions which result from the assimilation of atmospheric oxygen. the yeast, therefore, lives and performs its functions after the manner of ordinary fungi: so far it is no longer a ferment, so to say; moreover, we might expect to find it to cease to be a ferment at all if we could only surround each cell separately with all the air that it required. this is what the preceding phenomena teach us; we shall have occasion to compare them later on with others which relate to the vital action exercised on yeast by the sugar of milk. we may here be permitted to make a digression. in his work on fermentations, which m. schutzenberger has recently published, the author criticises the deductions that we have drawn from the preceding experiments, and combats the explanation which we have given of the phenomena of fermentation. [footnote: international science series, vol. xx, pp. 179-182. london, 1876.--d. c. r.] it is an easy matter to show the weak point of m. schutzenberger's reasoning. we determined the power of the ferment by the relation of the weight of sugar decomposed to the weight of the yeast produced. m. schutzenberger asserts that in doing this we lay down a doubtful hypothesis, and he thinks that this power, which he terms fermentative energy, may be estimated more correctly by the quantity of sugar decomposed by the unit-weight of yeast in unit-time; moreover, since our experiments show that yeast is very vigorous when it has a sufficient supply of oxygen, and that, in such a case, it can decompose much sugar in a little time, m. schutzenberger concludes that it must then have great power as a ferment, even greater than when it performs its functions without the aid of air, since under this condition it decomposes sugar very slowly. in short, he is disposed to draw from our observations the very opposite conclusion to that which we arrived at. m, schutzenberger has failed to notice that the power of a ferment is independent of the time during which it performs its functions. we placed a trace of yeast in one litre of saccharine wort; it propagated, and all the sugar was decomposed. now, whether the chemical action involved in this decomposition of sugar had required for its completion one day, or one month, or one year, such a factor was of no more importance in this matter than the mechanical labour required to raise a ton of materials from the ground to the top of a house would be affected by the fact that it had taken twelve hours instead of one. the notion of time has nothing to do with the definition of work. m. schutzenberger has not perceived that in introducing the consideration of time into the definition of the power of a ferment, he must introduce at the same time, that of the vital activity of the cells which is independent of their character as a ferment. apart from the consideration of the relation existing between the weight of fermentable substance decomposed and that of ferment produced, there is no occasion to speak of fermentations or of ferments. the phenomena of fermentation and of ferments have been placed apart from others, precisely because, in certain chemical actions, that ratio has been out of proportion; but the time that these phenomena require for their accomplishment has nothing to do with either their existence proper, or with their power. the cells of a ferment may, under some circumstances, require eight days for revival and propagation, whilst, under other conditions, only a few hours are necessary; so that, if we introduce the notion of time into our estimate of their power of decomposition, we may be led to conclude that in the first case that power was entirely wanting, and that in the second case it was considerable, although all the time we are dealing with the same organism--the identical ferment. m. schutzenberger is astonished that fermentation can take place in the presence of free oxygen, if, as we suppose, the decomposition of the sugar is the consequence of the nutrition of the yeast, at the expense of the combined oxygen, which yields itself to the ferment. at all events, he argues, fermentation ought to be slower in the presence of free oxygen. but why should it be slower? we have proved that in the presence of oxygen the vital activity of the cells increases, so that, as far as rapidity of action is concerned, its power cannot be diminished. it might, nevertheless, be weakened as a ferment, and this is precisely what happens. free oxygen imparts to the yeast a vital activity, but at the same time impairs its power as yeast--qua yeast, inasmuch as under this condition it approaches the state in which it can carry on its vital processes after the manner of an ordinary fungus; the mode of life, that is, in which the ratio between the weight of sugar decomposed and the weight of the new cells produced will be the same as holds generally among organisms which are not ferments. in short, varying our form of expression a little, we may conclude with perfect truth, from the sum total of observed facts, that the yeast which lives in the presence of oxygen and can assimilate as much of that gas as is necessary to its perfect nutrition, ceases absolutely to be a ferment at all. nevertheless, yeast formed under these conditions and subsequently brought into the presence of sugar, out of the influence of air, would decompose more in a given time than in any other of its states. the reason is that yeast which has formed in contact with air, having the maximum of free oxygen that it can assimilate is fresher and possessed of greater vital activity than that which has been formed without air or with an insufficiency of air. m. schutzenberger would associate this activity with the notion of time in estimating the power of the ferment; but he forgets to notice that yeast can only manifest this maximum of energy under a radical change of its life conditions; by having no more air at its disposal and breathing no more free oxygen. in other words, when its respiratory power becomes null, its fermentative power is at its greatest. m. schutzenberger asserts exactly the opposite (p. 151 of his work-paris, 1875) [footnote: page 182, english edition], and so gratuitously places himself in opposition to facts. in presence of abundant air supply, yeast vegetates with extraordinary activity. we see this in the weight of new yeast, comparatively large, that may be formed in the course of a few hours. the microscope still more clearly shows this activity in the rapidity of budding, and the fresh and active appearance of all the cells. fig. 6 represents the yeast of our last experiment at the moment when we stopped the fermentation. nothing has been taken from imagination, all the groups have been faithfully sketched as they were. [footnote: this figure is on a scale of 300 diameters, most of the figures in this work being of 400 diameters]. [illustration with caption: fig. 6] in passing it is of interest to note how promptly the preceding results were turned to good account practically. in well-managed distilleries, the custom of aerating the wort and the juices to render them more adapted to fermentation, has been introduced. the molasses mixed with water, is permitted to run in thin threads through the air at the moment when the yeast is added. manufactories have been erected in which the manufacture of yeast is almost exclusively carried on. the saccharine worts, after the addition of yeast, are left to themselves, in contact with air, in shallow vats of large superficial area, realizing thus on an immense scale the conditions of the experiments which we undertook in 1861, and which we have already described in determining the rapid and easy multiplication of yeast in contact with air. the next experiment was to determine the volume of oxygen absorbed by a known quantity of yeast, the yeast living in contact with air, and under such conditions that the absorption of air was comparatively easy and abundant. [illustration with caption: fig. 7] with this object we repeated the experiment that we performed with the large-bottomed flask (fig. 4), employing a vessel shaped like fig. b (fig. 7), which is, in point of fact, the flask a with its neck drawn out and closed in a flame, after the introduction of a thin layer of some saccharine juice impregnated with a trace of pure yeast. the following are the data and results of an experiment of this kind. we employed 60 cc. (about 2 fluid ounces) of yeast-water, sweetened with two percent. of sugar and impregnated with a trace of yeast. after having subjected our vessel to a temperature of 25 degrees c. (77 degrees f.) in an oven for fifteen hours, the drawn-out point was brought under an inverted jar filled with mercury and the point broken off. a portion of the gas escaped and was collected in the jar. for 25 cc. of this gas we found, after absorption by potash 20.6, and after absorption by pyrogallic acid, 17.3. taking into account the volume which remained free in the flask, which held 315 cc., there was a total absorption of 14.5 cc. (0.83 cub. in.) of oxygen. [footnote: it may be useful for the non-scientific reader to put it thus: that the 25 cc. which escaped, being a fair sample of the whole gas in the flask, and containing (1) 25-20.6=4.4 cc., absorbed by potash and therefore due to carbonic acid, and (2) 20.6-17.3=3.3 cc., absorbed by pyrogallate, and therefore due to oxygen, and the remaining 17.3 cc. being nitrogen, the whole gas in the flask, which has a capacity of 312 cc., will contain oxygen in the above portion and therefore its amount may be determined provided we know the total gas in the flask before opening. on the other hand we know that air normally contains approximately, 1-5 its volume of oxygen, the rest being nitrogen, so that, by ascertaining the diminution of the proportion in the flask, we can find how many cubic centimeters have been absorbed by the yeast. the author, however, has not given all the data necessary for accurate calculation.--d.c.r.] the weight of the yeast, in a state of dryness, was 0.035 gramme. it follows that in the production of 35 milligrammes (0.524 grain) of yeast there was an absorption of 14 or 15 cc. (about 7/8 cub. in.) of oxygen, even supposing that the yeast was formed entirely under the influence of that gas: this is equivalent to not less than 414 cc. for 1 gramme of yeast (or about 33 cubic inches for every 20 grains). [footnote: this number is probably too small; it is scarcely possible that the increase of weight in the yeast, even under the exceptional conditions of the experiment described, was not to some extent at least due to oxidation apart from free oxygen, inasmuch as some of the cells were covered by others. the increased weight of the yeast is always due to the action of two distant modes of vital energy-activity, namely, in presence and activity in absence of air. we might endeavor to shorten the duration of the experiment still further, in which case we would still more assimilate the life of the yeast to that of ordinary moulds.] such is the large volume of oxygen necessary for the development of one gramme of yeast when the plant can assimilate this gas after the manner of an ordinary fungus. let us now return to the first experiment described in the paragraph on page 292 in which a flask of three litres capacity was filled with fermentable liquid, which, when caused to ferment, yielded 2.25 grammes of yeast, under circumstances where it could not obtain a greater supply of free oxygen than 16.5 cc. (about one cubic inch). according to what we have just stated, if this 2.25 grammes (34 grains) of yeast had not been able to live without oxygen, in other words, if the original cells had been unable to multiply otherwise than by absorbing free oxygen, the amount of that gas required could not have been less than 2.25 x 4l4 cc., that is, 931.5 cc. (56.85 cubic inches). the greater part of the 2.25 grammes, therefore, had evidently been produced as the growth of an anaerobian plant. ordinary fungi likewise require large quantities of oxygen for their development, as we may readily prove by cultivating any mould in a closed vessel full of air, and then taking the weight of plant formed and measuring the volume of oxygen absorbed. to do this, we take a flask of the shape shown in fig. 8, capable of holding about 300 cc. (10 1/2 fluid ounces), and containing a liquid adapted to the life of moulds. we boil this liquid, and seal the drawn-out point after the steam has expelled the air wholly or in part; we then open the flask in a garden or in a room. should a fungus-spore enter the flask, as will invariably be the case in a certain number of flasks out of several used in the experiment, except under special circumstances, it will develop there and gradually absorb all the oxygen contained in the air of the flask. measuring the volume of this air, and weighing, after drying, the amount of plant formed, we find that for a certain quantity of oxygen absorbed we have a certain weight of mycelium, or of mycelium together with its organs of fructification. in an experiment of this kind, in which the plant was weighed a year after its development, we found for 0.008 gramme (0.123 gram) of mycelium, dried at 100 degrees c. (212 degrees f.), an absorption that amounted to not less than 43 cc. (2.5 cubic inches) of oxygen at 25 degrees. these numbers, however, must vary sensibly with the nature of the mould employed, and also with the greater or less activity of its development, because the phenomena is complicated by the presence of accessory oxidations, such as we find in the case of mycoderma vini and aceti, to which cause the large absorption of oxygen in our last experiment may doubtless be attributed. [footnote: in these experiments, in which the moulds remain for a long time in contact with a saccharine wort out of contact with oxygen--the oxygen being promptly absorbed by the vital action of the plant (see our memoire sur les generations dites spontanees, p. 54. note)--there is no doubt that an appreciable quantity of alcohol is formed because the plant does not immediately lose vital activity after the absorption of oxygen. a 300 cc. (10-oz.) flask, containing 100 cc. of must, after the air in it had been expelled by boiling, was open and immediately re-closed on august 15th, 1873. a fungoid growth--a unique one, of greenish-grey colour--developed from spontaneous impregnation, and decolourized the liquid, which originally was of a yellowishbrown. some large crystals, sparkling like diamonds, of neutral tartrate of lime, were precipitated, about a year afterwards, long after the death of the plant, we examined this liquid. it contained 0.3 gramme (4.6 grains) of alcohol, and 0.053 gramme (0.8 grain) of vegetable matter, dried at 100 degrees c. (212 degrees f.). we ascertained that the spores of the fungus were dead at the moment when the flask was opened. when sown, they did not develop in the least degree.] the conclusions to be drawn from the whole of the preceding facts can scarcely admit of doubt. as for ourselves, we have no hesitation in finding them the foundation of the true theory of fermentation. in the experiments which we have described, fermentation by yeast, that is to say, by the type of ferments properly so called, is presented to us, in a word, as the direct consequence of the processes of nutrition, assimilation and life, when these are carried on without the agency of free oxygen. the heat required in the accomplishment of that work must necessarily have been borrowed from the decomposition of the fermentable matter, that is from the saccharine substance which, like other unstable substances, liberates heat in undergoing decomposition. fermentation by means of yeast appears, therefore, to be essentially connected with the property possessed by this minute cellular plant of performing its respiratory functions, somehow or other, with oxygen existing combined in sugar. its fermentative power--which power must not be confounded with the fermentative activity or the intensity of decomposition in a given time--varies considerably between two limits, fixed by the greatest and least possible access to free oxygen which the plant has in the process of nutrition. if we supply it with a sufficient quantity of free oxygen for the necessities of its life, nutrition, and respiratory combustions, in other words, if we cause it to live after the manner of a mould, properly so called, it ceases to be a ferment, that is, the ratio between the weight of the plant developed and that of the sugar decomposed, which forms its principal food, is similar in amount to that in the case of fungi. [footnote: we find in m. raulin's note that "the minimum ratio between the weight of sugar and the weight of organized matter, that is, the weight of fungoid growth which it helps to form, may be expressed as 10/3.2=3.1." jules raulin, etudes chimiques sur la vegetation. recherches sur le developpement d'une mucedinee dans un milieu artificiel, p. 192, paris, 1870. we have seen in the case of yeast that this ratio may be as low as [proofers note: unreadable symbol]] on the other hand, if we deprive the yeast of air entirely, or cause it to develop in a saccharine medium deprived of free oxygen, it will multiply just as if air were present, although with less activity, and under these circumstances its fermentative character will be most marked; under these circumstances, moreover, we shall find the greatest disproportion, all other conditions being the same, between the weight of yeast formed and the weight of sugar decomposed. lastly, if free oxygen occurs in varying quantities, the ferment-power of the yeast may pass through all the degrees comprehended between the two extreme limits of which we have just spoken. it seems to us that we could not have a better proof of the direct relation that fermentation bears to life, carried on in the absence of free oxygen, or with a quantity of that gas insufficient for all the acts of nutrition and assimilation. another equally striking proof of the truth of this theory is the fact previously demonstrated that the ordinary moulds assume the character of a ferment when compelled to live without air, or with quantities of air too scant to permit of their organs having around them as much of that element as is necessary for their life as aerobian plants. ferments, therefore, only possess in a higher degree a character which belongs to many common moulds, if not to all, and which they share, probably, more or less, with all living cells, namely the power of living either an aerobian or anaerobian life, according to the conditions under which they are placed. it may be readily understood how, in their state of aerobian life, the alcoholic ferments have failed to attract attention. these ferments are only cultivated out of contract with air, at the bottom of liquids which soon become saturated with carbonic acid gas. air is only present in the earlier developments of their germs, and without attracting the attention of the operator, whilst in their state of anaerobian growth their life and action are of prolonged duration. we must have recourse to special experimental apparatus to enable us to demonstrate the mode of life of alcoholic ferments under the influence of free oxygen; it is their state of existence apart from air, in the depths of liquids, that attracts all our attention. the results of their action are, however, marvellous, if we regard the products resulting from them, in the important industries of which they are the life and soul. in the case of ordinary moulds, the opposite holds good. what we want to use special experimental apparatus for with them, is to enable us to demonstrate the possibility of their continuing to live for a time out of contact with air, and all our attention, in their case, is attracted by the facility with which they develop under the influence of oxygen. thus the decomposition of saccharine liquids, which is the consequence of the life of fungi without air, is scarcely perceptible, and so is of no practical importance. their aerial life, on the other hand, in which they respire and accomplish their process of oxidation under the influence of free oxygen is a normal phenomenon, and one of prolonged duration which cannot fail to strike the least thoughtful of observers. we are convinced that a day will come when moulds will be utilised in certain industrial operations, on account of their power in destroying organic matter. the conversion of alcohol into vinegar in the process of acetification and the production of gallic acid by the action of fungi on wet gall nuts, are already connected with this kind of phenomena. [footnote: we shall show, some day, that the processes of oxidation due to growth of fungi cause, in certain decompositions, liberation of ammonia to a considerable extent, and that by regulating their action we might cause them to extract the nitrogen from a host of organic debris, as also, by checking the production of such organisms, we might considerably increase the proportion of nitrates in the artificial nitrogenous substances. by cultivating the various moulds on the surface of damp bread in a current of air we have obtained an abundance of ammonia, derived from the decomposition of the albuminoids effected by the fungoid life. the decomposition of asparagus and several other animal or vegetable substances has similar results.] on this last subject, the important work of m. van tieghem (annales scientifiques de l'ecole normale, vol. vi.) may be consulted. the possibility of living without oxygen, in the case of ordinary moulds, is connected with certain morphological modifications which are more marked in proportion as this faculty is itself more developed. these changes in the vegetative forms are scarcely perceptible, in the case of penicillium and mycoderma vini, but they are very evident in the case of aspergillus, consisting of a marked tendency on the part of the submerged mycelial filaments to increase in diameter, and to develop cross partitions at short intervals, so that they sometimes bear a resemblance to chains of conidia. in mucor, again, they are very marked, the inflated filaments which, closely interwoven, present chains of cells, which fall off and bud, gradually producing a mass of cells. if we consider the matter carefully, we shall see that yeast presents the same characteristics. * * * * it is a great presumption in favor of the truth of theoretical ideas when the results of experiments undertaken on the strength of those ideas are confirmed by various facts more recently added to science, and when those ideas force themselves more and more on our minds, in spite of a prima facie improbability. this is exactly the character of those ideas which we have just expounded. we pronounced them in 1861, and not only have they remained unshaken since, but they have served to foreshadow new facts, so that it is much easier to defend them in the present day than it was to do so fifteen years ago. we first called attention to them in various notes, which we read before the chemical society of paris, notably at its meetings of april 12th and june 28th, 1861, and in papers in the comtes rendus de l'academie des sciences. it may be of some interest to quote here, in its entirety, our communication of june 28th, 1861, entitled, "influences of oxygen on the development of yeast and on alcoholic fermentation," which we extract from the bulletin de la societe chimique de paris:-"m. pasteur gives the result of his researches on the fermentation of sugar and the development of yeast-cells, according as that fermentation takes place apart from the influence of free oxygen or in contact with that gas. his experiments, however, have nothing in common with those of gaylussac, which were performed with the juice of grapes crushed under conditions where they would not be affected by air, and then brought into contact with oxygen. "yeast, when perfectly developed, is able to bud and grow in a saccharine and albuminous liquid, in the complete absence of oxygen or air. in this case but little yeast is formed, and a comparatively large quantity of sugar disappears--sixty or eighty parts for one of yeast formed. under these conditions fermentation is very sluggish. "if the experiment is made in contact with the air, and with a great surface of liquid, fermentation is rapid. for the same quantity of sugar decomposed much more yeast is formed. the air with which the liquid is in contact is absorbed by the yeast. the yeast develops very actively, but its fermentative character tends to disappear under these conditions; we find, in fact, that for one part of yeast formed, not more than from four to ten parts of sugar are transformed. the fermentative character of this yeast nevertheless, continues, and produces even increased effects, if it is made to act on sugar apart from the influence of free oxygen. "it seems, therefore, natural to admit that when yeast functions as a ferment by living apart from the influence of air, it derives oxygen from the sugar, and that this is the origin of its fermentative character. "m. pasteur explains the fact of the immense activity at the commencement of fermentations by the influence of the oxygen of the air held in solution in the liquids, at the time when the action commences. the author has found, moreover, that the yeast of beer sown in an albuminous liquid, such as yeast-water, still multiplies, even when there is not a trace of sugar in the liquid, provided always that atmospheric oxygen is present in large quantities. when deprived of air, under these conditions, yeast does not germinate at all. the same experiments may be repeated with albuminous liquid, mixed with a solution of nonfermentable sugar, such as ordinary crystallized milk-sugar. the results are precisely the same. "yeast formed thus in the absence of sugar does not change its nature; it is still capable of causing sugar to ferment, if brought to bear upon that substance apart from air. it must be remarked, however, that the development of yeast is effected with great difficulty when it has not a fermentable substance for its food. in short, the yeast of beer acts in exactly the same manner as an ordinary plant, and the analogy would be complete if ordinary plants had such an affinity for oxygen as permitted them to breathe by appropriating this element from unstable compounds, in which case, according to m. pasteur, they would appear as ferments for those substances. "m. pasteur declares that he hopes to be able to realize this result, that is to say, to discover the conditions under which certain inferior plants may live apart from air in the presence of sugar, causing that substance to ferment as the yeast of beer would do." this summary and the preconceived views that it set forth have lost nothing of their exactness; on the contrary, time has strengthened them. the surmises of the last two paragraphs have received valuable confirmation from recent observations made by messrs. lechartier and bellamy, as well as by ourselves, an account of which we must put before our readers. it is necessary, however, before touching upon this curious feature in connection with fermentations to insist on the accuracy of a passage in the preceding summary; the statement, namely, that yeast could multiply in an albuminous liquid, in which it found a nonfermentable sugar, milk-sugar, for example. the following is an experiment on this point:--on august 15th, 1875, we sowed a trace of yeast in 150 cc. (rather more than 5 fluid ounces) of yeast-water, containing 2 1/2 per cent, of milk-sugar. the solution was prepared in one of our double-necked flasks, with the necessary precautions to secure the absence of germs, and the yeast sown was itself perfectly pure. three months afterwards, november 15th, 1875, we examined the liquid for alcohol; it contained only the smallest trace; as for the yeast (which had sensibly developed), collected and dried on a filter paper, it weighed 0.050 gramme (0.76 grain). in this case we have the yeast multiplying without giving rise to the least fermentation, like a fungoid growth, absorbing oxygen, and evolving carbonic acid, and there is no doubt that the cessation of its development in this experiment was due to the progressive deprivation of oxygen that occurred. as soon as the gaseous mixture in the flask consisted entirely of carbonic acid and nitrogen, the vitality of the yeast was dependent on, and in proportion to, the quantity of air which entered the flask in consequence of variations of temperature. the question now arose, was this yeast, which had developed wholly as an ordinary fungus, still capable of manifesting the character of a ferment? to settle this point we had taken the precaution on august 15th, 1875, of preparing another flask, exactly similar to the preceding one in every respect, and which gave results identical with those described. we decanted this november 15th, pouring some wort on the deposit of the plant, which remained in the flask. in less than five hours from the time we placed it in the oven, the plant started fermentation in the wort, as we could see by the bubbles of gas rising to form patches on the surface of the liquid. we may add that yeast in the medium which we have been discussing will not develop at all without air. the importance of these results can escape no one; they prove clearly that the fermentative character is not an invariable phenomenon of yeast-life, they show that yeast is a plant which does not differ from ordinary plants, and which manifests its fermentative power solely in consequence of particular conditions under which it is compelled to live. it may carry on its life as a ferment or not, and after having lived without manifesting the slightest symptom of fermentative character, it is quite ready to manifest that character when brought under suitable conditions. the fermentative property, therefore, is not a power peculiar to cells of a special nature. it is not a permanent character of a particular structure, like, for instance, the property of acidity or alkalinity. it is a peculiarity dependent on external circumstances and on the nutritive conditions of the organism. ii. fermentation in saccharine fruits immersed in carbonic acid gas the theory which we have, step by step, evolved, on the subject of the cause of the chemical phenomena of fermentation, may claim a character of simplicity and generality that is well worthy of attention. fermentation is no longer one of those isolated and mysterious phenomena which do not admit of explanation. it is the consequence of a peculiar vital process of nutrition which occurs tinder certain conditions, differing from those which characterize the life of all ordinary beings, animal or vegetable, but by which the latter may be affected, more or less, in a way which brings them, to some extent within the class of ferments, properly so called. we can even conceive that the fermentative character may belong to every organized form, to every animal or vegetable cell, on the sole condition that the chemico-vital acts of assimilation and excretion must be capable of taking place in that cell for a brief period, longer or shorter it may be, without necessity for recourse to supplies of atmospheric oxygen; in other words, the cell must be able to derive its needful heat from the decomposition of some body which yields a surplus of heat in the process. as a consequence of these conclusions it should be an easy matter to show, in the majority of living beings, the manifestation of the phenomena of fermentation; for there are, probably, none in which all chemical action entirely disappears, upon the sudden cessation of life. one day, when we were expressing these views in our laboratory, in the presence of m. dumas, who seemed inclined to admit their truth, we added: "we should like to make a wager that if we were to plunge a bunch of grapes into carbonic acid gas, there would be immediately produced alcohol and carbonic acid gas, in consequence of a renewed action starting in the interior cells of the grapes, in such a way that these cells would assume the functions of yeast cells. we will make the experiment, and when you come to-morrow--it was our good fortune to have m. dumas working in our laboratory at that time--we will give you an account of the result." our predictions were realized. we then endeavoured to find, in the presence of m. dumas, who assisted us in our endeavour, cells of yeast in the grapes; but it was quite impossible to discover any. [footnote: to determine the absence of cells of ferment in fruits that have been immersed in carbonic acid gas, we must first of all carefully raise the pellicle of the fruit, taking care that the subjacent parenchyma does not touch the surface of the pellicle, since the organized corpuscles existing on the exterior of the fruit might introduce an error into our miscroscopical observations. experiments on grapes have given us an explanation of a fact generally known, the cause of which, however, had hitherto escaped our knowledge. we all know that the taste and aroma of the vintage, that is, of the grapes stripped from the bunches and thrown into tubs, where they get soaked in the juice that issues from the wounded specimens, are very different from the taste and aroma of an uninjured bunch. now grapes that have been immersed in an atmosphere of carbonic acid gas have exactly the flavour and smell of the vintage; the reason is that, in the vintage tub, the grapes are immediately surrounded by an atmosphere of carbonic acid gas, and undergo, in consequence, the fermentation peculiar to grapes that have been plunged into this gas. these facts deserve to be studied from a practical point of view. it would be interesting, for example, to learn what difference there would be in the quality of two wines, the grapes of which, in the once case, had been perfectly crushed, so as to cause as great a separation of the cells of the parenchyma as possible; in the other case, left, for the most part, whole, as in the case in the ordinary vintage. the first wine would be deprived of those fixed and fragrant principles produced by the fermentation of which we have just spoken, when the grapes are immersed in carbonic acid gas, by such a comparison as that which we suggest we should be able to form a priori judgment on the merits of the new system, which had not been carefully studied, although already widely adopted, of milled, cylindrical crushers, for pressing the vintage.] encouraged by this result, we undertook fresh experiments on grapes, on a melon, on oranges, on plums, and on rhubarb leaves, gathered in the garden of the ecole normale, and, in every case, our substance, when immersed in carbonic acid gas, gave rise to the production of alcohol and carbonic acid. we obtained the following surprising results from some prunes de monsieur:[footnote: we have sometimes found small quantities of alcohol in fruits and other vegetable organs, surrounded with ordinary air, but always in small proportion, and in a manner which suggested its accidental character. it is east to understand how, in the thickness of certain fruits, certain parts of those fruits might be deprived of air, under which circumstances they would have been acting under conditions similar to those under which fruits act when wholly immersed in the carbonic acid gas. moreover, it would be useful to determine whether alcohol is not a normal product of vegatation.]--on july 21, 1872, we placed twenty-four of these plums under a glass bell, which we immediately filled with carbonic acid gas. the plums had been gathered on the previous day. by the side of the bell we placed other twenty-four plums, which were left there uncovered. eight days afterwards, in the course of which time there had been a considerable evolution of carbonic acid from the bell, we withdrew the plums and compared them with those which had been left exposed to the air. the difference was striking, almost incredible. whilst the plums which had been surrounded with air (the experiments of berard have long since taught us that, under this latter condition, fruits absorb oxygen from the air and emit carbonic acid gas in almost equal volume) had become very soft and watery and sweet, the plums taken from under the jar had remained very firm and hard, the flesh was by no means watery, but they had lost much sugar. lastly, when submitted to distillation, after crushing, they yielded 6.5 grammes (99.7 grains) of alcohol, more than 1 per cent, of the total weight of the plums. what better proof than these facts could we have of the existence of a considerable chemical action in the interior of fruit, an action which derives the heat necessary for its manifestation from the decomposition of the sugar present in the cells? moreover, and this circumstance is especially worthy of our attention, in all these experiments we found that there was a liberation of heat, of which the fruits and other organs were the seat, as soon as they were plunged in the carbonic acid gas. this heat is so considerable that it may at times be detected by the hand, if the two sides of the bell, one of which is in contact with the objects, are touched alternately. it also makes itself evident in the formation of little drops on those parts of the bell which are less directly exposed to the influence of the heat resulting from the decomposition of the sugar of the cells. [footnote: in these studies of plants living immersed in carbonic acid gas, we have come across a fact which corroborated those which we have already given in reference to the facility with which lactic and viscous ferments, and generally speaking, those which we have termed the disease ferments or beer, develop when deprived of air, and which shows, consequently, how very marked their aerobian character is. if we immerse beet-roots or turnips in carbonic acid gas, we produce well-defined fermentations in those roots. their whole surface readily permits the escape of the highly acid liquids, and they become filled with lactic, viscous, and other ferments, this shows us the great danger which may result from the use of pits, in which the beet-roots are preserved, when the air is not renewed, and that the original oxygen is expelled by the vital processes of fungi or other deoxidizing chemical actions. we nave directed the attention of the manufacturers of beet-root sugar to this point.] in short, fermentation is a very general phenomenon. it is life without air, or life without free oxygen, or, more generally still, it is the result of a chemical process accomplished on a fermentable substance capable of producing heat by its decomposition, in which process the entire heat used up is derived from a part of the heat that the decomposition of the fermentable substance sets free. the class of fermentations properly so called, is, however, restricted by the small number of substances capable of decomposing with the production of heat, and at the same time of serving for the nourishment of lower forms of life, when deprived of the presence and action of air. this, again, is a consequence of our theory, which is well worthy of notice, the facts that we have just mentioned in reference to the formation of alcohol and carbonic acid in the substance of ripe fruits, under special conditions, and apart from the action of ferment, are already known to science. they were discovered in 1869 by m. lechartier, formerly a pupil in the ecole normale superieure, and his coadjutor, m. bellamy. [footnote: lechartier and bellamy, comptes rendus de l'academie des sciences, vol. lxix., pp., 366 and 466, 1869.] in 1821, in a very remarkable work, especially when we consider the period when it appeared, berard demonstrated several important propositions in connection with the maturation of fruits: i. all fruits, even those that are still green, and likewise even those that are exposed to the sun, absorb oxygen and set free an almost equal volume of carbonic acid gas. this is a condition of their proper ripening. ii. ripe fruits placed in a limited atmosphere, after having absorbed all the oxygen and set free an almost equal volume of carbonic acid, continue to emit that gas in notable quantity, even when no bruise is to be seen--"as though by a kind of fermentation," as berard actually observes--and lose their saccharine particles, a circumstance which causes the fruits to appear more acid, although the actual weight of their acid may undergo no augmentation whatever. in this beautiful work, and in all subsequent ones of which the ripening of fruits has been the subject, two facts of great theoretical value have escaped the notice of the authors; these are the two facts which messrs. lechartier and bellamy pointed out for the first time, namely, the production of alcohol and the absence of cells of ferments. it is worthy of remark that these two facts, as we have shown above, were actually fore-shadowed in the theory of fermentation that we advocated as far back as 1861, and we are happy to add that messrs. lechartier and bellamy, who at first had prudently drawn no theoretical conclusions from their work, now entirely agree with the theory we have advanced. [footnote: those gentlemen express themselves thus: "in a note presented to the academy in november, 1872, we published certain experiments which showed that carbonic acid and alcohol may be produced in fruits kept in a closed vessel, out of contact with atmospheric oxygen, without our being able to discover alcoholic ferment in the interior of those fruits. "m. pasteur, as a logical deduction from the principle which he has established in connection with the theory of fermentation, considers that the formation of alcohol may be attributed to the fact that the physical and chemical precesses of life in the cells of fruit continue under new conditions, in a manner similar to those of the cells of ferment. experiments, continued during 1872, 1873, and 1874, on different fruits have furnished results all of which seem to us to harmonize with this proposition, and to establish it on a firm basis of proof."--comptes rendus, t. lxxix., p. 949, 1874.] their mode of reasoning is very different from that of the savants with whom we discussed the subject before the academy, on the occasion when the communication which we addressed to the academy in october, 1872, attracted attention once more to the remarkable observations of messrs. lechartier and bellamy. [footnote: pasteur, faites nouveaux pour servir a la connaissance de la theorie des fermentations proprement dites. (comptes rendus de l'academie des sciences, t. lxxv., p. 784.) see in the same volume the discussion that followed; also, pasteur, note sur la production de l'alcool par les fruits, same volume, p. 1054, in which we recount the observations anterior to our own, made by messrs. lechartier and bellamy in 1869.] m. fremy, in particular, was desirous of finding in these observations a confirmation of his views on the subject of hemiorganism, and a condemnation of ours, notwithstanding the fact that the preceding explanations, and, more particularly our note of 1861, quoted word for word in the preceding section, furnish the most conclusive evidence in favor of those ideas which we advocate. indeed, as far back as 1861 we pointed out very clearly that if we could find plants able to live when deprived of air, in the presence of sugar, they would bring about a fermentation of that substance, in the same manner that yeast does. such is the case with the fungi already studied; such, too, is the case with the fruits employed in the experiments of messrs. lechartier and bellamy, and in our own experiments, the results of which not only confirm those obtained by these gentlemen, but even extend them, in so far as we have shown that fruits, when surrounded with carbonic acid gas immediately produce alcohol. when surrounded with air, they live in their aerobian state and we have no fermentation; immersed immediately afterwards in carbonic acid gas, they now assume their anaerobian state, and at once begin to act upon the sugar in the manner of ferments, and emit heat. as for seeing in these facts anything like a confirmation of the theory of hemi-organism, imagined by m. fremy, the idea of such a thing is absurd. the following, for instance, is the theory of the fermentation of the vintage, according to m. fremy. [footnote: comptes rendus, meeting of january 15th, 1872.] "to speak here of alcoholic fermentation alone," our author says, "i hold that in the production of wine it is the juice of the fruit itself that, in contact with air, produces grains of ferment, by the transformation of the albuminous matter; pasteur, on the other hand, maintains that the fermentation is produced by germs existing outside of the grapes." [footnote: as a matter of fact, m. fremy applies his theory of hemi-organism, not only to the alcoholic fermentation of grape juice, but to all other fermentations. the following passage occurs in one of his notes (comptes rendus de l'academie, t. lxxv., p. 979, october 28th, 1872): "experiments on germinated barley.--the object of these was to show that when barley, left to itself in sweetened water, produces in succession alcoholic, lactic, butyric, and acetic fermentations, these modifications are brought about by ferments which are produced inside the grains themselves, and not by atmospheric germs. more than forty different experiments were devoted to this part of my work." need we add that this assertion is based on no substantial foundation? the cells belonging to the grains of barley, or their albuminous contents, never do produce cells of alcoholic ferment, or of lactic ferment, or butyric vibrios. whenever those ferments appear, they may be traced to germs of those organisms, diffused throughout the interior of the grains, or adhering to the exterior surface, or existing in the water employed, or on the side of the vessels used. there are many ways of demonstrating this, of which the following is one: since the results of our experiments have shown that sweetened water, phosphates, and chalk very readily give rise to lactic and butyric fermentations, what reason is there for supposing that if we substitute grains of barley for chalk, the lactic and butyric ferments will spring from those grains, in consequence of a transformation of their cells and albuminous substances? surely there is no ground for maintaining that they are produced by hemi-organism, since a medium composed of sugar, or chalk, or phosphates of ammonia, potash, or magnesia contains no albuminous substances. this is an indirect but irresistible argument against the hemi-organism theory.] now what bearing on this purely imaginary theory can the fact have, that a whole fruit, immersed in carbonic acid gas, immediately produces alcohol and carbonic acid? in the preceding passage which we have borrowed from m. fremy, an indispensable condition of the transformation of the albuminous matter is the contact with air and the crushing of the grapes. here, however, we are dealing with uninjured fruits in contact with carbonic acid gas. our theory, on the other hand, which, we may repeat, we have advocated since 1861, maintains that all cells become fermentative when their vital action is protracted in the absence of air, which are precisely the conditions that hold in the experiments on fruits immersed in carbonic acid gas. the vital energy is not immediately suspended in their cells, and the latter are deprived of air. consequently, fermentation must result. moreover, we may add, if we destroy the fruit, or crush it before immersing it in the gas, it no longer produces alcohol or fermentation of any kind, a circumstance that may be attributed to the fact of the destruction of vital action in the crushed fruit. on the other hand, in what way ought this crushing to affect the hypothesis of hemi-organism? the crushed fruit ought to act quite as well, or even better than that which is uncrushed. in short, nothing can be more directly opposed to the theory of the mode of manifestation of that hidden force to which the name of hemi-organism has been given, than the discovery of the production of these phenomena of fermentation in fruits surrounded with carbonic acid gas; whilst the theory, which sees in fermentation a consequence of vital energy in absence of air, finds in these facts the strictest confirmation of an express prediction, which from the first formed an integral part of its statement. we should not be justified in devoting further time to opinions which are not supported by any serious experiment. abroad, as well as in france, the theory of the transformation of albuminous substances into organized ferments had been advocated long before it had been taken up by m. fremy. it no longer commands the slightest credit, nor do any observers of note any longer give it the least attention; it might even be said that it has become a subject of ridicule. an attempt has also been made to prove that we have contradicted ourselves, inasmuch as in 1860 we published our opinion that alcoholic fermentation can never occur without a simultaneous occurrence of organization, development, and multiplication of globules; or continued life, carried on from globules already formed. [footnote: pasteur, memoire sur la fermentation alcoolique, 1860: annales de chimie et de physique. the word globules is here used for cells. in our researches we have always endeavoured to prevent any confusion of ideas. we stated at the beginning of our memoir of 1860 that: "we apply the term alcoholic to that fermentation which sugar undergoes under the influence of the ferment known as beer yeast." this is, the fermentation which produces wine and all alcoholic beverages. this, too, is regarded as the type for a host of similar phenomena designated, by general usage, under the generic name of fermentation, and qualified by the name of one of the essential products of the special phenomenon under observation. bearing in mind this fact in reference to the nomenclature that we have adopted it will be seen that the expression alcoholic fermentation cannot be applied to every phenomenon of fermentation in which alcohol is produced, inasmuch as there may be a number of phenomena having this character in common. if we had not at starting defined that particular one amongst the number of very distinct phenomena, which, to the exclusion of the others, should bear the name of alcoholic fermentation, we should inevitably have given rise to a confusion of language that would soon pass from words to ideas, and tend to introduce unnecessary complexity into researches which are already, in themselves, sufficiently complex to necessitate the adoption of scrupulous care to prevent their becoming still more involved. it seems to us that any further doubt as to the meaning of the words alcoholic fermentation, and the sense in which they are employed, is impossible, inasmuch as lavoisier, gay-lussac, and thenard have applied this term to the fermentation of sugar by means of beer yeast. it would be both dangerous and unprofitable to discard the example set by these illustrious masters, to whom we are indebted for our earliest knowledge of this subject.] nothing, however, can be truer than that opinion, and at the present moment, after fifteen years of study devoted to the subject since the publication to which we have referred, we need no longer say, "we think," but instead, "we affirm," that it is correct. it is, as a matter of fact, to alcoholic fermentation, properly so called, that the charge to which we have referred relates--to that fermentation which yields, besides alcohol, carbonic acid, succinic acid, glycerine, volatile acids, and other products. this fermentation undoubtedly requires the presence of yeast--cells under the conditions that we have named. those who have contradicted us have fallen into the error of supposing that the fermentation of fruits is an ordinary alcoholic fermentation, identical with that produced by beer yeast, and that, consequently, the cells of that yeast must, according to own theory, be always present. there is not the least authority for such a supposition. when we come to exact quantitative estimations--and these are to be found in the figures supplied by messrs. lechartier and bellamy--it will be seen that the proportions of alcohol and carbonic acid gas produced in the fermentation of fruits differ widely from those that we find in alcoholic fermentations properly so called, as must necessarily be the case since in the former the fermentaction is effected by the cells of a fruit, but in the latter by cells of ordinary alcoholic ferment. indeed we have a strong conviction that each fruit would be found to give rise to special action, the chemical equation of which would be different from that in the case of other fruits. as for the circumstance that the cells of these fruits cause fermentation without multiplying, this comes under the kind of activity which we have already distinguished by the expression continuous life in cells already formed. we will conclude this section with a few remarks on the subject of equations of fermentations, which have been suggested to us principally in attempts to explain the results derived from the fermentation of fruits immersed in carbonic acid gas. originally, when fermentations were put amongst the class of decompositions by contact-action, it seemed probable, and, in fact, was believed, that every fermentation has its own welldefined equation which never varied. in the present day, on the contrary, it must be borne in mind that the equation of a fermentation varies essentially with the conditions under which that fermentation is accomplished, and that a statement of this equation is a problem no less complicated than that in the case of the nutrition of a living being. to every fermentation may be assigned an equation in a general sort of way, an equation, however, which, in numerous points of detail, is liable to the thousand variations connected with the phenomena of life. moreover, there will be as many distinct fermentations brought about by one ferment as there are fermentable substances capable of supplying the carbon element of the food of that same ferment, in the same way that the equation of the nutrition of an animal will vary with the nature of the food which it consumes. as regards fermentation producing alcohol, which may be effected by several different ferments, there will be as in the case of a given sugar, as many general equations as there are ferments, whether they be ferment-cells properly so called, or cells of the organs of living beings functioning as ferments. in the same way the equation of nutrition varies in the case of different animals nourished on the same food. and it is from the same reason that ordinary wort produces such a variety of beers when treated with the numerous alcoholic ferments which we have described. these remarks are applicable to all ferments alike; for instance, butyric ferment is capable of producing a host of distinct fermentations, in consequence of its ability to derive the carbonaceous part of its food from very different substances, from sugar, or lactic acid, or glycerine, or mannite, and many others. when we say that every fermentation has its own peculiar ferment, it must be understood that we are speaking of the fermentation considered as a whole, including all the accessory products. we do not mean to imply that the ferment in question is not capable of acting on some other fermentable substance and giving rise to fermentation of a very different kind. moreover, it is quite erroneous to suppose that the presence of a single one of the products of a fermentation implies the co-existence of a particular ferment. if, for example, we find alcohol among the products of a fermentation, or even alcohol and carbonic acid gas together, this does not prove that the ferment must be an alcoholic ferment, belonging to alcoholic fermentations, in the strict sense of the term. nor, again, does the mere presence of lactic acid necessarily imply the presence of lactic ferment. as a matter of fact, different fermentations may give rise to one or even several identical products. we could not say with certainty, from a purely chemical point of view, that we were dealing, for example, with an alcoholic fermentation properly so called, and that the yeast of beer must be present in it, if we had not first determined the presence of all the numerous products of that particular fermentation under conditions similar to those under which the fermentation in question had occurred. in works on fermentation the reader will often find those confusions against which we are now attempting to guard him. it is precisely in consequence of not having had their attention drawn to such observations that some have imagined that the fermentation in fruits immersed in carbonic acid gas is in contradiction to the assertion which we originally made in our memoir on alcoholic fermentation published in 1860, the exact words of which we may here repeat:--"the chemical phenomena of fermentation are related essentially to a vital activity, beginning and ending with the latter; we believe that alcoholic fermentation never occurs"--we were discussing the question of ordinary alcoholic fermentation produced by the yeast of beer--"without the simultaneous occurrence of organization, development, and multiplication of globules, or continued life, carried on by means of the globules already formed. the general results of the present memoir seem to us to be it direct opposition to the opinions of mm. liebig and berzelius." these conclusions, we repeat, are as true now as they ever were, and are as applicable to the fermentation of fruits, of which nothing was known in 1860, as they are to the fermentation produced by the means of yeast. only, in the case of fruits, it is the cells of the parenchyma that function as ferment, by a continuation of their activity in carbonic acid gas whilst in the other case the ferment consists of cells of yeast. there should be nothing very surprising in the fact that fermentation can originate in fruits and form alcohol without the presence of yeast, if the fermentation of fruits were not confounded completely with alcoholic fermentation yielding the same products and in the same proportions. it is through the misuse of words that the fermentation of fruits has been termed alcoholic, in a way which has misled many persons. [footnote: see, for example, the communications of mm. colin and poggiale, and the discussion on them. in the bulletin de l'academie de medecine, march 2d, 9th, and 30th, and february 16th and 23rd, 1875.] in this fermentation, neither alcohol nor carbonic acid gas exists in those proportions in which they are found in fermentation produced by yeast; and, although we may determine in it the presence of succinic acid, glycerine, and a small quantity of volatile acids [footnote: we have elsewhere determined the formation of minute quantities of volatile acids in alcoholic fermentation. m. bechamp, who studied these, recognized several belonging to the series of fatty acids, acetic acid, butyric acid &c. "the presence of succinic acid is not accidental, but constant; if we put aside volatile acids that form in quantities which we may call infinitely small, we may say that succinic acid is the only normal acid of alcoholic fermentation."--pasteur, comptes rendus de l' academie, t. xlvii., p. 224, 1858] the relative proportions of these substances will be different from what they are in the case of alcoholic fermentation. iii. reply to certain critical observations of the german naturalists, oscar brefeld and moritz traube. the essential point of the theory of fermentation which we have been concerned in proving in the preceding paragraphs may be briefly put in the statement that ferments properly so called constitute a class of beings possessing the faculty of living out of contact with free oxygen; or, more concisely still, we may say that fermentation is a result of life without air. if our affirmation were inexact, if ferment cells did require for their growth or for their increase in number or weight, as all other vegetable cells do, the presence of oxygen, whether gaseous or held in solution in liquids, this new theory would lose all value, its very raison d'etre would be gone, at least as far as the most important part of fermentations is concerned. this is precisely what m. oscar brefeld has endeavoured to prove in a memoir read to the physico-medical society of wurzburg on july 26th, 1873, in which, although we have ample evidence of the great experimental skill of its author, he has nevertheless, in our opinion, arrived at conclusions entirely opposed to fact. "from the experiments which i have just described," he says, "it follows, in the most indisputable manner, that a ferment cannot increase without free oxygen. pasteur's supposition that a ferment, unlike all other living organisms, can live and increase at the expense of oxygen held in combination, is, consequently, altogether wanting in any solid basis of experimental proof. moreover, since, according to the theory of pasteur, it is precisely this faculty of living and increasing at the expense of the oxygen held in combination that constitutes the phenomenon of fermentation, it follows that the whole theory, commanding though it does such general assent, is shown to be untenable; it is simply inaccurate." the experiments to which dr. brefeld alludes, consisted in keeping under continued study with the microscope, in a room specially prepared for the purpose, one or more cells of ferment in wort in an atmosphere of carbonic acid gas free from the least traces of free oxygen. we have, however, recognized the fact that the increase of a ferment out of contact with air is only possible in the case of a very young specimen; but our author employed brewer's yeast taken after fermentation, and to this fact we may attribute the non-success of his growths. dr. brefeld, without knowing it, operated on yeast in one of the states in which it requires gaseous oxygen to enable it to germinate again. a perusal of what we have previously written on the subject of the revival of yeast according to its age will show how widely the time required for such revival may vary in different cases. what may be perfectly true of the state of a yeast to-day may not be so to-morrow, since yeast is continually undergoing modifications. we have already shown the energy and activity with which a ferment can vegetate in the presence of free oxygen, and we have pointed out the great extent to which a very small quantity; of oxygen held in solution in fermenting liquids can operate at the beginning of fermentation. it is this oxygen that produces revival in the cells of the ferment and enables them to resume the faculty of germinating and continuing their life, and of multiplying when deprived of air. in our opinion, a simple reflection should have guarded dr. brefeld against the interpretation which he has attached to his observations. if a cell of ferment cannot bud or increase without absorbing oxygen, either free or held in solution in the liquid, the ratio between the weight of the ferment formed during fermentation and that of oxygen used up must be constant. we had, however, clearly established, as far back as 1861, the fact that this ratio is extremely variable, a fact, moreover, which is placed beyond doubt by the experiments described in the preceding section. though but small quantities of oxygen are absorbed, a considerable weight of ferment may be generated; whilst if the ferment has abundance of oxygen at its disposal, it will absorb much, and the weight of yeast formed will be still greater. the ratio between the weight of ferment formed and that of sugar decomposed may pass through all stages within certain very wide limits, the variations depending on the greater or less absorption of free oxygen. and in this fact, we believe, lies one of the most essential supports of the theory which we advocate. in denouncing the impossibility, as he considered it, of a ferment living without air or oxygen, and so acting in defiance of that law which governs all living beings, animal or vegetable, dr. brefeld ought also to have borne in mind the fact which we have pointed out, that alcoholic yeast is not the only organized ferment which lives in an anaerobian state. it is really a small matter that one more ferment should be placed in a list of exceptions to the generality of living beings, for whom there is a rigid law in their vital economy which requires for continued life a continuous respiration, a continuous supply of free oxygen. why, for instance, has dr. brefeld omitted the facts bearing on the life of the vibrios of butyric fermentation? doubtless he thought we were equally mistaken in these: a few actual experiments would have put him right. these remarks on the criticisms of dr. brefeld are also applicable to certain observations of m. moritz traube's, although, as regards the principal object of dr. brefeld's attack, we are indebted to m. traube for our defence. this gentleman maintained the exactness of our results before the chemical society of berlin, proving by fresh experiments that yeast is able to live and multiply without the intervention of oxygen. "my researches," he said, "confirm in an indisputable manner m. pasteur's assertion that the multiplication of yeast can take place in media which contain no trace of free oxygen. ... m. brefeld's assertion to the contrary is erroneous." but immediately afterwards m. traube adds: "have we here a confirmation of pasteur's theory? by no means. the results of my experiments demonstrate on the contrary that this theory has no true foundation." what were these results? whilst proving that yeast could live without air, m. traube, as we ourselves did, found that it had great difficulty in living under these conditions; indeed he never succeeded in obtaining more than the first stages of true fermentation. this was doubtless for the two following reasons: first, in consequence of the accidental production of secondary and diseased fermentations which frequently prevent the propagation of alcoholic ferment; and, secondly, in consequence of the original exhausted condition of the yeast employed. as long ago as 1861, we pointed out the slowness and difficulty of the vital action of yeast when deprived of air; and a little way back, in the preceding section, we have called attention to certain fermentations that cannot be completed under such conditions without going into the causes of these peculiarities. m. traube expresses himself thus: "pasteur's conclusion, that yeast in the absence of air is able to derive the oxygen necessary for its development from sugar, is erroneous; its increase is arrested even when the greater part of the sugar still remains undecomposed. it is in a mixture of albuminous substances that yeast, when deprived of air, finds the materials for its development." this last assertion of m. traube's is entirely disproved by those fermentation experiments in which, after suppressing the presence of albuminous substances, the action, nevertheless, went on in a purely inorganic medium, out of contact with air, a fact, of which we shall give irrefutable proofs. [footnote: traube's conceptions are governed by a theory of fermentation entirely his own, a hypothetical one, as he admits, of which the following is a brief summary: "we have no reason to doubt," traube says, "that the protoplasm of vegetable cells is itself, or contains within it, a chemical ferment which causes the alcoholic fermentation of sugar; its efficacy seems closely connected with the presence of the cell, inasmuch as, up to the present time, we have discovered no means of isolating it from the cells with success. in the presence of air this ferment oxidizes sugar by bringing oxygen to bear upon it; in the absence of air it decomposes the sugar by taking away oxygen from one group of atoms of the molecule of sugar and bringing it to act upon other atoms; on the one hand yielding a product of alcohol by reduction, on the other hand a product of carbonic acid gas by oxidation." traube supposes that this chemical ferment exists in yeast and in all sweet fruits, but only when the cells are intact, for he has proved for himself that thoroughly crushed fruits give rise to no fermentation whatever in carbonic acid gas. in this respect this imaginary chemical ferment would differ entirely from those which we call soluble ferments, since diastase, emulsine, &c., may be easily isolated. for a full account of the views of brefeld and traube, and the discussion which they carried on on the subject of the results of our experiments, our readers may consult the journal of the chemical society of berlin, vii., p. 872. the numbers for september and december, 1874, in the same volume, contain the replies of the two authors.] iv. fermentation of dextro-tartrate of lime. [footnote: see pasteur, comptes rendus de l'academie des sciences, t. lvi., p. 416.] tartrate of lime, in spite of its insolubility in waters is capable of complete fermentation in a mineral medium. if we put some pure tartrate of lime, in the form of a granulated, crystalline powder, into pure water, together with some sulphate of ammonia and phosphates of potassium and magnesium, in very small proportions, a spontaneous fermentation will take place in the deposit in the course of a few days, although no germs of ferment have been added. a living, organized ferment, of the vibrionic type, filiform, with tortuous motions, and often of immense length, forms spontaneously by the development of some germs derived in some way from the inevitable particles of dust floating in the air or resting on the surface of the vessels or material which we employ. the germs of the vibrios concerned in putrefaction are diffused around us on every side, and, in all probability, it is one or more of these germs that develop in the medium in question. in this way they effect the decomposition of the tartrate, from which they must necessarily obtain the carbon of their food without which they cannot exist, while the nitrogen is furnished by the ammonia of the ammoniacal salt, the mineral principles by the phosphate of potassium and magnesium, and the sulphur by the sulphate of ammonia. how strange to see organization, life, and motion originating under such conditions! stranger still to think that this organization, life, and motion are effected without the participation of free oxygen. once the germ gets a primary impulse on its living career by access of oxygen, it goes on reproducing indefinitely, absolutely without atmospheric air. here then we have a fact which it is important to establish beyond the possibility of doubt, that we may prove that yeast is not the only organized ferment able to live and multiply when out of the influence of free oxygen. into a flask, like that represented in fig. 9, of 2.5 litres (about four pints) in capacity, we put: pure, crystallized, neutral tartrate of lime. .. 100 grammes phosphate of ammonia. ... . ... . .. ... . ... 1 grammes phosphate of magnesium. ... . ... . ... . ... .. 1 grammes phosphate of potassium. ... . ... . ... . .. 0.5 grammes sulphate of ammonia. ... . ... . ... . ... .. 0.5 grammes (1 gramme = 15.43 grains) to this we added pure distilled water, so as entirely to fill the flask. in order to expel all the air dissolved in the water and adhering to the solid substances, we first placed our flask in a bath of chloride of calcium in a large cylindrical white iron pot set over a flame. the exit tube of the flask was plunged in a test tube of bohemian glass three-quarters full of distilled water, and also heated by a flame. we boiled the liquids in the flask and test-tube for a sufficient time to expel all the air contained in them. we then withdrew the heat from under the testtube, and immediately afterwards covered the water which it contained with a layer of oil and then permitted the whole apparatus to cool down. [illustration with caption: fig. 9] next day we applied a finger to the open extremity of the exittube, which we then plunged in a vessel of mercury. in this particular experiment which we are describing, we permitted the flask to remain in this state for a fort-night. it might have remained there for a century without ever manifesting the least sign of fermentation, the fermentation of the tartrate being a consequence of life, and life after boiling no longer existed in the flask. when it was evident that the contents of the flask were perfectly inert, we impregnated them rapidly, as follows: all the liquid contained in the exit-tube was removed by means of a fine caoutchouc tube, and replaced by about 1 c. (about 17 minims) of liquid and deposit from another flask, similar to the one we have just described, but which had been fermenting spontaneously for twelve days; we lost no time in refilling completely the exit tube with water which had been first boiled and then cooled down in carbonic acid gas. this operation lasted only a few minutes. the exit-tube was again plunged under mercury. subsequently the tube was not moved from under the mercury, and as it formed part of the flask, and there was neither cork nor india-rubber, any introduction of air was consequently impossible. the small quantity of air introduced during the impregnation was insignificant and it might even be shown that it injured rather than assisted the growth of the organisms, inasmuch as these consisted of adult individuals which had lived without air and might be liable to be damaged or even destroyed by it. be this as it may, in a subsequent experiment we shall find the possibility removed of any aeration taking place in this way, however infinitesimal, so that no doubts may linger on this subject. the following days the organisms multiplied, the deposit of tartrate gradually disappeared, and a sensible ferment action was manifest on the surface, and throughout the bulk of the liquid. the deposit seemed lifted up in places, and was covered with a layer of dark-grey colour, puffed up, and having an organic and gelatinous appearance. for several days, in spite of this action in the deposit, we detected no disengagement of gas, except when the flask was slightly shaken, in which case rather large bubbles adhering to the deposit rose, carrying with them some solid particles, which quickly fell back again, whilst the bubbles diminished in size as they rose, from being partially taken into solution, in consequence of the liquid not being saturated. the smallest bubbles had even time to dissolve completely before they could reach the surface of the liquid. in course of time the liquid was saturated, and the tartrate was gradually displaced by mammillated crusts, or clear, transparent crystals of carbonate of lime at the bottom and on the sides of the vessel. the impregnation took place on february 10th, and on march 15th the liquid was nearly saturated. the bubbles then began to lodge in the bent part of the exit-tube, at the top of the flask. a glass measuring-tube containing mercury was now placed with its open end over the point of the exit-tube under the mercury in the trough, so that no bubble might escape. a steady evolution of gas went on from the 17th to the 18th, 17.4 cc. (1.06 cubic inches) having been collected. this was proved to be nearly absolutely pure carbonic acid, as indeed might have been suspected from the fact that the evolution did not begin before a distinct saturation of the liquid was observed. [footnote: carbonic add being considerably more soluble than other gases possible under the circumstances.--ed.] the liquid, which was turbid on the day after its impregnation, had, in spite of the liberation of gas, again become so transparent that we could read our handwriting through the body of the flask. notwithstanding this, there was still a very active operation going on in the deposit, but it was confined to that spot. indeed, the swarming vibrios were bound to remain there, the tartrate of lime being still more insoluble in water saturated with carbonate of lime than it is in pure water. a supply of carbonaceous food, at all events, was absolutely wanting in the bulk of the liquid. every day we continued to collect and analyze the total amount of gas disengaged. to the very last it was composed of pure carbonic acid gas. only during the first few days did the absorption by the concentrated potash leave a very minute residue. by april 26th all liberation of gas had ceased, the last bubbles having risen in the course of april 23rd. the flask had been all the time in the oven, at a temperature between 25 degrees c. and 28 degrees c. (77 degrees f. and 83 degrees f.). the total volume of gas collected was 2.135 litres (130.2 cubic inches). to obtain the whole volume of gas formed we had to add to this what was held in the liquid in the state of acid carbonate of lime. to determine this we poured a portion of the liquid from the flask into another flask of similar shape, but smaller, up to the gaugemark on the neck. [footnote: we had to avoid filling the small flask completely, for fear of causing some of the liquid to pass on to the surface of the mercury in the measuring tube. the liquid condensed by boiling forms pure water, the solvent affinity of which for carbonic acid, at the temperature we employ, is well known. this smaller flask had been previously filled with carbonic acid. the carbonic acid of the fermented liquid was then expelled by means of heat, and collected over mercury. in this way we found a volume of 8.322 litres (508 cubic inches) of gas in solution, which, added to the 2.135 litres, gave a total of 10.457 litres (638.2 cubic inches) at 20 degrees and 760 mm., which, calculated to 0 degrees, c. and 760 mm. atmospheric pressure (32 degrees f. and 30 inches) gave a weight of 19.700 grammes (302.2 grains) of carbonic acid. exactly half of the lime in the tartrate employed got used up in the soluble salts formed during fermentation; the other half was partly precipitated in the form of carbonate of lime, partly dissolved in the liquid by the carbonic acid. the soluble salts seemed to us to be a mixture or combination of 1 equivalent of metacetate of lime, with 2 equivalents of the acetate, for every 10 equivalents of carbonic acid produced, the whole corresponding to the fermentation of 3 equivalents of neutral tartrate of lime. [footnote: the following is a curious consequence of these numbers and of the nature of the products of this fermentation. the carbonic acid liberated being quite pure, especially when the liquid has been boiled to expel all air from the flask, and capable of perfect solution, it follows that the volume of liquid being sufficient and the weight of tartrate suitably chosen--we may set aside tartrate of lime in an insoluble, crystalline powder, alone with phosphates at the bottom of a closed vessel full of water, and find soon afterwards in their place carbonate of lime, and in the liquid soluble salts of lime, with a mass of organic matter at the bottom, without any liberation of gas or appearance of fermentation ever taking place, except as far as the vital action and transformation in the tartrate are concerned. it is easy to calculate that a vessel or flask of five litres (rather more than a gallon) would be large enough for the accomplishment of this remarkable and singularly quiet transformation, in the case of 50 grammes (767 grains) of tartrate of lime.]. this point, however, is worthy of being studied with greater care: the present statement of the nature of the products formed is given with all reserve. for our point, indeed, the matter is of little importance, since the equation of the fermentation does not concern us. after the completion of fermentation there was not a trace of tartrate of lime remaining at the bottom of the vessel: it had disappeared gradually as it got broken up into the different products of fermentation, and its place was taken by some crystallized carbonate of lime--the excess, namely, which had been unable to dissolve by the action of the carbonic acid. associated, moreover, with this carbonate of lime there was a quantity of some kind of animal matter, which, under the microscope, appeared to be composed of masses of granules mixed with very fine filaments of varying lengths, studded with minute dots, and presenting all the characteristics of a nitrogenous organic substance. [footnote: we treated the whole deposit with dilute hydrochloric acid, which dissolved the carbonate of lime and the insoluble phosphates of calcium and magnesium; afterwards filtering the liquid through a weighed filter paper. dried at 100 degrees c. (212 degrees f.), the weight of the organic matter thus obtained was 0.54 gramme (8.3 grains), which was rather more than 1/200 of the weight of fermentable matter.] that this was really the ferment is evident enough from all that we have already said. to convince ourselves more thoroughly of the fact, and at the same time to enable us to observe the mode of activity of the organism, we instituted the following supplementary observation. side by side with the experiment just described, we conducted a similar one, which we intermitted after the fermentation was somewhat advanced, and about half of the tartrate dissolved. breaking off with a file the exit-tube at the point where the neck began to narrow off, we took some of the deposit from the bottom by means of a long straight piece of tubing, in order to bring it under microscopical examination. we found it to consist of a host of long filaments of extreme tenuity, their diameter being about 1/1000th of a millimetre (0.000039 in.); their length varied, in some cases being as much as 1/20th of a millimetre (0.0019 in.). a crowd of these long vibrios were to be seen creeping slowly along, with a sinuous movement, showing three, four, or even five flexures. the filaments that were at rest had the same aspect as these last, with the exception that they appeared punctuate, as though composed of a series of granules arranged in irregular order. no doubt these were vibrios in which vital action had ceased, exhausted specimens which we may compare with the old granular ferment of beer, whilst those in motion may be compared with young and vigorous yeast. the absence of movement in the former seems to prove that this view is correct. both kinds showed a tendency to form clusters, the compactness of which impeded the movements of those which were in motion. moreover, it was noticeable that the masses of these latter rested on tartrate not yet dissolved, whilst the granular clusters of the others rested directly on the glass, at the bottom of the flask, as if, having decomposed the tartrate, the only carbonaceous food at their disposal, they had then died on the spot where we captured them, from inability to escape, precisely in consequence of that state of entanglement which they combined to form, during the period of their active development. besides these we observed vibrios of the same diameter, but of much smaller length, whirling round with great rapidity, and darting backwards and forwards; these were probably identical with the longer ones, and possessed greater freedom of movement, no doubt in consequence of their shortness. not one of these vibrios could be found throughout the mass of the liquid. [illustration with caption: figure 10.] we may remark that as there was a somewhat putrid odour from the deposit in which the vibrios swarmed, the action must have been one of reduction, and no doubt to this fact was due the greyish coloration of the deposit. we suppose that the substances employed, however pure, always contain some trace of iron, which becomes converted into the sulphide, the black colour of which would modify the originally white deposit of insoluble tartrate and phosphate. but what is the nature of these vibrios? we have already said that we believe that they are nothing but the ordinary vibrios of putrefaction, reduced to a state of extreme tenuity by the special conditions of nutrition involved in the fermentable medium used; in a word, we think that the fermentation in question might be called putrefaction of tartrate of lime. it would be easy enough to determine this point by growing the vibrios of such fermentation in media adapted to the production of the ordinary forms of vibrio; but this is an experiment which we have not ourselves tried. one word more on the subject of these curious beings. in a great many of them there appears to be something like a clear spot, a kind of bead, at one of their extremities. this is an illusion arising from the fact that the extremity of these vibrios is curved, hanging downwards, thus causing a greater refraction at that particular point, and leading us to think that the diameter is greater at that extremity. we may easily undeceive ourselves if we watch the movements of the vibrio, when we will readily recognize the bend, especially as it is brought into the vertical plane passing over the rest of the filament. in this way we will see the bright spot, the head, disappear, and then reappear. the chief inference that it concerns us to draw from the preceding facts is one which cannot admit of doubt, and which we need not insist on any further--namely that vibrios, as met with in the fermentation of neutral tartrate of lime, are able to live and multiply when entirely deprived of air. v.--another example of life without air--fermentation of lactate of lime as another example of life without air, accompanied by fermentation properly so called, we may lastly cite the fermentation of lactate of lime in a mineral medium. in the experiment described in the last paragraph, it will be remembered that the ferment liquid and the germs employed in its impregnation came in contact with air, although only for a very brief time. now, notwithstanding that we possess exact observations which prove that the diffusion of oxygen and nitrogen in a liquid absolutely deprived of air, so far from taking place rapidly, is, on the contrary, a very slow process indeed; yet we were anxious to guard the experiment that we are about to describe from the slightest possible trace of oxygen at the moment of impregnation. we employed a liquid prepared as follows: into from 9 to 10 litres (somewhat over 2 gallons) of pure water the following salts [footnote: should the solution of lactate of lime be turbid, it may be clarified by filtration, after previously adding a small quantity of phosphate of ammonia, which throws down phosphate of lime. it is only after this process of clarification and filtration that the phosphates of the formula are added. the solution soon becomes turbid if left in contact with air, in consequence of the spontaneous formation of bacteria.] were introduced successively, viz: pure lactate of lime. ... . ... . ... . ... . .. 225 grammes phosphate of ammonia. ... . ... . ... . ... . .. 0.75 grammes phosphate of potassium. ... . ... . ... . ... .. 0.4 grammes sulphate of magnesium. ... . ... . ... . ... ... 0.4 grammes sulphate of ammonia. ... . ... . ... . ... . ... 0.2 grammes (1 gramme = 15.43 grains.) [illustration with caption: fig. 11] on march 23rd, 1875, we filled a 6 litre (about 11 pints) flask, of the shape represented in fig. 11, and placed it over a heater. another flame was placed below a vessel containing the same liquid, into which the curved tube of the flask plunged. the liquids in the flask and in the basin were raised to boiling together, and kept in this condition for more than half-an-hour, so as to expel all the air held in solution. the liquid was several times forced out of the flask by the steam, and sucked back again; but the portion which re-entered the flask was always boiling. on the following day when the flask had cooled, we transferred the end of the delivery tube to a vessel full of mercury and placed the whole apparatus in an oven at a temperature varying between 25 degrees c. and 30 degrees c. (77 degrees f. and 86 degrees f.) then, after having refilled the small cylindrical tap-funnel with carbonic acid, we passed into it with all necessary precautions 10 cc. (0.35 fl. oz) of a liquid similar to that described, which had been already in active fermentation for several days out of contact with air and now swarmed with vibrios. we then turned the tap of the funnel, until only a small quantity of liquid was left, just enough to prevent the access of air. in this way the impregnation was accomplished without either the ferment-liquid or the fermentgerms having been brought in contact, even for the shortest space, with the external air. the fermentation, the occurrence of which at an earlier or later period depends for the most part on the condition of the impregnating germs, and the number introduced in the act, in this case began to manifest itself by the appearance of minute bubbles from march 29th. but not until april 9th did we observe bubbles of larger size rise to the surface. from that date onward they continued to come in increasing number, from certain points at the bottom of the flask, where a deposit of earthy phosphates existed; and at the same time the liquid, which for the first few days remained perfectly clear, began to grow turbid in consequence of the development of vibrios. it was on the same day that we first observed a deposit on the sides of carbonate of lime in crystals. it is a matter of some interest to notice here that, in the mode of procedure adopted, everything combined to prevent the interference of air. a portion of the liquid expelled at the beginning of the experiment, partly because of the increased temperature in the oven and partly also by the force of the gas, as it began to be evolved from the fermentative action, reached the surface of the mercury, where, being the most suitable medium we know for the growth of bacteria, it speedily swarmed with these organisms. [footnote: the naturalist cohn, of breslau, who published an excellent work on bacteria in 1872, described, after mayer, the composition of a liquid peculiarly adapted to the propagation of these organisms, which it would be well to compare for its utility in studies of this kind with our solution of lactate and phosphates. the following is cohn's formula: distilled water. ... . ... . ... . ..20 cc. (0.7 fl. oz.) phosphate of potassium. ... . ... ...0.1 gramme (1.5 grains) sulphate of magnesium. ... . ... . 0.1 gramme (1.5 grains) tribasic phosphate of lime. ... ... 0.01 gramme (0.15 grain) tartrate of ammonia. ... . ... . ... 0.2 gramme (3 grains) this liquid, the author says, has a feeble acid reaction and forms a perfectly clear solution.] in this way any passage of air, if such a thing were possible, between the mercury and the sides of the delivery-tube was altogether prevented, since the bacteria would consume every trace of oxygen which might be dissolved in the liquid lying on the surface of the mercury. hence it is impossible to imagine that the slightest trace of oxygen could have got into the liquid in the flask. before passing on we may remark that in this ready absorption of oxygen by bacteria we have a means of depriving fermentable liquids of every trace of that gas with a facility and success equal or even greater than by the preliminary method of boiling. such a solution as we have described, if kept at summer heat, without any previous boiling, becomes turbid in the course of twenty-four hours from a spontaneous development of bacteria; and it is easy to prove that they absorb all the oxygen held in solution. [footnote: on the rapid absorption of oxygen by bacteria, see also our memoire of 1872, sur les generations dites spontanees, especially the note on page 78.] if we completely fill a flask of a few litres capacity (about a gallon) (fig. 9) with the liquid described, taking care to have the delivery-tube also filled, and its opening plunged under mercury, and, fortyeight hours afterwards by means of a chloride of calcium bath, expel from the liquid on the surface of the mercury all the gas which it holds in solution, this gas, when analyzed, will be found to be composed of a mixture of nitrogen and carbonic acid gas, without the least trace of oxygen. here, then, we have an excellent means of depriving the fermentable liquid of air; we simply have completely to fill a flask with the liquid, and place it in the oven, merely avoiding any addition of butyric vibrios, before the lapse of two or three days. we may wait even longer; and then, if the liquid does become impregnated spontaneously with vibrio germs, the liquid, which at first was turbid from the presence of bacteria, will become bright again, since the bacteria, when deprived of life, or, at least, of the power of moving, after they have exhausted all the oxygen in solution, will fall inert to the bottom of the vessel. on several occasions we have determined this interesting fact, which tends to prove that the butyric vibrios cannot be regarded as another form of bacteria, inasmuch as, on the hypothesis of an original relation between the two productions, butyric fermentation ought in every case to follow the growth of bacteria. we may also call attention to another striking experiment, well suited to show the effect of differences in the composition of the medium upon the propagation of microscopic beings. the fermentation which we last described commenced on march 27th and continued until may 10th; that to which we are now to refer, however, was completed in four days, the liquid employed being similar in composition and quantity to that employed in the former experiment. on april 23, 1875, we filled a flask of the same shape as that represented in fig. 11, and of similar capacity, viz., 6 litres, with a liquid composed as described at page 69. this liquid had been previously left to itself for five days in large open flasks, in consequence of which it had developed an abundant growth of bacteria. on the fifth day a few bubbles, rising from the bottom of the vessels, at long intervals, betokened the commencement of butyric fermentation, a fact, moreover, confirmed by the microscope, in the appearance of the vibrios of this fermentation in specimens of the liquid taken from the bottom of the vessels, the middle of its mass, and even in the layer on the surface that was swarming with bacteria. we transferred the liquid so prepared to the 6 litre flask arranged over the mercury. by evening a tolerably active fermentation had begun to manifest itself. on the 24th this fermentation was proceeding with astonishing rapidity, which continued during the 25th and 26th. during the evening of the 26th it slackened, and on the 27th all signs of fermentation had ceased. this was not, as might be supposed, a sudden stoppage due to some unknown cause; the fermentation was actually completed, for when we examined the fermented liquid on the 28th we could not find the smallest quantity of lactate of lime. if the needs of industry should ever require the production of large quantities of butyric acid, there would, beyond doubt, be found in the preceding fact valuable information in devising an easy method of preparing that product in abundance. [footnote: in what way are we to account for so great a difference between the two fermentations that we have just described? probably it was owing to some modification effected in the medium by the previous life of the bacteria, or to the special character of the vibrios used in impregnation. or, again, it might have been due to the action of the air, which, under the conditions of our second experiment, was not absolutely eliminated, since we took no precaution against its introduction at the moment of filling our flask, and this would tend to facilitate the multiplication of anaerobian vibrios, just as, under similar conditions, would have been the case if we had been dealing with a fermentation by ordinary yeast.] before we go any further, let us devote some attention to the vibrios of the preceding fermentations. on may 27th, 1862, we completely filled a flask capable of holding 2.780 litres (about five pints) with the solution of lactate and phosphates. [footnote: in this case the liquid was composed as follows: a saturated solution of lactate of lime, at a temperature of 25 degrees c. (77 degrees f.), was prepared, containing for every 1oo cc. (3 1/2 fl. oz.) 25.65 grammes (394 grains) of the lactate, c6 h5 o5 ca o (new notation, c6 h10 ca o6) this solution was rendered very clear by the addition of 1 gramme of phosphate of ammonia and subsequent filtration. for a volume of 8 litres (14 pints) of this clear saturated solution we used (1 gramme = 15.43 grains): phosphate of ammonia. ... . ... . ... . ... 2 grammes phosphate of potassium. ... . ... . ... . ... 1 gramme phosphate of magnesium. ... . ... . ... . ... 1 gramme sulphate of ammonia. ... . ... . ... . ... 0.5 gramme] we refrained from impregnating it with any germs. the liquid became turbid from a development of bacteria and then underwent butyric fermentation. by june 9th the fermentation had become sufficiently active to enable us to collect in the course of twenty-four hours, over mercury, as in all our experiments, about 100 cc. (about 6 cubic inches) of gas. by june 11th, judging from the volume of gas liberated in the course of twenty-four hours, the activity of the fermentation had doubled. we examined a drop of the turbid liquid. here are the notes accompanying the sketch (fig. 12) as they stand in our note-book: "a swarm of vibrios, so active in their movements that the eye has great difficulty in following them. they may be seen in pairs throughout the field, apparently making efforts to separate from each other. the connection would seem to be by some invisible, gelatinous thread, which yields so far to their efforts that they succeed in breaking away from actual contact, but yet are, for a while, so far restrained that the movements of one have a visible effect on those of the other. by and by, however, we see a complete separation effected, and each moves on its separate way with an activity greater than it ever had before." [illustration with caption: fig. 12] one of the best methods that can be employed for the microscopical examination of these vibrios, quite out of contact with air, is the following. after butyric fermentation has been going on for several days in a flask, (fig. 13), we connect this flask by an india-rubber tube with one of the flattened bulbs previously described, which we then place on the stage of the microscope (fig. 13). when we wish to make an observation we close, under the mercury, at the point b, the end of the drawnout and bent delivery-tube. the continued evolution of gas soon exerts such a pressure within the flask, that when we open the tap r, the liquid is driven into the bulb ll, until it becomes quite full and the liquid flows over into the glass v. in this manner we may bring the vibrios under observation without their coming into contact with the least trace of air, and with as much success as if the bulb, which takes the place of an object glass, had been plunged into the very centre of the flask. the movements and fissiparous multiplication of the vibrios may thus be seen in all their beauty, and it is indeed a most interesting sight. the movements do not immediately cease when the temperature is suddenly lowered, even to a considerable extent, 15 degrees c. (59 degrees f.) for example; they are only slackened. nevertheless, it is better to observe them at the temperatures most favourable to fermentation, even in the oven where the vessels employed in the experiment are kept at a temperature between 25 degrees c. and 30 degrees c. (77 degrees f. and 86 degrees f.). [illustration: fig. 13] we may now continue our account of the fermentation which we were studying when we made this last digression. on june 17th that fermentation produced three times as much gas as it did on june 11th, when the residue of hydrogen, after absorption by potash, was 72.6 per cent.; whilst on the 17th it was only 49.2 per cent. let us again discuss the microscopic aspect of the turbid liquid at this stage. appended is the sketch we made (fig. 14) and our notes on it: "a most beautiful object: vibrios all in motion, advancing or undulating. they have grown considerably in bulk and length since the 11th; many of them are joined together in long sinuous chains, very mobile at the articulations, visibly less active and more wavering in proportion to the number that go to form the chain, of the length of the individuals." this description is applicable to the majority of the vibrios which occur in cylindrical rods and are homogeneous in aspect. there are others, of rare occurrence in chains, which have a clear corpuscle, that is to say, a portion more refractive than other parts of the segments, at one of their extremities. sometimes the foremost segment has the corpuscle at one end, sometimes the other. the long segments of the commoner kind attain a length of from 10 to 30 and even 45 thousandths of a millimetre. their diameter is from 1 1/2 to 2, very rarely 3, thousandths of a millimetre. [footnote: 1 millimetre = 0.039 inch: hence the dimensions indicated will be--length, from 0.00039 to 0.00117, or even 0.00176 in.; diameter, from 0.000058 to 0.000078, rarely 0.000117 in.--d. c. r.] [illustration: figure 14.] on june 28th, fermentation was quite finished; there was no longer any trace of gas, nor any lactate in solution. all the infusoria were lying motionless at the bottom of the flask. the liquid clarified by degrees, and in the course of a few days became quite bright. here we may inquire, were these motionless infusoria, which from complete exhaustion of the lactate, the source of the carbonaceous part of their food, were now lying inert at the bottom of the fermenting vessel--were they dead beyond the power of revival? [footnote: the carbonaceous supply, as we remarked, had failed them, and to this failure the absence of vital action, nutrition, and multiplication was attributable. the liquid, however, contained butyrate of lime, a salt possessing properties similar to those of the lactate. why could not this salt equally well support the life of the vibrios? the explanation of the difficulty seems to us to lie simply in the fact that lactic acid produces heat by its decomposition, whilst butyric acid does not, and the vibrios seem to require heat during the chemical process of their nutrition.] the following experiment leads us to believe that they were not perfectly lifeless, and that they might behave in the same manner as the yeast of beer, which, after it has decomposed all the sugar in a fermentable liquid, is ready to revive and multiply in a fresh saccharine medium. on april 22nd, 1875, we left in the oven at a temperature of 25 degrees c. (77 degrees f.) a fermentation of lactate of lime that had been completed. the delivery tube of the flask a, (fig. 15), in which it had taken place, had never been withdrawn from under the mercury. we kept the liquid under observation daily, and saw it gradually become brighter; this went on for fifteen days. we then filled a similar flask, b, with the solution of lactate, which we boiled, not only to kill the germs of vibrios which the liquid might contain, but also to expel the air that it held in solution. when the flask, b, had cooled, we connected the two flasks, avoiding the introduction of air, [footnote: to do this it is sufficient, first, to fill the curved ends of the stop-cocked tubes of the flasks, as well as the india-rubber tube c c which connects them, with boiling water that contains no air.] after having slightly shaken the flask, a, to stir up the deposit at the bottom. there was then a pressure due to carbonic acid at the end of the delivery tube of this latter flask, at the point a, so that on opening the taps r and s, the deposit at the bottom of flask a was driven over into flask b, which in consequence was impregnated with the deposit of a fermentation that had been completed fifteen days before. two days after impregnation the flask b began to show signs of fermentation. it follows that the deposit of vibrios of a completed butyric fermentation may be kept, at least for a certain time, without losing the power of causing fementation. it furnishes a butyric ferment, capable of revival and action in a suitable fresh fermentable medium. [illustration: fig. 15] the reader who has attentively studied the facts which we have placed before him cannot, in our opinion, entertain the least doubt on the subject of the possible multiplication of the vibrios of a fermentation of lactate of lime out of contact with atmospheric oxygen. if fresh proofs of this important proposition were necessary, they might be found in the following observations, from which it may be inferred that atmospheric oxygen is capable of suddenly checking a fermentation produced by butyric vibrios, and rendering them absolutely motionless, so that it cannot be necessary to enable them to live. on may 7th, 1862, we placed in the oven a flask holding 2.580 litres (4 1/2 pints), and filled with the solution of lactate of lime and phosphates, which we had impregnated on the 9th with two drops of a liquid in butyric fermentation. in the course of a few days fermentation declared itself: on the 18th it was active; on the 30th it was very active. on june 1st it yielded hourly 35 cc. (2.3 cubic inches) of gas, containing ten per cent, of hydrogen. on the 2nd we began the study of the action of air on the vibrios of this fermentation. to do this we cut off the delivery-tube on a level with its point of junction to the flask, then with a 50 cc. pipette we took out that quantity (1 3/4 fl. oz.) of liquid which was, of course, replaced at once by air. we then reversed the flask with the opening under the mercury, and shook it every ten minutes for more than an hour. wishing to make sure, to begin with, that the oxygen had been absorbed we connected under the mercury the beak of the flask by means of a thin india-rubber tube filled with water, with a small flask, the neck of which had been drawn out and was filled with water; we then raised the large flask with the smaller kept above it. a mohr's clip, which closed the india-rubber tube, and which we then opened, permitted the water contained in the small flask to pass into the large one, whilst the gas, on the contrary, passed upwards from the large flask into the small one. we analyzed the gas immediately, and found that, allowing for the carbonic acid and hydrogen, it did not contain more than 14.2 per cent. of oxygen, which corresponds to an absorption of 6.6 cc., or of 3.3 cc. (0.2 cubic inch) of oxygen for the 50 cc. (3.05 cubic inches) of air employed. lastly, we again established connection by an indiarubber tube between the flasks, after having seen by microscopical examination that the movements of the vibrios were very languid. fermentation had become less vigorous without having actually ceased, no doubt because some portions of the liquid had not been brought into contact with the atmospheric oxygen, in spite of the prolonged shaking that the flask had undergone after the introduction of the air. whatever the cause might have been, the significance of the phenomenon is not doubtful. to assure ourselves further of the effect of air on the vibrios, we half filled two test tubes with the fermenting liquid taken from another fermentation which had also attained its maximum of intensity, into one of which we passed a current of air, into the other carbonic acid gas. in the course of half an hour, all the vibrios in the aerated tube were dead, or at least motionless, and fermentation had ceased. in the other tube, after three hours' exposure to the effects of the carbonic acid gas, the vibrios were still very active, and fermentation was going on. there is a most simple method of observing the deadly effect of atmospheric air upon vibrios. we have seen in the microscopical examination made by means of the apparatus represented in fig. 13, how remarkable were the movements of the vibrios when absolutely deprived of air, and how easy it was to discern them. we will repeat this observation, and at the same time make a comparative study of the same liquid under the microscope in the ordinary way, that is to say, by placing a drop of the liquid on an object-glass, and covering it with a thin glass slip, a method which must necessarily bring the drop into contact with air, if only for a moment. it is surprising what a remarkable difference is observed immediately between the movements of the vibrios in the bulb and those under the glass. in the case of the latter, we generally see all movement at once cease near the edges of the glass, where the drop of liquid is in direct contact with the air; the movements continue for a longer or shorter time about the centre, in proportion as the air is more or less intercepted by the vibrios at the circumference of the liquid. it does not require much skill in experiments of this kind to enable one to see plainly that immediately after the glass has been placed on the drop, which has been affected all over by atmospheric air, the whole of the vibrios seem to languish and to manifest symptoms of illness--we can think of no better expression to explain what we see taking place--and that they gradually recover their activity about the centre, in proportion as they find themselves in a part of the medium that is less affected by the presence of oxygen. some of the most curious facts are to be found in connection with an observation, the correlative and inverse of the foregoing, on the ordinary aerobian bacteria. if we examine below the microscope a drop of liquid full of these organisms under a coverslip, we very soon observe a cessation of motion in all the bacteria which lie in the central portion of the liquid, where the oxygen rapidly disappears to supply the necessities of the bacteria existing there; whilst, on the other hand, near the edges of the cover-glass the movements are very active, in consequence of the constant supply of air. in spite of the speedy death of the bacteria beneath the centre of the glass, we see life prolonged there if by chance a bubble of air has been enclosed. all round this bubble a vast number of bacteria collect in a thick, moving circle, but as soon as all the oxygen of the bubble has been absorbed they fall apparently lifeless, and are scattered by the movement of the liquid. [footnote: we find this fact, which we published as long ago as 1863, confirmed in a work of h. hoffman's, published in 1861 under the title of memoire sur les bacteries, which has appeared in french (annales des sciences naturelles, 5th series, vol. ix.). on this subject we may cite an observation that has not yet been published. aerobian bacteria lose all power of movement when suddenly plunged into carbonic acid gas; they recover it, however, as if they had only been suffering from anaesthesia, as soon as they are brought into the air again.] we may here be permitted to add, as a purely historical matter, that it was these two observations just described, made successively one day in 1861, on vibrios and bacteria, that first suggested to us the idea of the possibility of life without air, and caused us to think that the vibrios which we met so frequently in our lactic fermentations must be the true butyric ferment. we may pause to consider an interesting question in reference to the two characters under which vibrios appear in butyric fermentations. what is the reason that some vibrios exhibit refractive corpuscles, generally of a lenticular form, such as we see in fig. 14. we are strongly inclined to believe that these corpuscles have to do with a special mode of reproduction in the vibrios, common alike to the anaerobian forms which we are studying, and the ordinary aerobian forms in which also the corpuscles of which we are speaking may occur. the explanation of the phenomenon, from our point of view, would be that, after a certain number of fisiparous generations, and under the influence of variations in the composition of the medium, which is constantly changing through fermentation as well as through the active life of the vibrios themselves, cysts, which are simply the refractive corpuscles, form along them at different points. from these gemmules we have ultimately produced vibrios, ready to reproduce others by the process of transverse division for a certain time, to be themselves encysted, later on. various observations incline us to believe that, in their ordinary form of minute, soft, exuberant rods, the vibrios perish when submitted to desiccation, but when they occur in corpuscular or encysted form they possess unusual powers of resistance and may be brought to the state of dry dust and be wafted about by winds. none of the matter which surrounds the corpuscle or cyst seems to take part in the preservation of the germ, when the cyst is formed, for it is all re-absorbed, gradually leaving the cyst bare. the cysts appear as masses of corpuscles, in which the most practiced eye cannot detect anything of an organic nature, or anything to remind one of the vibrios which produced them; nevertheless, these minute bodies are endowed with a latent vital action, and only await favourable conditions to develop long rods of vibrios. we are not, it is true, in a position to adduce any very forcible proofs in support of these opinions. they have been suggested to us by experiments, none of which, however, have been absolutely decisive in their favour. we may cite one of our observations on this subject. in a fermentation of glycerine in a mineral medium--the glycerine was fermenting under the influence of butyric vibrios--after we had determined the, we may say, exclusive presence of lenticular vibrios, with refractive corpuscles, we observed the fermentation, which for some unknown reason had been very languid, suddenly become extremely active, but now through the influence of the ordinary vibrios. the gemmules with brilliant corpuscles had almost disappeared; we could see but very few, and those now consisted of the refractive bodies alone, the bulk of the vibrios accompanying them having undergone some process of re-absorption. another observation which still more closely accords with this hypothesis is given in our work on silk-worm disease (vol. 1, p. 256). we there demonstrated that, when we place in water some of the dust formed of desiccated vibrios, containing a host of these refractive corpuscles, in the course of a very few hours large vibrios appear, well-developed rods fully grown, in which the brilliant points are absent; whilst in the water no process of development from smaller vibrios is to be discerned, a fact which seems to show that the former had issued fully grown from the refractive corpuscles, just as we see colpoda issue with their adult aspect from the dust of their cysts. this observation, we may remark, furnishes one of the best proofs that can be adduced against the spontaneous generation of vibrios or bacteria, since it is probable that the same observation applies to bacteria. it is true that we cannot say of mere points of dust examined under the microscope, that one particular germ belongs to vibrio, another to bacterium; but how is it possible to doubt that the vibrios issue, as we see them, from an ovum of some kind, a cyst, or germ, of determinate character, when, after having placed some of those indeterminate motes of dust into clean water, we suddenly see, after an interval of not more than one or two hours, an adult vibrio crossing the field of the microscope, without our having been able to detect any intermediate state between its birth and adolescence? [illustration: fig. 16] it is a question whether differences in the aspect and nature of vibrios, which depend upon their more or less advanced age, or are occasioned by the influence of certain conditions on the medium in which they propagate, do not bring about corresponding changes in the course of the fermentation and the nature of its products. judging at least from the variations in the proportions of hydrogen, and carbonic acid gas produced in butyric fermentations, we are inclined to think that this must be the case; nay, more, we find that hydrogen is not even a constant product in these fermentations. we have met with butyric fermentations of lactate of lime which did not yield the minutest trace of hydrogen, or anything besides carbonic acid. fig. 16 represents the vibrios which we observed in a fermentation of this kind. they present no special features. butyl alcohol is, according to our observations, an ordinary product, although it varies and is by no means a necessary concomitant of these fermentations. it might be supposed, since butylic alcohol may be produced and hydrogen be in deficit, that the proportion of the former of these products would attain its maximum when the latter assumed a minimum. this, however, is by no means the case; even in those few fermentations that we have met with in which hydrogen was absent, there was no formation of butylic alcohol. from a consideration of all the facts detailed in this section we can have no hesitation in concluding that, on the one hand, in cases of butyric fermentation, the vibrios which abound in them and constitute their ferment, live without air or free oxygen; and that, on the other hand, the presence of gaseous oxygen operates prejudicially against the movements and activity of those vibrios. but how does it follow that the presence of minute quantities of air brought into contact with a liquid undergoing butyric fermention would prevent the continuance of that fermentation or even exercise any check upon it? we have not made any direct experiments upon this subject; but we should not be surprised to find that, so far from hindering, air may, under such circumstances, facilitate the propagation of the vibrios and accelerate fermentation. this is exactly what happens in the case of yeast. but how could we reconcile this, supposing it were proved to be the case, with the fact just insisted on as to the danger of bringing the butyric vibrios into contact with air? it may be possible that life without air results from habit, whilst death through air may be brought about by a sudden change in the conditions of the existence of the vibrios. the following remarkable experiment is well-known: a bird is placed in a glass jar of one or two litres (60 to 120 cubic inches) in capacity which is then closed. after a time the creature shows every sign of intense uneasiness and asphyxia long before it dies; a similar bird of the same size is introduced into the jar; the death of the latter takes place instanteously, whilst the life of the former may still be prolonged under these conditions for a considerable time, and there is no, difficulty even in restoring the bird to perfect health by taking it out of the jar. it seems impossible to deny that we have here a case of the adaptation of an organism to the gradual contamination of the medium; and so it may likewise happen that the anaerobian vibrios of a butyric fermentation, which develop and multiply absolutely without free oxygen, perish immediately when suddenly taken out of their airless medium, and that the result might be different if they had been gradually brought under the action of air in small quantities at a time. we are compelled here to admit that vibrios frequently abound in liquids exposed to the air, and that they appropriate the atmospheric oxygen, and could not withstand a sudden removal from its influence. must we, then, believe that such vibrios are absolutely different from those of butyric fermentations? it would, perhaps, be more natural to admit that in the one case there is an adaptation to life with air, and in the other case an adaptation to life without air; each of the varieties perishing when suddenly transferred from its habitual condition to that of the other, whilst by a series of progressive changes one might be modified into the other. [footnote: these doubts might be easily removed by putting the matter to the test of direct experiment.] we know that in the case of alcoholic ferments, although these can actually live without air, propagation is wonderfully assisted by the presence of minute quantities of air; and certain experiments which we have not yet published lead us to believe that, after having lived without air, they cannot be suddenly exposed with impunity to the influence of large quantities of oxygen. we must not forget, however, that aerobian torulae and anaerobian ferments present an example of organisms apparently identical, in which, however, we have not yet been able to discover any ties of a common origin. hence we are forced to regard them as a distinct species; and so it is possible that there may likewise be aerobian and anaerobian vibrios without any transformation of the one into the other. the question has been raised whether vibrios, especially those which we have shown to be the ferment of butyric and many other fermentations, are in their nature, animal or vegetable. m. ch. robin attaches great importance to the solution of this question, of which he speaks as follows: [footnote: robin, sur la nature des fermentations, &c. (journal de l'academie et de la physiologie, july and august, 1875, p. 386).] "the determination of the nature, whether animal or vegetable, of organisms, either as a whole or in respect to their anatomical parts, assimilative or reproductive, is a problem which has been capable of solution for a quarter of a century. the method has been brought to a state of remarkable precision, experimentally, as well as in its theoretical aspects, since those who devote their attention to the organic sciences consider it indispensable in every observation and experiment to determine accurately, before anything else, whether the object of their study is animal or vegetable in its nature, whether adult or otherwise. to neglect this is as serious an omission for such students as for chemists would be the neglecting to determine whether it is nitrogen or hydrogen, urea or stearine, that has been extracted from a tissue, or which it is whose combinations they are studying in this or that chemical operation. now, scarcely any one of those who study fermentations, properly so-called, and putrefactions, ever pay any attention to the preceding data. ... among the observers to whom i allude, even m. pasteur is to be found, who, even in his most recent communications, omits to state definitely what is the nature of many of the ferments which he has studied, with the exception, however, of those which belong to the cryptogamic group called torulaceae. various passages in his work seem to show that he considers the cryptogamic organisms called bacteria, as well as those known as vibrios, as belonging to the animal kingdom (see bulletin de l'academie de medecine, paris, 1875, pp. 249, 251, especially 256, 266, 267, 289, and 290). these would be very different, at least physiologically, the former being anaerobian, that is to say, requiring no air to enable them to live, and being killed by oxygen, should it be dissolved in the liquid to any considerable extent." we are unable to see the matter in the same light as our learned colleague does; to our thinking, we should be labouring under a great delusion were we to suppose "that it is quite as serious an omission not to determine the animal or vegetable nature of a ferment as it would be to confound nitrogen with hydrogen or urea with stearine." the importance of the solutions of disputed questions often depends on the point of view from which these are regarded. as far as the result of our labours is concerned, we devoted our attention to these two questions exclusively: 1. is the ferment, in every fermentation properly so called, an organized being? 2. can this organized being live without air? now, what bearing can the question of the animal or vegetable nature of the ferment, of the organized being, have upon the investigation of these two problems? in studying butyric fermentation, for example, we endeavoured to establish these two fundamental points; 1. the butyric ferment is a vibrio. 2. this vibrio may dispense with air in its life, and, as a matter of fact, does dispense with it in the act of producing butyric fermentation. we did not consider it at all necessary to pronounce any opinion as to the animal or vegetable nature of this organism, and, even up to the present moment, the idea that vibrio is an animal and not a plant is in our minds, a matter of sentiment rather than of conviction. m. robin, however, would have no difficulty in determining the limits of the two kingdoms. according to him, "every variety of cellulose is, we may say, insoluble in ammonia, as also are the reproductive elements of plants, whether male or female. whatever phase of evolution the elements which reproduce a new individual may have reached, treatment with this reagent, either cold or raised to boiling, leaves them absolutely intact under the eyes of the observer, except that their contents, from being partially dissolved, become more transparent. every vegetable whether microscopic or not, every mycelium and every spore, thus preserves in its entirety its special characteristics of form, volume and structural arrangements; whilst in the case of microscopic animals, or the ova and microscopic embryos of different members of the animal kingdom, the very opposite is the case." we should be glad to learn that the employment of a drop of ammonia would enable us to pronounce an opinion with this degree of confidence on the nature of the lowest microscopic beings; but is m. robin absolutely correct in his assumptions? that gentleman himself remarks that spermatozoa, which belong to animal organisms, are insoluble in ammonia, the effect of which is merely to make them paler. if a difference of action in certain reagents, in ammonia, for example, were sufficient to determine the limits of the animal and vegetable kingdoms, might we not argue that there must be a very great and natural difference between moulds and bacteria, inasmuch as the presence of a small quantity of acid in the nutritive medium facilitates the growth and propagation of the former, whilst it is able to prevent the life of bacteria and vibrios? although as is well known, movement is not an exclusive characteristic of animals, yet we have always been inclined to regard vibrios as animals, on account of the peculiar character of their movements. how greatly they differ in this respect from the diatomacae, for example! when the vibrio encounters an obstacle it turns, or after assuring itself by some visual effort or other that it cannot overcome it, it retraces its steps. the colpoda--undoubted infusoria--behave in an exactly similar manner. it is true one may argue that the zoospores of certain cryptogamia exhibit similar movements; but do not these zoospores possess as much of an animal nature as do the spermatozoa? as far as bacteria are concerned, when, as already remarked, we see them crowd round a bubble of air in a liquid to prolong their life, oxygen having failed them everywhere else, how can we avoid believing that they are animated by an instinct for life, of the same kind that we find in animals? m. robin seems to us to be wrong in supposing that it is possible to draw any absolute line of separation between the animal and vegetable kingdoms. the settlement of this line however, we repeat again, no matter what it may be, has no serious bearing upon the questions that have been the subject of our researches. in like manner the difficulty which m. robin has raised in objecting to the employment of the word germ, when we cannot specify whether the nature of that germ is animal or vegetable, is in many respects an unnecessary one. in all the questions which we have discussed, whether we were speaking of fermentation or spontaneous generation, the word germ has been used in the sense of origin of living organism. if liebig, for example, said of an albuminous substance that it gave birth to ferment, could we contradict him more plainly than by replying "no; ferment is an organized being, the germ of which is always present, and the albuminous substance merely serves by its occurrence to nourish the germ and its successive generations"? in our memoir of 1862, on so-called spontaneous generations, would it not have been an entire mistake to have attempted to assign specific names to the microscopic organisms which we met with in the course of our observations? not only would we have met with extreme difficulty in the attempt, arising from the state of extreme confusion which even in the present day exists in the classification and nomenclature of these microscopic organisms, but we should have been forced to sacrifice clearness in our work besides; at all events, we should have wandered from our principal object, which was the determination of the presence or absence of life in general, and had nothing to do with the manifestation of a particular kind of life in this or that species, animal or vegetable. thus we have systematically employed the vaguest nomenclature, such as mucors, torulae, bacteria, and vibrios. there was nothing arbitrary in our doing this, whereas there is much that is arbitrary in adopting a definite system of nomenclature, and applying it to organisms but imperfectly known, the differences or resemblances between which are only recognizable through certain characteristics, the true signification of which is obscure. take, for example, the extensive array of widely different systems which have been invented during the last few years for the species of the genera bacterium and vibrio in the works of cohn, h. hoffmann, hallier, and billroth. the confusion which prevails here is very great, although we do not of course by any means place these different works on the same footing as regards their respective merits. m. robin is, however, right in recognizing the impossibility of maintaining in the present day, as he formerly did, "that fermentation is an exterior phenomenon, going on outside cryptogamic cells, a phenomenon of contact. it is probably," he adds, "an interior and molecular action at work in the innermost recesses of the substance of each cell." from the day when we first proved that it is possible for all organized ferments, properly so called, to spring up and multiply from their respective germs, sown, whether consciously or by accident, in a mineral medium free from organic and nitrogenous matters other than ammonia, in which medium the fermentable matter alone is adapted to provide the ferment with whatever carbon enters into its composition, from that time forward the theories of liebig, as well of berzelius, which m. robin formerly defended, have had to give place to others more in harmony with facts. we trust that the day will come when m. robin will likewise acknowledge that he has been in error on the subject of the doctrine of spontaneous generation, which he continues to affirm, without adducing any direct proofs in support of it, at the end of the article to which we have been here replying. we have devoted the greater part of this chapter to the establishing with all possible exactness the extremely important physiological fact of life without air, and its correlation to the phenomena of fermentations properly so called--that is to say, of those which are due to the presence of microscopic cellular organisms. this is the chief basis of the new theory that we propose for the explanation of these phenomena. the details into which we have entered were indispensable on account of the novelty of the subject no less than on account of the necessity we were under of combating the criticisms of the two german naturalists, drs. oscar brefeld and traube, whose works had cast some doubts on the correctness of the facts upon which we had based the preceding propositions. we have much pleasure in adding that at the very moment we were revising the proofs of this chapter, we received from m. brefeld an essay, dated berlin, january, 1876, in which, after describing his later experimental researches, he owns with praiseworthy frankness that dr. traube and he were both of them mistaken. life without air is now a proposition which he accepts as perfectly demonstrated. he has witnessed it in the case of mucor racemosus and has also verified it in the case of yeast. "if," he says, "after the results of my previous researches, which i conducted with all possible exactness, i was inclined to consider pasteur's assertion as inaccurate and to attack them, i have no hesitation now in recognizing them as true, and in proclaiming the service which pasteur has rendered to science in being the first to indicate the exact relation of things in the phenomenon of fermentation." in his later researches, dr. brefeld has adopted the method which we have long employed for demonstrating the life and multiplication of butyric vibrios in the entire absence of air, as well as the method of conducting growths in mineral media associated with fermentable substance. we need not pause to consider certain other secondary criticisms of dr. brefeld. a perusal of the present work will, we trust, convince him that they are based on no surer foundation than were his former criticisms. to bring one's self to believe in a truth that has just dawned upon one is the first step towards progress; to persuade others is the second. there is a third step, less useful perhaps, but highly gratifying nevertheless, which is, to convince one's opponents. we therefore, have experienced great satisfaction in learning that we have won over to our ideas an observer of singular ability, on a subject which is of the utmost importance to the physiology of cells. vi. reply to the critical observations of liebig, published in 1870. [footnote: liebig, sur la fermentation et la source de la force musculaire (annales de chimie et de physique, 4th series, t. xxiii., p. 5, 1870).] in the memoir which we published, in 1860, on alcoholic fermentation, and in several subsequent works, we were led to a different conclusion on the causes of this very remarkable phenomenon from that which liebig had adopted. the opinions of mitscherlich and berzelius had ceased to be tenable in the presence of the new facts which we had brought to light. from that time we felt sure that the celebrated chemist of munich had adopted our conclusions, from the fact that he remained silent on this question for a long time, although it had been until then the constant subject of his study, as is shown by all his works. suddenly there appeared in the annales de chimie et de physique a long essay, reproduced from a lecture delivered by him before the academy of bavaria in 1868 and 1869. in this liebig again maintained, not, however, without certain modifications, the views which he had expressed in his former publications, and disputed the correctness of the principal facts enunciated in our memoir of 1860, on which were based the arguments against his theory. "i had admitted," he says, "that the resolution of fermentable matter into compounds of a simpler kind must be traced to some process of decomposition taking place in the ferment, and that the action of this same ferment on the fermentable matter must continue or cease according to the prolongation or cessation of the alteration produced in the ferment. the molecular change in the sugar, would, consequently, be brought about by the destruction or modification of one or more of the component parts of the ferment, and could only take place through the contact of the two substances. m. pasteur regards fermentation in the following light: the chemical action of fermentation is essentially a phenomenon correlative with a vital action, beginning and ending with it. he believes that alcoholic fermentation can never occur without the simultaneous occurrence of organization, development, and multiplication of globules, or continuous life, carried on from globules already formed. but the idea that the decomposition of sugar during fermentation is due to the development of the cellules of the ferment, is in contradiction with the fact that the ferment is able to bring about the fermentation of a pure solution of sugar. the greater part of the ferment is composed of a substance that is rich in nitrogen and contains sulphur. it contains, moreover, an appreciable quantity of phosphates, hence it is difficult to conceive how, in the absence of these elements in a pure solution of sugar undergoing fermentation, the number of cells is capable of any increase." notwithstanding liebig's belief to the contrary, the idea that the decomposition of sugar during fermentation is intimately connected with a development of the cellules of the ferment, or a prolongation of the life of cellules already formed, is in no way opposed to the fact that the ferment is capable of bringing about the fermentation of a pure solution of sugar. it is manifest to any one who has studied such fermentation with the microscope, even in those cases where the sweetened water has been absolutely pure, that ferment-cells do multiply, the reason being that the cells carry with them all the food-supplies necessary for the life of the ferment. they may be observed budding, at least many of them, and there can be no doubt that those which do not bud still continue to live; life has other ways of manifesting itself besides development and cell-proliferation. if we refer to the figures on page 81 of our memoir of 1860, experiments d, e, f, h, i, we shall see that the weight of yeast, in the case of the fermentation of a pure solution of sugar, undergoes a considerable increase, even without taking into account the fact that the sugared water gains from the yeast certain soluble parts, since in the experiments just mentioned, the weights of solid yeast, washed and dried at 100 degrees c. (212 degrees f.), are much greater than those of the raw yeast employed, dried at the same temperature. in these experiments we employed the following weights of yeast, expressed in grammes (1 gramme=15.43 grains): (1) 2.313 (2) 2.626 (3) 1.198 (4) 0.699 (5) 0.326 (6) 0.476 which became, after fermentation, we repeat, without taking into account the matters which the sugared water gained from the yeast: grammes. grains. (1) 2.486 increase 0.173 = 2.65 (2) 2.963 increase 0.337 = 5.16 (3) 1.700 increase 0.502 = 7.7 (4) 0.712 increase 0.013 = 0.2 (5) 0.325 increase 0.009 = 0.14 (6) 0.590 increase 0.114 = 1.75 have we not in this marked increase in weight a proof of life, or, to adopt an expression which may be preferred, a proof of a profound chemical work of nutrition and assimilation? we may cite on this subject one of our earlier experiments, which is to be found in the comptes rendus de l'academie for the year 1857, and which clearly shows the great influence exerted on fermentation by the soluble portion that the sugared water takes up from the globules of ferment: "we take two equal quantities of fresh yeast that have been washed very freely. one of these we cause to ferment in water containing nothing but sugar, and, after removing from the other all its soluble particles--by boiling it in an excess of water and then filtering it to separate the globules--we add to the filtered liquid as much sugar as was used in the first case along with a mere trace of fresh yeast insufficient, as far as its weight is concerned, to affect the results of our experiment. the globules which we have sown bud, the liquid becomes turbid, a deposit of yeast gradually forms, and, side by side with these appearances, the decomposition of the sugar is effected, and in the course of a few hours manifests itself clearly. these results are such as we might have anticipated. the following fact, however, is of importance. in effecting by these means the organization into globules of the soluble part of the yeast that we used in the second case, we find that a considerable quantity of sugar is decomposed. the following are the results of our experiment; 5 grammes of yeast caused the fermentation of 12.9 grammes of sugar in six days, at the end of which time it was exhausted. the soluble portion of a like quantity of 5 grammes of the same yeast caused the fermentation of 10 grammes of sugar in nine days, after which the yeast developed by the sowing was likewise exhausted." how is it possible to maintain that, in the fermentation of water containing nothing but sugar, the soluble portion of the yeast does not act, either in the production of new globules or the perfection of old ones, when we see, in the preceding experiment, that after this nitrogenous and mineral portion has been removed by boiling, it immediately serves for the production of new globules, which, under the influence of the sowing of a mere trace of globules, causes the fermentation of so much sugar? [footnote: it is important that we should here remark that, in the fermentation of pure solution of sugar by means of yeast, the oxygen originally dissolved in the water, as well as that appropriated by the globules of yeast in their contact with air, has a considerable effect on the activity of the fermentation. as a matter of fact, if we pass a strong current of carbonic acid through the sugared water and the water in which the yeast has been treated, the fermentation will be rendered extremely sluggish, and the few new cells of yeast which form will assume strange and abnormal aspects. indeed this might have been expected, for we have seen that yeast, when somewhat old, is incapable of development or of causing fermentation even in a fermentable medium containing all the nutritive principles of yeast if the liquid has been deprived of air; much more should we expect this to be the case in pure sugared water, likewise deprived of air.] in short, liebig is not justified in saying that the solution of pure sugar, caused to ferment by means of yeast, contains none of the elements needed for the growth of yeast, neither nitrogen, sulphur nor phosphorus, and that, consequently, it should not be possible, by our theory, for the sugar to ferment. on the contrary, the solution does contain all these elements, as a consequence of the introduction and presence of the yeast. let us proceed without examination of liebig's criticisms: "to this," he goes on to say, "must be added the decomposing action which yeast exercises on a great number of substances, and which resembles that which sugar undergoes. i have shown that malate of lime ferments readily enough through the action of yeast, and that it splits up into three other calcareous salts, namely, the acetate, the carbonate and the succinate. if the action of yeast consists in its increase and multiplication, it is difficult to conceive this action in the case of malate of lime and other calcareous salts of vegetable acids." this statement, with all due deference to the opinion of our illustrious critic, is by no means correct. yeast has no action on malate of lime, or on other calcareous salts formed by vegetable acids. liebig had previously, much to his own satisfaction, brought forward urea as being capable of transformation into carbonate of ammonia during alcoholic fermentation in contact with yeast. this has been proved to be erroneous. it is an error of the same kind that liebig again brings forward here. in the fermentation of which he speaks (that of malate of lime), certain spontaneous ferments are produced, the germs of which are associated with the yeast, and develop in the mixture of yeast and malate. the yeast merely serves as a source of food for these new ferments without taking any direct part in the fermentations of which we are speaking. our researches leave no doubt on this point, as is evident from the observations on the fermentation of tartrate of lime previously given. it is true that there are circumstances under which yeast brings about modifications in different substances. doebereiner and, mitscherlich, more especially, have shown that yeast imparts to water a soluble material, which liquefies cane-sugar and produces inversion in it by causing it to take up the elements of water, just as diastase behaves to starch or emulsin to amygdalin. m. berthelot also has shown that this substance may be isolated by precipitating it with alcohol, in the same way as diastase is precipitated from its solutions. [footnote: doebereiner, journal de chimie de schweigger, vol. xii., p. 129, and journal de pharmacie, vol. i., p. 342. mitscherlich, monatsberichte d. kon. preuss. akad. d. wissen, eu berlin, and rapports annuels da berzelius, paris, 1843, 3rd year. on the occasion of a communication on the inversion of cane-sugar by h. rose, published in 1840, m. mitscherlich observed: "the inversion of cane-sugar in alcoholic fermentation is not due to the globules of yeast, but to a soluble matter in the water with which they mix. the liquid obtained by straining off the ferment on a filter paper possesses the property of converting cane-sugar into uncrystallizable sugar." berthelot, comptes rendus de l'academie. meeting of may 28th, 1860, m. berthelot confirms the preceding experiment of mitscherlich, and proves, moreover, that the soluble matter of which the author speaks may be precipitated with alcohol without losing its invertive power. m. bechamp has applied mitscherlich's observation, concerning the soluble fermentative part of yeast, to fungoid growths, and has made the interesting discovery that fungoid growths, like yeast, yield to water a substance that inverts sugar. when the production of fungoid growths is prevented by means of an antiseptic, the inversion of sugar does not take place. we may here say a few words respecting m. bechamp's claim to priority of discovery. it is a well-known fact that we were the first to demonstrate that living ferments might be completely developed if their germs were placed in pure water together with sugar, ammonia, and phosphates. relying on this established fact, that moulds are capable of development in sweetened water in which, according to m. bechamp, they invert the sugar, our author asserts that he has proved that "living organized ferments may originate in media which contain no albuminous substances." (see comptes rendus, vol. ixxv., p. 1519.) to be logical, m. bechamp might say that he has proved that certain moulds originate in pure sweetened water without nitrogen or phosphates or other mineral elements, for such a deduction might very well be drawn from his work, in which we do not find the least expression of astonishment at the possibility of moulds developing in pure water containing nothing but sugar without other mineral or organic principles. m. bechamp's first note on the inversion of sugar was published in 1855. in it we find nothing relating to the influence of moulds. his second, in which that influence is noticed, was published in january, 1858, that is, subsequently to our work on lactic fermentation, which appeared in november, 1857. in that work we established for the first time that the lactic ferment is a living, organized being, that albuminous substances have no share in the production of fermentation, and that they only serve as the food of the ferment. m. bechamp's note was even subsequent to our first work on alcoholic fermentation, which appeared on december 21st, 1857. it is since the appearance of these two works of ours that the preponderating influence of the life of microscopic organism in the phenomena of fermentation has been better understood. immediately after their appearance m. bechamp, who from 1855 had made no observation on the action of fungoid growths on sugar, although he had remarked their presence, modified his former conclusions. (comptes rendus, january 4th, 1858.)] these are remarkable facts, which are, however, at present but vaguely connected with the alcoholic fermentation of sugar by means of yeast. the researches in which we have proved the existence of special forms of living ferments in many fermentations, which one might have supposed to have been produced by simple contact action, had established beyond doubt the existence of profound differences between those fermentations, which we have distinguished as fermentations proper, and the phenomena connected with soluble substances. the more we advance, the more clearly we are able to detect these differences. m. dumas has insisted on the fact that the ferments of fermentation proper multiply and reproduce themselves in the process whilst the others are destroyed. [footnote: "there are two classes of ferments; the first, of which the yeast of beer may be taken as the type, perpetuate and renew themselves if they can find in the liquid in which they produce fermentation food enough for their wants; the second, of which diastase is the type, always sacrifice themselves in the exercise of their activity." (dumas, comptes rendus de l'academie, t. lxxv., p. 277, 1872.)] still more recently m. muntz has shown that chloroform prevents fermentations proper, but does not interfere with the action of diastase (comptes rendus, 1875). m. bouchardat had already established the fact that hydrocyanic acid, salts of mercury, ether, alcohol, creosote, and the oils of turpentine, lemon, cloves, and mustard destroy or check alcoholic fermentations, whilst in no way interfering with the glucoside fermentations (annales de chimie et de physique. 3rd series, t. xiv., 1845). we may add in praise of m. bouchardat's sagacity, that that skilful observer has always considered these results as a proof that alcoholic fermentation is dependent on the life of the yeast-cell, and that a distinction should be made between the two orders of fermentation. m. paul bert, in his remarkable studies on the influence of barometric pressure on the phenomena of life, has recognized the fact that compressed oxygen is fatal to certain ferments, whilst under similar conditions it does not interfere with the action of those substances classed under the name of soluble ferments, such as diastase (the ferment which inverts cane sugar) emulsin and others. during their stay in compressed air, ferments proper ceased their activity, nor did they resume it, even after exposure to air at ordinary pressures, provided the access of germs was prevented. we now come to liebig's principal objection, with which he concludes his ingenious argument, and to which no less than eight or nine pages of the annales are devoted. our author takes up the question of the possibility of causing yeast to grow in sweetened water, to which a salt of ammonia and some yeast-ash have been added--a fact which is evidently incompatible with his theory that a ferment is always an albuminous substance on its way to decomposition. in this case the albuminous substance does not exist; we have only the mineral substances which will serve to produce it. we know that liebig regarded yeast, and, generally speaking, any ferment whatever, as being a nitrogenous, albuminous substance which, in the same way as emulsin, for example, possesses the power of bringing about certain chemical decompositions. he connected fermentation with the easy decomposition of that albuminous substance, and imagined that the phenomenon occurred in the following manner: "the albuminous substance on its way to decomposition possesses the power of communicating to certain other bodies that same state of mobility by which its own atoms are already affected; and through its contact with other bodies it imparts to them the power of decomposing or of entering into other combinations." here liebig failed to perceive that the ferment, in its capacity of a living organism, had anything to do with the fermentation. this theory dates back as far as 1843. in 1846 messrs. boutron and fremy, in a memoir on lactic fermentation, published in the annales de chimie et de physique, strained the conclusions deducible from it to a most unjustifiable extent. they asserted that one and the same nitrogenous substance might undergo various modifications in contact with air, so as to become successively alcoholic, lactic, butyric, and other ferments. there is nothing more convenient than purely hypothetical theories, theories which are not the necessary consequences of facts; when fresh facts which cannot be reconciled with the original hypothesis are discovered, new hypotheses can be tacked on to the old ones. this is exactly what liebig and fremy have done, each in his turn, under the pressure of our studies, commenced in 1857. in 1864 fremy devised the theory of hemi-organism, which meant nothing more than that he gave up liebig's theory of 1843, together with the additions which boutron and he had made to it in 1846; in other words, he abandoned the idea of albuminous substances being ferments, to take up another idea, that albuminous substances in contact with air are peculiarly adapted to undergo organization into new beings--that is, the living ferments which we had discovered--and that the ferments of beer and of the grape have a common origin. this theory of hemi-organism was word for word the antiquated opinion of turpin. * * * the public, especially a certain section of the public did not go very deeply into an examination of the subject. it was the period when the doctrine of spontaneous generation was being discussed with much warmth. the new word hemi-organism, which was the only novelty in m. fremy's theory, deceived people. it was thought that m. fremy had really discovered the solution of the question of the day. it is true that it was rather difficult to understand the process by which an albuminous substance could become all at once a living and budding cell. this difficulty was solved by m. fremy, who declared that it was the result of some power that was not yet understood, the power of "organic impulse." [footnote: fremy, comptes rendus de l'academie, vol. lviii., p. 1065, 1864.] liebig, who, as well as m. fremy, was compelled to renounce his original opinions concerning the nature of ferments, devised the following obscure theory (memoir by liebig, 1870, already cited): "there seems to be no doubt as to the part which the vegetable organism plays in the phenomenon of fermentation. it is through it alone that an albuminous substance and sugar are enabled to unite and form this particular combination, this unstable form under which alone, as a component part of the mycoderm, they manifest an action on sugar. should the mycoderm cease to grow, the bond which unites the constituent parts of the cellular contents is loosened, and it is through the motion produced therein that the cells of yeast bring about a disarrangement or separation of the elements of the sugar into molecules." one might easily believe that the translator for the annales has made some mistake, so great is the obscurity of this passage. whether we take this new form of the theory or the old one, neither can be reconciled at all with the development of yeast and fermentation in a saccharine mineral medium, for in the latter experiment fermentation is correlative to the life of the ferment and to its nutrition, a constant change going on between the ferment and its food-matters, since all the carbon assimilated by the ferment is derived from sugar, its nitrogen from ammonia and phosphorus from the phosphates in solution. and even all said, what purpose can be served by the gratuitous hypothesis of contact-action or communicated motion? the experiment of which we are speaking is thus a fundamental one; indeed, it is its possibility that constitutes the most effective point in the controversy. no doubt liebig might say, "but it is the motion of life and of nutrition which constitutes your experiment, and this is the communicated motion that my theory requires." curiously enough, liebig does endeavour, as a matter of fact, to say this, but he does so timidly and incidentally: "from a chemical point of view, which point of view i would not willingly abandon, a vital action is a phenomenon of motion, and, in this double sense of life m. pasteur's theory agrees with my own, and is not in contradiction with it (page 6)." this is true. elsewhere liebig says: "it is possible that the only correlation between the physiological act and the phenomenon of fermentation is the production, in the living cell, of the substance which, by some special property analogous to that by which emulsin exerts a decomposing action on salicin and amygdalin, may bring about the decomposition of sugar into other organic molecules; the physiological act, in this view, would be necessary for the production of this substance, but would have nothing else to do with the fermentation (page 10)." to this, again, we have no objection to raise. liebig, however, does not dwell upon these considerations, which he merely notices in passing, because he is well aware that, as far as the defence of his theory is concerned, they would be mere evasions. if he had insisted on them, or based his opposition solely upon them, our answer would have been simply this: "if you do not admit with us that fermentation is correlated with the life and nutrition of the ferment, we agree upon the principal point. so agreeing, let us examine, if you will, the actual cause of fermentation;--this is a second question, quite distinct from the first. science is built up of successive solutions given to questions of ever increasing subtlety, approaching nearer and nearer towards the very essence of phenomena. if we proceed to discuss together the question of how living, organized beings act in decomposing fermentable substances, we will be found to fall out once more on your hypothesis of communicated motion, since according to our ideas, the actual cause of fermentation is to be sought, in most cases, in the fact of life without air, which is the characteristic of many ferments." let us briefly see what liebig thinks of the experiment in which fermentation is produced by the impregnation of a saccharine mineral medium, a result so greatly at variance with his mode of viewing the question. [footnote: see our memoir of 1860 (annales de chimie et de physique, vol. lviii, p. 61, and following, especially pp. 69 and 70, where the details of the experiment will be found).] after deep consideration he pronounces this experiment to be inexact, and the result ill-founded. liebig, however, was not one to reject a fact without grave reasons for doing so, or with the sole object of evading a troublesome discussion. "i have repeated this experiment," he says, "a great number of times, with the greatest possible care, and have obtained the same results as m. pasteur, excepting as regards the formation and increase of the ferment." it was, however, the formation and increase of the ferment that constituted the point of the experiment. our discussion was, therefore, distinctly limited to this: liebig denied that the ferment was capable of development in a saccharine mineral medium, whilst we asserted that this development did actually take place, and was comparatively easy to prove. in 1871 we replied to m. liebig before the paris academy of sciences in a note, in which we offered to prepare in a mineral medium, in the presence of a commission to be chosen for the purpose, as great a weight of ferment as liebig could reasonably demand. [footnote: pasteur, comptes rendus de l'academie des sciences, vol. lxxiii., p. 1419. 1871.] we were bolder than we should, perhaps, have been in 1860; the reason was that our knowledge of the subject had been strengthened by ten years of renewed research. liebig did not accept our proposal, nor did he even reply to our note. up to the time of his death, which took place on april 18th, 1873, he wrote nothing more on the subject. [footnote: in his memoir of 1870, liebig made a remarkable admission: "my late friend pelouze," he says, "had communicated to me nine years ago certain results of m. pasteur's researches on fermentation. i told him that just then i was not disposed to alter my opinion on the cause of fermentation, and that if it were possible, by means of ammonia, to produce or multiply the yeast in fermenting liquors, industry would soon avail itself of the fact, and that i would wait to see if it did so; up to the present time, however, there had not been the least change in the manufacture of yeast. "we do not know what m. pelouze's reply was; but it is not difficult to conceive so sagacious an observer remarking to his illustrious friend that the possibility of deriving pecuniary advantage from the wide application of a new scientific fact had never been regarded as the criterion of the exactness of that fact. we could prove, moreover, by the undoubted testimony of very distinguished practical men, notably by that of m. pezeyre, director of distilleries, that upon this point also liebig was mistaken.] when we published, in 1860, the details of the experiment in question, we pointed out at some length the difficulties of conducting it successfully, and the possible causes of failure. we called attention particularly to the fact that saccharine mineral media are much more suited for the nutrition of bacteria, lactic ferment, and other lowly forms, than they are to that of yeast, and in consequence readily become filled with various organisms from the spontaneous growth of germs derived from the particles of dust floating in the atmosphere. the reason why we do not observe the growth of alcoholic ferments, especially at the commencement of the experiments, is because of the unsuitableness of those media for the life of yeast. the latter may, nevertheless, form in them subsequent to this development of other organized forms, by reason of the modification produced in the original mineral medium by the albuminous matters that they introduce into it. it is interesting to peruse, in our memoir of 1860, certain facts of the same kind relating to fermentation by means of albumens--that of the blood for example, from which, we may mention incidentally, we were led to infer the existence of several distinct albumens in the serum, a conclusion which, since then, has been confirmed by various observers, notably by m. bechamp. now, in his experiments on fermentation in sweetened water, with yeast-ash and a salt of ammonia, there is no doubt that liebig had failed to avoid those difficulties which are entailed by the spontaneous growth of other organisms than yeast. moreover, it is possible that, to have established the certainty of this result, liebig should have had recourse to a closer microscopical observation than from certain passages in his memoir he seems to have adopted. we have little doubt that his pupils could tell us that liebig did not even employ that instrument without which any exact study of fermentation is not merely difficult but well-nigh impossible. we ourselves, for the reasons, mentioned, did not obtain a simple alcoholic fermentation any more than liebig did. in that particular experiment, the details of which we gave in our memoir of 1860, we obtained lactic and alcoholic fermentation together; an appreciable quantity of lactic acid formed and arrested the propagation of the lactic and alcoholic ferments, so that more than half of the sugar remained in the liquid without fermenting. this, however, in no way detracted from the correctness of the conclusion which we deduced from the experiment, and from other similar ones; it might even be said that, from a general and philosophical point of view--which is the only one of interest here--the result was doubly satisfactory, inasmuch as we demonstrated that mineral media were adapted to the simultaneous development of several organized ferments instead of only one. the fortuitous association of different ferments could not invalidate the conclusion that all the nitrogen of the cells of the alcoholic and lactic ferments was derived from the nitrogen in the ammoniacal salts, and that all the carbon of those ferments was taken from the sugar, since, in the medium employed in our experiment, the sugar was the only substance that contained carbon. liebig carefully abstained from noticing this fact, which would have been fatal to the very groundwork of his criticisms, and thought that he was keeping up the appearance of a grave contradiction by arguing that we had never obtained a simple alcoholic fermentation. it would be unprofitable to dwell longer upon the subject of the difficulties which the propagation of yeast in a saccharine mineral medium formerly presented. as a matter of fact, the progress of our studies has imparted to the question an aspect very different from that which it formerly wore; it was this circumstance which emboldened us to offer, in our reply to liebig before the academy of sciences in 1871, to prepare, in a saccharine mineral medium, in the presence of a commission to be appointed by our opponent, any quantity of ferment that he might require, and to effect the fermentation of any weight of sugar whatsoever. our knowledge of the facts detailed in the preceding chapter concerning pure ferments, and their manipulation in the presence of pure air, enables us completely to disregard those causes of embarrassment that result from the fortuitous occurrence of the germs of organisms different in character from the ferments introduced by the air or from the sides of vessels, or even by the ferment itself. let us once more take one of our double-necked flasks, which we will suppose is capable of containing three or four litres (six to eight pints). let us put into it the following: pure distilled water. sugar candy. ... . ... . ... . ... . ... . 200 grammes bitartrate of potassium. ... . ... . 1.0 grammes bitartrate of ammonia. ... . ... ... 0.5 grammes sulphate of ammonia.,. ... . ... ... 1.5 grammes ash of yeast. ... . ... . ... . ... . ... 1.5 grammes (1 gramme = 15.43 grains) let us boil the mixture, to destroy all germs of organisms that may exist in the air or liquid or on the sides of the flask, and then permit it to cool, after having placed, by way of extra precaution a small quantity of asbestos in the end of the fine curved tube. let us next introduce a trace of ferment into the liquid, through the other neck, which, as we have described, is terminated by a small piece of india-rubber tube closed with a glass stopper. here are the details of such an experiment:-on december 9th, 1873, we sowed some pure ferment--saccharomyces pastorianus. from december 11, that is, within so short a time as forty-eight hours after impregnation, we saw a multitude of extremely minute bubbles rising almost continuously from the bottom, indication that at this point the fermentation had commenced. on the following days, several patches of froth appeared on the surface of the liquid. we left the flask undisturbed in the oven, at a temperature of 25 degrees c. (77 degrees f.) on april 24, 1874, we tested some of the liquid, obtained by means of the straight tube, to see if it still contained any sugar. we found that it contained less than two grammes, so that 198 grammes (4.2 oz. troy) had already disappeared. some time afterwards the fermentation came to an end; we carried on the experiment, nevertheless, until april 18, 1875. there was no development of any organism absolutely foreign to the ferment, which was itself abundant, a circumstance that, added to the persistent vitality of the ferment, in spite of the unsuitableness of the medium for its nutrition, permitted the perfect completion of fermentation. there was not the minutest quantity of sugar remaining. the total weight of ferment, after washing and drying at 100 degrees c. (212 degrees f.), was 2.563 grammes (39.5 grains). in experiments of this kind, in which the ferment has to be weighed, it is better not to use any yeast-ash that cannot be dissolved completely, so as to be capable of easy separation from the ferment formed. raulin's liquid [footnote: m. jules raulin has published a well-known and remarkable work on the discovery of the mineral medium best adapted by its composition to the life of certain fungoid growth; he has given a formula for the composition of such a medium. it is this that we call here "raulin's liquid" for abbreviation. water . . . . . . . . . . . . . . . . . . 1,500 sugar candy . . . . . . . . . . . . . . . 70 tartaric acid . . . . . . . . . . . . . . 4 nitrate of ammonia . . . . . . . . . . . 4 phosphate of ammonia . . . . . . . . . . 0.6 carbonate of potassium . . . . . . . . . 0.6 carbonate of magnesia . . . . . . . . . . 0.4 sulphate of ammonia . . . . . . . . . . . 0.25 sulphate of zinc . . . . . . . . . . . . 0.07 sulphate of iron . . . . . . . . . . . . 0.07 silicate of potassium . . . . . . . . . . 0.07 --j. raulin, paris, victor masson, 1870. these pour le doctorat.] may be used in such cases with success. all the alcoholic ferments are not capable to the same extent of development by means of phosphates, ammoniacal salts, and sugar. there are some whose development is arrested a longer or shorter time before the transformation of all the sugar. in a series of comparative experiments, 200 grammes of sugar-candy being used in each case, we found that whilst saccharomyces pastorianus effected a complete fermentation of the sugar, the caseous ferment did not decompose more than two-thirds, and the ferment we have designated new "high" ferment not more than one-fifth: and keeping the flasks for a longer time in the oven had no effect in increasing the proportions of sugar fermented in these two last cases. we conducted a great number of fermentations in mineral media, in consequence of a circumstance which it may be interesting to mention here. a person who was working in our laboratory asserted that the success of our experiments depended upon the impurity of the sugar-candy which we employed, and that if this sugar had been pure--much purer than was the ordinary, white, commercial sugar-candy, which up to that time we had always used--the ferment could not have multiplied. the persistent objections of our friend, and our desire to convince him, caused us to repeat all our previous experiments on the subject, using sugar of great purity, which had been specially prepared for us, with the utmost care, by a skilful confectioner, seugnot. the result only confirmed our former conclusions. even this did not satisfy our obstinate friend, who went to the trouble of preparing some pure sugar for himself, in little crystals, by repeated crystallizations of carefully selected commercial sugar-candy; he then repeated our experiments himself. this time his doubts were overcome. it even happened that the fermentations with the perfectly pure sugar instead of being slow were very active, when compared with those which we had conducted with, the commercial sugar-candy. we may here add a few words on the non-transformation of yeast into penicillium glaucum. if at any time during fermentation we pour off the fermenting liquid, the deposit of yeast remaining in the vessel may continue there, in contact with air, without our ever being able to discover the least formation of penicillium glaucum in it. we may keep a current of pure air constantly passing through the flask; the experiment will give the same result. nevertheless, this is a medium peculiarly adapted to the development of this mould, inasmuch as if we were to introduce merely a few spores of penicillium an abundant vegetation of that growth will afterwards appear on the deposit. the descriptions of messrs. turpin, hoffmann, and trecul have, therefore, been based on one of these illusions which we meet with so frequently in microscopical observations. when we laid these facts before the academy, [footnote: pasteur, comptes rendus de l'academie, vol. lxxviii., pp. 213-216.] m. trecul professed his inability to comprehend them: [footnote: trecul, comptes rendus de l'academie, vol. lxxviii., pp. 217, 218.] "according to m. pasteur," he said, "the yeast of beer is anaerobian, that is to say, it lives in a liquid deprived of free oxygen; and to become mycoderma or penicillium it is above all things necessary that it should be placed in air, since, without this, as the name signifies, an aerobian being cannot exist. to bring about the transformation of the yeast of beer into mycoderma cerevisiae or into penicillium glaucum we must accept the conditions under which these two forms are obtained. if m. pasteur will persist in keeping his yeast in media which are incompatible with the desired modification, it is clear that the results which he obtains must always be negative." contrary to this perfectly gratuitous assertion of m. trecul's we do not keep our yeast in media which are calculated to prevent its transformation into penicillium. as we have just seen, the principal aim and object of our experiment was to bring this minute plant into contact with air, and under conditions that would allow the penicillium to develop with perfect freedom. we conducted our experiments exactly as turpin and hoffmann conducted theirs, and exactly as they stipulate that such experiments should be conducted--with the one sole difference, indispensable to the correctness of our observations, that we carefully guarded ourselves against those causes of error which they did not take the least trouble to avoid. it is possible to produce a ready entrance and escape of pure air in the case of the double-necked flasks which we have so often employed in the course of this work, without having recourse to the continuous passage of a current of air. having made a file-mark on the thin curved neck at a distance of two or three centimetres (an inch) from the flask, we must cut round the neck at this point with a glazier's diamond, and then remove it, taking care to cover the opening immediately with a sheef of paper which has been passed through the flame, and which we must fasten with a thread round the part of the neck still left. in this manner we may increase or prolong the fructification of fungoid growths, or the life of the aerobian ferments in our flasks. what we have said of penicillium glaucum will apply equally to mycoderma cerevisiae. notwithstanding that turpin and trecul may assert to the contrary, yeast, in contact with air as it was under the conditions of the experiment just described, will not yield mycoderma vini or mycoderma cerevisiae any more than it will penicillium. the experiments described in the preceding paragraphs on the increase of organized ferments in mineral media of the composition described, are of the greatest physiological interest. amongst other results, they show that all the proteic matter of ferments may be produced by the vital activity of the cells, which, apart altogether from the influence of light or free oxygen (unless indeed, we are dealing with aerobian moulds which require free oxygen), have the power of developing a chemical activity between carbohydrates, ammoniacal salts, phosphates, and sulphates of potassium and magnesium. it may be admitted with truth that a similar effect obtains in the case of the higher plants, so that in the existing state of science we fail to conceive what serious reason can be urged against our considering this effect as general. it would be perfectly logical to extend the results of which we are speaking to all plants, and to believe that the proteic matter of vegetables, and perhaps of animals also, is formed exclusively by the activity of the cells operating upon the ammoniacal and other mineral salts of the sap or plasma of the blood, and the carbo-hydrates, the formation of which, in the case of the higher plants, requires only the concurrence of the chemical impulse of green light. viewed in this manner, the formation of the proteic substances, would be independent of the great act of reduction of carbonic acid gas under the influence of light. these substances would not be built up from the elements of water, ammonia, and carbonic acid gas, after the decomposition of this last; they would be formed where they are found in the cells themselves, by some process of union between the carbo-hydrates imported by the sap, and the phosphates of potassium and magnesium and salts of ammonia. lastly, in vegetable growth, by means of a carbo-hydrate and a mineral medium, since the carbo-hydrate is capable of many variations, and it would be difficult to understand how it could be split up into its elements before serving to constitute the proteic substances, and even cellulose substances, as these are carbo-hydrates. we have commenced certain studies in this direction. if solar radiation is indispensable to the decomposition of carbonic acid and the building up of the primary substances in the case of higher vegetable life, it is still possible that certain inferior organisms may do without it and nevertheless yield the most complex substances, fatty or carbo-hydrate, such as cellulose, various organic acids, and proteic matter; not, however, by borrowing their carbon from the carbonic acid which is saturated with oxygen, but from other matters still capable of acquiring oxygen, and so of yielding heat in the process, such as alcohol and acetic acid, for example, to cite merely carbon compounds most removed from organization. as these last compounds, and a host of others equally adapted to serve as the carbonaceous food of mycoderms and the mucedines, may be produced synthetically by means of carbon and the vapour of water, after the methods that science owes to berthelot, it follows that, in the case of certain inferior beings, life would be possible even if it should be that the solar light was extinguished. [footnote: see on this subject the verbal observations which we addressed to the academy of sciences at its meetings of april 10th and 24th, 1876]. the germ theory and its applications to medicine and surgery [footnote: read before the french academy of sciences, april 29th, 1878. published in comptes rendus de l' academie des sciences, lxxxvi., pp. 1037-43.] the sciences gain by mutual support. when, as the result of my first communications on the fermentations in 1857-1858, it appeared that the ferments, properly so-called, are living beings, that the germs of microscopic organisms abound in the surface of all objects, in the air and in water; that the theory of spontaneous generation is chimerical; that wines, beer, vinegar, the blood, urine and all the fluids of the body undergo none of their usual changes in pure air, both medicine and surgery received fresh stimulation. a french physician, dr. davaine, was fortunate in making the first application of these principles to medicine, in 1863. our researches of last year, left the etiology of the putrid disease, or septicemia, in a much less advanced condition than that of anthrax. we had demonstrated the probability that septicemia depends upon the presence and growth of a microscopic body, but the absolute proof of this important conclusion was not reached. to demonstrate experimentally that a microscopic organism actually is the cause of a disease and the agent of contagion, i know no other way, in the present state of science, than to subject the microbe (the new and happy term introduced by m. sedillot) to the method of cultivation out of the body. it may be noted that in twelve successive cultures, each one of only ten cubic centimeters volume, the original drop will be diluted as if placed in a volume of fluid equal to the total volume of the earth. it is just this form of test to which m. joubert and i subjected the anthrax bacteridium. [footnote: in making the translation, it seems wiser to adhere to pasteur's nomenclature. bacillus anthracis would be the term employed to-day.-translator.] having cultivated it a great number of times in a sterile fluid, each culture being started with a minute drop from the preceding, we then demonstrated that the product of the last culture was capable of further development and of acting in the animal tissues by producing anthrax with all its symptoms. such is--as we believe--the indisputable proof that anthrax is a bacterial disease. our researches concerning the septic vibrio had not so far been convincing, and it was to fill up this gap that we resumed our experiments. to this end, we attempted the cultivation of the septic vibrio from an animal dead of septicemia. it is worth noting that all of our first experiments failed, despite the variety of culture media we employed--urine, beer yeast water, meat water, etc. our culture media were not sterile, but we found--most commonly--a microscopic organism showing no relationship to the septic vibrio, and presenting the form, common enough elsewhere, of chains of extremely minute spherical granules possessed of no virulence whatever. [footnote: it is quite possible that pasteur was here dealing with certain septicemic streptococci that are now know to lose their virulence with extreme rapidity under artificial cultivation.--translator.] this was an impurity, introduced, unknown to us, at the same time as the septic vibrio; and the germ undoubtedly passed from the intestines--always inflamed and distended in septicemic animals-into the abdominal fluids from which we took our original cultures of the septic vibrio. if this explanation of the contamination of our cultures was correct, we ought to find a pure culture of the septic vibrio in the heart's blood of an animal recently dead of septicemia. this was what happened, but a new difficulty presented itself; all our cultures remained sterile. furthermore this sterility was accompanied by loss in the culture media of (the original) virulence. it occurred to us that the septic vibrio might be an obligatory anaerobe and that the sterility of our inoculated culture fluids might be due to the destruction of the septic vibrio by the atmospheric oxygen dissolved in the fluids. the academy may remember that i have previously demonstrated facts of this nature in regard to the vibrio of butyric fermentation, which not only lives without air but is killed by the air. it was necessary therefore to attempt to cultivate the septic vibrio either in a vacuum or in the presence of inert gases--such as carbonic acid. results justified our attempt; the septic vibrio grew easily in a complete vacuum, and no less easily in the presence of pure carbonic acid. these results have a necessary corollary. if a fluid containing septic vibrios be exposed to pure air, the vibrios should be killed and all virulence should disappear. this is actually the case. if some drops of septic serum be spread horizontally in a tube and in a very thin layer, the fluid will become absolutely harmless in less than half a day, even if at first it was so virulent as to produce death upon the inoculation of the smallest portion of a drop. furthermore all the vibrios, which crowded the liquid as motile threads, are destroyed and disappear. after the action of the air, only fine amorphous granules can be found, unfit for culture as well as for the transmission of any disease whatever. it might be said that the air burned the vibrios. if it is a terrifying thought that life is at the mercy of the multiplication of these minute bodies, it is a consoling hope that science will not always remain powerless before such enemies, since for example at the very beginning of the study we find that simple exposure to air is sufficient at times to destroy them. but, if oxygen destroys the vibrios, how can septicemia exist, since atmospheric air is present everywhere? how can such facts be brought in accord with the germ theory? how can blood, exposed to air, become septic through the dust the air contains? all things are hidden, obscure and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known. what we have just said is true only of a septic fluid containing adult vibrios, in active development by fission: conditions are different when the vibrios are transformed into their germs, [footnote: by the terms "germ" and "germ corpuscles," pasteur undoubtedly means "spores," but the change is not made, in accordance with note 3, above.--translator.] that is into the glistening corpuscles first described and figured in my studies on silk-worm disease, in dealing with worms dead of the disease called "flacherie." only the adult vibrios disappear, burn up, and lose their virulence in contact with air: the germ corpuscles, under these conditions, remain always ready for new cultures, and for new inoculations. all this however does not do away with the difficulty of understanding how septic germs can exist on the surface of objects, floating in the air and in water. where can these corpuscles originate? nothing is easier than the production of these germs, in spite of the presence of air in contact with septic fluids. if abdominal serous exudate containing septic vibrios actively growing by fission be exposed to the air, as we suggested above, but with the precaution of giving a substantial thickness to the layer, even if only one centimeter be used, this curious phenomenon will appear in a few hours. the oxygen is absorbed in the upper layers of the fluid--as is indicated by the change of color. here the vibrios are dead and disappear. in the deeper layers, on the other hand, towards the bottom of this centimeter of septic fluid we suppose to be under observation, the vibrios continue to multiply by fission--protected from the action of oxygen by those that have perished above them: little by little they pass over to the condition of germ corpuscles with the gradual disappearance of the thread forms. so that instead of moving threads of varying length, sometimes greater than the field of the microscope, there is to be seen only a number of glittering points, lying free or surrounded by a scarcely perceptible amorphous mass. [footnote: in our note of july 16th, 1877, it is stated that the septic vibrio is not destroyed by the oxygen of the air nor by oxygen at high tension, but that under these conditions it is transformed into germ-corpuscles. this is, however, an incorrect interpretation of facts. the vibrio is destroyed by oxygen, and it is only where it is in a thick layer that it is transformed to germ-corpuscles in the presence of oxygen and that its virulence is preserved.] thus is formed, containing the latent germ life, no longer in danger from the destructive action of oxygen, thus, i repeat, is formed the septic dust, and we are able to understand what has before seemed so obscure; we can see how putrescible fluids can be inoculated by the dust of the air, and how it is that putrid diseases are permanent in the world. the academy will permit me, before leaving these interesting results, to refer to one of their main theoretical consequences. at the very beginning of these researches, for they reveal an entirely new field, what must be insistently demanded? the absolute proof that there actually exist transmissible, contagious, infectious diseases of which the cause lies essentially and solely in the presence of microscopic organisms. the proof that for at least some diseases, the conception of spontaneous virulence must be forever abandoned--as well as the idea of contagion and an infectious element suddenly originating in the bodies of men or animals and able to originate diseases which propagate themselves under identical forms: and all of those opinions fatal to medical progress, which have given rise to the gratuitous hypotheses of spontaneous generation, of albuminoid ferments, of hemiorganisms, of archebiosis, and many other conceptions without the least basis in observation. what is to be sought for in this instance is the proof that along with our vibrio there does not exist an independent virulence belonging to the surrounding fluids or solids, in short that the vibrio is not merely an epiphenomenon of the disease of which it is the obligatory accompaniment. what then do we see, in the results that i have just brought out? a septic fluid, taken at the moment that the vibrios are not yet changed into germs, loses its virulence completely upon simple exposure to the air, but preserves this virulence, although exposed to air on the simple condition of being in a thick layer for some hours. in the first case, the virulence once lost by exposure to air, the liquid is incapable of taking it on again upon cultivation: but, in the second case, it preserves its virulence and can propagate, even after exposure to air. it is impossible, then, to assert that there is a separate virulent substance, either fluid or solid, existing, apart from the adult vibrio or its germ. nor can it be supposed that there is a virus which loses its virulence at the moment that the adult vibrio dies; for such a substance should also lose its virulence when the vibrios, changed to germs, are exposed to the air. since the virulence persists under these conditions it can only be due to the germ corpuscles--the only thing present. there is only one possible hypothesis as to the existence of a virus in solution, and that is that such a substance, which was present in our experiment in nonfatal amounts, should be continuously furnished by the vibrio itself, during its growth in the body of the living animal. but it is of little importance since the hypothesis supposes the forming and necessary existence of the vibrio. [footnote: the regular limits, oblige me to omit a portion of my speech.] i hasten to touch upon another series of observations which are even more deserving the attention of the surgeon than the preceding: i desire to speak of the effects of our microbe of pus when associated with the septic vibrio. there is nothing more easy to superpose--as it were--two distinct diseases and to produce what might be called a septicemic purulent infection, or a purulent septicemia. whilst the microbe-producing pus, when acting alone, gives rise to a thick pus, white, or sometimes with a yellow or bluish tint, not putrid, diffused or enclosed by the so-called pyogenic membrane, not dangerous, especially if localized in cellular tissue, ready, if the expression may be used for rapid resorption; on the other hand the smallest abscess produced by this organism when associated with the septic vibrio takes on a thick gangrenous appearance, putrid, greenish and infiltrating the softened tissues. in this case the microbe of pus carried so to speak by the septic vibrio, accompanies it throughout the body: the highly-inflamed muscular tissues, full of serous fluid, showing also globules of pus here and there, are like a kneading of the two organisms. by a similar procedure the effects of the anthrax bacteridium and the microbe of pus may be combined and the two diseases may be superposed, so as to obtain a purulent anthrax or an anthracoid purulent infection. care must be taken not to exaggerate the predominance of the new microbe over the bacteridum. if the microbe be associated with the latter in sufficient amount it may crowd it out completely--prevent it from growing in the body at all. anthrax does not appear, and the infection, entirely local, becomes merely an abscess whose cure is easy. the microbeproducing pus and the septic vibrio (not) [footnote: there is undoubtedly a mistake in the original. pasteur could not have meant to say that both bacteria are anaerobes. the word "not" is introduced to correct the error.--translator.] being both anaerobes, as we have demonstrated, it is evident that the latter will not much disturb its neighbor. nutrient substances, fluid or solid, can scarcely be deficient in the tissues from such minute organisms. but the anthrax bacteridium is exclusively aerobic, and the proportion of oxygen is far from being equally distributed throughout the tissues: innumerable conditions can diminish or exhaust the supply here and there, and since the microbe-producing pus is also aerobic, it can be understood how, by using a quantity slightly greater than that of the bacteridium it might easily deprive the latter of the oxygen necessary for it. but the explanation of the fact is of little importance: it is certain that under some conditions the microbe we are speaking of entirely prevents the development of the bacteridium. summarizing--it appears from the preceding facts that it is possible to produce at will, purulent infections with no elements of putrescence, putrescent purulent infections, anthracoid purulent infections, and finally combinations of these types of lesions varying according to the proportions of the mixtures of the specific organisms made to act on the living tissues. these are the principal facts i have to communicate to the academy in my name and in the names of my collaborators, messrs. joubert and chamberland. some weeks ago (session of the 11th of march last) a member of the section of medicine and surgery, m. sedillot, after long meditation on the lessons of a brilliant career, did not hesitate to assert that the successes as well as the failures of surgery find a rational explanation in the principles upon which the germ theory is based, and that this theory would found a new surgery--already begun by a celebrated english surgeon, dr. lister, [footnote: see lord lister's paper in the present volume.--ed.] who was among the first to understand its fertility. with no professional authority, but with the conviction of a trained experimenter, i venture here to repeat the words of an eminent confrere. on the extension of the germ theory to the etiology of certain common diseases [footnote: read before the french academy of sciences, may 3, 1880. published in comptes rendus, de l'academie des sciences, xc., pp. 1033-44.] when i began the studies now occupying my attention, [footnote: in 1880. especially engaged in the study of chicken cholera and the attenuation of virulence--translator.] i was attempting to extend the germ theory to certain common diseases. i do not know when i can return to that work. therefore in my desire to see it carried on by others, i take the liberty of presenting it to the public in its present condition. i. furuncles. in may, 1879, one of the workers in my laboratory had a number of furuncles, appearing at short intervals, sometimes on one part of the body and sometimes on another. constantly impressed with the thought of the immense part played by microscopic organisms in nature, i queried whether the pus in the furuncles might not contain one of these organisms whose presence, development, and chance transportation here and there in the tissues after entrance would produce a local inflammation, and pus formation, and might explain the recurrence of the illness during a longer or shorter time. it was easy enough to subject this thought to the test of experiment. first observation.--on june second, a puncture was made at the base of the small cone of pus at the apex of a furuncle on the nape of the neck. the fluid obtained was at once sowed in the presence of pure air--of course with the precautions necessary to exclude any foreign germs, either at the moment of puncture, at the moment of sowing in the culture fluid, or during the stay in the oven, which was kept at the constant temperature of about 35 degrees c, the next day, the culture fluid had become cloudy and contained a single organism, consisting of small spherical points arranged in pairs, sometimes in fours, but often in irregular masses. two fluids were preferred in these experiments--chicken and yeast bouillon. according as one or the other was used, appearances varied a little. these should be described. with the yeast water, the pairs of minute granules are distributed throughout the liquid, which is uniformly clouded. but with the chicken bouillon, the granules are collected in little masses which line the walls and bottom of the flasks while the body of the fluid remains clear, unless it be shaken: in this case it becomes uniformly clouded by the breaking up of the small masses from the walls of the flasks. second observation.--on the tenth of june a new furuncle made its appearance on the right thigh of the same person. pus could not yet be seen under the skin, but this was already thickened and red over a surface the size of a franc. the inflamed part was washed with alcohol, and dried with blotting paper passed through the flame of an alcohol lamp. a puncture at the thickened portion enabled us to secure a small amount of lymph mixed with blood, which was sowed at the same time as some blood taken from the finger of the hand. the following days, the blood from the finger remained absolutely sterile: but that obtained from the center of the forming furuncle gave an abundant growth of the same small organism as before. third observation.--the fourteenth of june, a new furuncle appeared on the neck of the same person. the same examination, the same result, that is to say the development of the microscopic organism previously described and complete sterility of the blood of the general circulation, taken this time at the base of the furuncle outside of the inflamed area. at the time of making these observations i spoke of them to dr. maurice reynaud, who was good enough to send me a patient who had had furuncles for more than three months. on june thirteenth i made cultures of the pus from a furuncle of this man. the next day there was a general cloudiness of the culture fluids, consisting entirely of the preceding parasite, and of this alone. fourth observation.--june fourteenth, the same individual showed me a newly forming furuncle in the left axilla: there was widespread thickening and redness of the skin, but no pus was yet apparent. an incision at the center of the thickening showed a small quantity of pus mixed with blood. sowing, rapid growth for twenty-four hours and the appearance of the same organism. blood from the arm at a distance from the furuncle remained completely sterile. june 17, the examination of a fresh furuncle on the same individual gave the same result, the development of a pure culture of the same organism. fifth observation.--july twenty-first, dr. maurice reynaud informed me that there was a woman at the lariboisiere hospital with multiple furuncles. as a matter of fact her back was covered with them, some in active suppuration, others in the ulcerating stage. i took pus from all of these furuncles that had not opened. after a few hours, this pus gave an abundant growth in cultures. the same organism, without admixture, was found. blood from the inflamed base of the furuncle remained sterile. in brief, it appears certain that every furuncle contains an aerobic microscopic parasite, to which is due the local inflammation and the pus formation that follows. culture fluids containing the minute organism inoculated under the skin of rabbits and guinea-pigs produce abscesses generally small in size and that promptly heal. as long as healing is not complete the pus of the abscesses contains the microscopic organism which produced them. it is therefore living and developing, but its propagation at a distance does not occur. these cultures of which i speak, when injected in small quantities in the jugular vein of guinea pigs show that the minute organism does not grow in the blood. the day after the injection they cannot be recovered even in cultures. i seem to have observed as a general principle, that, provided the blood corpuscles are in good physiological condition it is difficult for aerobic parasites to develop in the blood. i have always thought that this is to be explained by a kind of struggle between the affinity of the blood corpuscles for oxygen and that belonging to the parasite in cultures. whilst the blood corpuscles carry off, that is, take possession of all the oxygen, the life and development of the parasite become extremely difficult or impossible. it is therefore easily eliminated, digested, if one may use the phrase. i have seen these facts many times in anthrax and chicken-cholera, diseases both of which are due to the presence of an aerobic parasite. blood cultures from the general circulation being always sterile in these experiments, it would seem that under the conditions of the furuncular diathesis, the minute parasite does not exist in the blood. that it cannot be cultivated for the reason given, and that it is not abundant is evident; but, from the sterility of the cultures reported (five only) it should not be definitely concluded that the little parasite may not, at some time, be taken up by the blood and transplanted from a furuncle when it is developing to another part of the body, where it may be accidentally lodged, may develop and produce a new furuncle. i am convinced that if, in cases of furuncular diathesis, not merely a few drops but several grams of blood from the general circulation could be placed under cultivation frequent successful growths would be obtained. [footnote: this prediction is fully carried out in the present day successful use of considerable amounts of blood in cultures and the resultant frequent demonstrations of bacteria present in the circulation in many infections.-translator.] in the many experiments i have made on the blood in chicken-cholera, i have frequently demonstrated that repeated cultures from droplets of blood do not show an even development even where taken from the same organ, the heart for example, and at the moment when the parasite begins its existence in the blood, which can easily be understood. once even, it happened that only three out of ten chickens died after inoculation with infectious blood in which the parasite had just began to appear, the remaining seven showed no symptoms whatever. in fact, the microbe, at the moment of beginning its entrance into the blood may exist singly or in minute numbers in one droplet and not at all in its immediate neighbor. i believe therefore that it would be extremely instructive in furunculosis, to find a patient willing to submit to a number of punctures in different parts of the body away from formed or forming furuncles, and thus secure many cultures, simultaneous of otherwise, of the blood of the general circulation. i am convinced that among them would be found growths of the micro-organism of furuncles. ii. on osteomyelitis. single observation. i have but one observation relating to this severe disease, and in this dr. lannelongue took the initiative. the monograph on osteomyelitis published by this learned practitioner is well known, with his suggestion of the possibility of a cure by trephining the bone and the use of antiseptic washes and dressings. on the fourteenth of february, at the request of dr. lannelongue i went to the sainte-eugenie hospital, where this skillful surgeon was to operate on a little girl of about twelve years of age. the right knee was much swollen, as well as the whole leg below the calf and a part of the thigh above the knee. there was no external opening. under chloroform, dr. lannelongue made a long incision below the knee which let out a large amount of pus; the tibia was found denuded for a long distance. three places in the bone were trephined. from each of these, quantities of pus flowed. pus from inside and outside the bone was collected with all possible precautions and was carefully examined and cultivated later. the direct microscopic study of the pus, both internal and external, was of extreme interest. it was seen that both contained large numbers of the organism similar to that of furuncles, arranged in pairs, in fours and in packets, some with sharp clear contour, others only faintly visible and with very pale outlines. the external pus contained many pus corpuscles, the internal had none at all. it was like a fatty paste of the furuncular organism. also, it may be noted, that growth of the small organism had begun in less than six hours after the cultures were started. thus i saw, that it corresponded exactly with the organism of furuncles. the diameter of the individuals was found to be one one-thousandth of a millimeter. if i ventured to express myself so i might say that in this case at least the osteomyelitis was really a furuncle of the bone marrow. [footnote: this has been demonstrated, as is well known.--translator.] it is undoubtedly easy to induce osteomyelitis artificially in living animals. iii. on puerperal fever.--first observation. on the twelfth of march, 1878, dr. hervieux was good enough to admit me to his service in the maternity to visit a woman delivered some days before and seriously ill with puerperal fever. the lochia were extremely fetid. i found them full of micro-organisms of many kinds. a small amount of blood was obtained from a puncture on the index finger of the left hand, (the finger being first properly washed and dried with a sterile towel,) and then sowed in chicken bouillon. the culture remained sterile during the following days. the thirteenth, more blood was taken from a puncture in the finger and this time growth occurred. as death took place on the sixteenth of march at six in the morning, it seems that the blood contained a microscopic parasite at least three days before. the fifteenth of march, eighteen hours before death, blood from a needle-prick in the left foot was used. this culture also was fertile. the first culture, of march thirteenth, contained only the organism of furuncles; the next one, that of the fifteenth, contained an organism resembling that of furunculosis, but which always differed enough to make it easy usually to distinguish it. in this way; whilst the parasite of furuncles is arranged in pairs, very rarely in chains of three or four elements, the new one, that of the culture of the fifteenth, occurs in long chains, the number of cells in each being indefinite. the chains are flexible and often appear as little tangled packets like tangled strings of pearls. the autopsy was performed on the seventeenth at two o'clock. there was a large amount of pus in the peritoneum. it was sowed with all possible precautions. blood from the basilic and femoral veins was also sowed. so also was pus from the mucous surface of the uterus, from the tubes, and finally that from a lymphatic in the uterine wall. these are the results of these cultures: in all there were the long chains of cells just spoken of above, and nowhere any mixture of other organisms, except in the culture from the peritoneal pus, which, in addition to the long chains, also contained the small pyogenic vibrio which i describe under the name organism of pus in the note i published with messrs. joubert and chamberland on the thirtieth of april, 1878. [footnote: see preceding paper.] interpretation of the disease and of the death.--after confinement, the pus that always naturally forms in the injured parts of the uterus instead of remaining pure becomes contaminated with microscopic organisms from outside, notably the organism in long chains and the pyogenic vibrio. these organisms pass into the peritoneal cavity through the tubes or by other channels, and some of them into the blood, probably by the lymphatics. the resorption of the pus, always extremely easy and prompt when it is pure, becomes impossible through the presence of the parasites, whose entrance must be prevented by all possible means from the moment of confinement. second observation.--the fourteenth of march, a woman died of puerperal fever at the lariboisiere hospital; the abdomen was distended before death. pus was found in abundance by a peritoneal puncture and was sowed; so also was blood from a vein in the arm. the culture of pus yielded the long chains noted in the preceding observation and also the small pyogenic vibrio. the culture from the blood contained only the long chains. third observation.--the seventeenth of may, 1879, a woman, three days past confinement, was ill, as well as the child she was nursing. the lochia were full of the pyogenic vibrio and of the organism of furuncles, although there was but a small proportion of the latter. the milk and the lochia were sowed. the milk gave the organism in long chains of granules, and the lochia only the pus organism. the mother died, and there was no autopsy. on may twenty-eighth, a rabbit was inoculated under the skin of the abdomen with five drops of the preceding culture of the pyogenic vibrio. the days following an enormous abscess formed which opened spontaneously on the fourth of june. an abundantly cheesy pus came from it. about the abscess there was extensive induration. on the eighth of june, the opening of the abscess was larger, the suppuration active. near its border was another abscess, evidently joined with the first, for upon pressing it with the finger, pus flowed freely from the opening in the first abscess. during the whole of the month of june, the rabbit was sick and the abscesses suppurated, but less and less. in july they closed; the animal was well. there could only be felt some nodules under the skin of the abdomen. what disturbances might not such an organism carry into the body of a parturient woman, after passing into the peritoneum, the lymphatics or the blood through the maternal placenta! its presence is much more dangerous than that of the parasite arranged in chains. furthermore, its development is always threatening, because, as said in the work already quoted (april, 1878) this organism can be easily recovered from many ordinary waters. i may add that the organism in long chains, and that arranged in pairs are also extremely widespread, and that one of their habitats is the mucous surfaces of the genital tract. [footnote: when, by the procedure i elsewhere described, urine is removed in a pure condition by the urethra from the bladder, if any chance growth occurs through some error of technic, it is the two organisms of which i have been speaking that are almost exclusively present.] apparently there is no puerperal parasite, properly speaking. i have not encountered true septicemia in my experiments; but it ought to be among the puerperal affections. fourth observation.--on june fourteenth, at the lariboisiere, a woman was very ill following a recent confinement; she was at the point of death; in fact she did die on the fourteenth at midnight. some hours before death pus was taken from an abscess on the arm, and blood from a puncture in a finger. both were sowed. on the next day (the fifteenth) the flask containing the pus from the abscess was filled with long chains of granules. the flask containing the blood was sterile. the autopsy was at ten o'clock on the morning of the sixteenth. blood from a vein of the arm, pus from the uterine walls and that from a collection in the synovial sac of the knee were all placed in culture media. all showed growth, even the blood, and they all contained the long strings of granules. the peritoneum contained no pus. interpretation of the disease and of the death.--the injury of the uterus during confinement as usual furnished pus, which gave a lodging place for the germs of the long chains of granules. these, probably through the lymphatics, passed to the joints and to some other places, thus being the origin of the metastic abscesses which produced death. fifth observation.--on june seventeenth, m. doleris, a well-known hospital interne, brought to me some blood, removed with the necessary precautions, from a child dead immediately after birth, whose mother, before confinement had had febrile symptoms with chills. this blood, upon cultivation, gave an abundance of the pyogenic vibrio. on the other hand, blood taken from the mother on the morning of the eighteenth (she had died at one o'clock that morning) showed no development whatever, on the nineteenth nor on following days. the autopsy on the mother took place on the nineteenth. it is certainly worthy of note that the uterus, peritoneum and intestines showed nothing special, but the liver was full of metastatic abscesses. at the exit of the hepatic vein from the liver there was pus, and its walls were ulcerated at this place. the pus from the liver abscesses was filled with the pyogenic vibrio. even the liver tissues, at a distance from the visible abscesses, gave abundant cultures of the same organism. interpretation of the disease and of the death.--the pyogenic vibrio, found in the uterus, or which was perhaps already in the body of the mother, since she suffered from chills before confinement, produced metastatic abscesses in the liver and, carried to the blood of the child, there induced one of the forms of infection called purulent, which caused its death. sixth observation.--the eighteenth of june, 1879, m. doleris informed me that a woman confined some days before at the cochin hospital, was very ill. on the twentieth of june, blood from a needle-prick in the finger was sowed; the culture was sterile. on july fifteenth, that is to say twenty-five days later, the blood was tried again. still no growth. there was no organism distinctly recognizable in the lochia: the woman was nevertheless, they told me, dangerously ill and at the point of death. as a matter of fact, she did die on the eighteenth of july at nine in the morning: as may be seen, after a very long illness, for the first observations were made over a month before: the illness was also very painful, for the patient could make no movement without intense suffering. an autopsy was made on the nineteenth at ten in the morning, and was of great interest. there was purulent pleurisy with a considerable pocket of pus, and purulent false membranes on the walls of the pleura. the liver was bleached, fatty, but of firm consistency, and with no apparent metastatic abscesses. the uterus, of small size, appeared healthy; but on the external surface whitish nodules filled with pus were found. there was nothing in the peritoneum, which was not inflamed; but there was much pus in the shoulder joints and the symphysis pubis. the pus from the abscesses, upon cultivation, gave the long chains of granules--not only that of the pleura, but that from the shoulders and a lymphatic of the uterus as well. an interesting thing, but easily understood, was that the blood from a vein in the arm and taken three-quarters of an hour after death was entirely sterile. nothing grew from the fallopian tubes nor the broad ligaments. interpretation of the disease and of the death.--the pus found in the uterus after confinement became infected with germs of microscopic organisms which grew there, then passed into the uterine lymphatics, and from there went on to produce pus in the pleura and in the articulations. seventh observation.--on june eighteenth, m. doleris informed me that a woman had been confined at the cochin hospital five days before and that fears were entertained as to the results of an operation that had been performed, it having been necessary to do an embryotomy. the lochia were sowed on the 18th; there was not the slightest trace of growth the next day nor the day after. without the least knowledge of this woman since the eighteenth, on the twentieth i ventured to assert that she would get well. i sent to inquire about her. this is the text of the report: "the woman is doing extremely well; she goes out tomorrow" interpretation of the facts.--the pus naturally formed on the surface of the injured parts did not become contaminated with organisms brought from without. natura medicatrix carried it off, that is to say the vitality of the mucous surfaces prevented the development of foreign germs. the pus was easily resorbed, and recovery took place. i beg the academy to permit me, in closing, to submit certain definite views, which i am strongly inclined to consider as legitimate conclusions from the facts i have had the honor to communicate to it. under the expression puerperal fever are grouped very different diseases, [footnote: interesting as the starting point of the conception of diseases according to the etiological factor, not by groups of symptoms.--translator.] but all appearing to be the result of the growth of common organisms which by their presence infect the pus naturally formed on injured surfaces, which spread by one means or another, by the blood or the lymphatics, to one or another part of the body, and there induce morbid changes varying with the condition of the parts, the nature of the parasite, and the general constitution of the subject. whatever this constitution, does it not seem that by taking measures opposing the production of these common parasitic organisms recovery would usually occur, except perhaps when the body contains, before confinement, microscopic organisms, in contaminated internal or external abscesses, as was seen in one striking example (fifth observation). the antiseptic method i believe likely to be sovereign in the vast majority of cases. it seems to me that immediately after confinement the application of antiseptics should be begun. carbolic acid can render great service, but there is another antiseptic, the use of which i am strongly inclined to advise, this is boric acid in concentrated solution, that is, four per cent. at the ordinary temperature. this acid, whose singular influence on cell life has been shown by m. dumas, is so slightly acid that it is alkaline to certain test papers, as was long ago shown by m. chevreul, besides this it has no odor like carbolic acid, which odor often disturbs the sick. lastly, its lack of hurtful effects on mucous membranes, notably of the bladder, has been and is daily demonstrated in the hospitals of paris. the following is the occasion upon which it was first used. the academy may remember that i stated before it, and the fact has never been denied, that ammoniacal urine is always produced by a microscopic organism, entirely similar in many respects to the organism of furuncles. later, in a joint investigation with m. joubert, we found that a solution of boric acid was easily fatal to these organisms. after that, in 1877, i induced dr. guyon, in charge of the genito-urinary clinic at the necker hospital, to try injections of a solution of boric acid in affections of the bladder. i am informed by this skilful practitioner that he has done so, and daily observes good results from it. he also tells me that he performs no operation of lithotrity without the use of similar injections. i recall these facts to show that a solution of boric acid is entirely harmless to an extremely delicate mucous membrane, that of the bladder, and that it is possible to fill the bladder with a warm solution of boric acid without even inconvenience. to return to the confinement cases. would it not be of great service to place a warm concentrated solution of boric acid, and compresses, at the bedside of each patient; which she could renew frequently after saturating with the solution, and this also after confinement. it would also be acting the part of prudence to place the compresses, before using, in a hot air oven at 150 degrees c., more than enough to kill the germs of the common organisms. [footnote: the adoption of precautions, similar to those here suggested, has resulted in the practically complete disappearance of puerperal fevor.--translator.] was i justified in calling this communication "on the extension of the germ theory to the etiology of certain common diseases?" i have detailed the facts as they have appeared to me and i have mentioned interpretations of them: but i do not conceal from myself that, in medical territory, it is difficult to support one's self wholly on subjective foundations. i do not forget that medicine and veterinary practice are foreign to me. i desire judgment and criticism upon all my contributions. little tolerant of frivolous or prejudiced contradiction, contemptuous of that ignorant criticism which doubts on principle, i welcome with open arms the militant attack which has a method in doubting and whose rule of conduct has the motto "more light." it is a pleasure once more to acknowledge the helpfulness of the aid given me by messrs. chamberland and roux during the studies i have just recorded. i wish also to acknowledge the great assistance of m. doleris. prejudices which have retarded the progress of geology uniformity in the series of past changes in the animate and inanimate world by sir charles lyell introductory note sir charles lyell was born near kirriemuir, forfarshire, scotland, on november 14, 1797. he graduated from exeter college, oxford, in 1819, and proceeded to the study of law. although he practised for a short time, he was much hampered in this profession, as in all his work, by weak eyesight; and after the age of thirty he devoted himself chiefly to science. lyell's father was a botanist of some distinction, and the son seems to have been interested in natural history from an early age. while still an undergraduate he made geological journeys in scotland and on the continent of europe, and throughout his life he upheld by precept and example the importance of travel for the geologist. the first edition of his "principles of geology" was published in 1830; and the phrase used in the sub-title, "an attempt to explain the former changes of the earth's surface, by reference to causes now in action" strikes the keynote of his whole work. all his life he continued to urge this method of explanation in opposition to the hypotheses, formerly much in vogue, which assumed frequent catastrophes to account for geologic changes. the chapters here printed give his own final statement of his views on this important issue. lyell's scientific work received wide recognition: he was more than once president of the geological society, in 1864 was president of the british association, was knighted in 1848, and made a baronet in 1864. he possessed a broad general culture, and his home was a noted center of the intellectual life of london. he twice came to the united states to lecture, and created great interest. on his death, on february 22, 1875, he was buried in westminster abbey. persistent as were lyell's efforts for the establishment of his main theory, he remained remarkably open-minded; and when the evolutionary hypothesis was put forward he became a warm supporter of it. darwin in his autobiography thus sums up lyell's achievement: "the science of geology is enormously indebted to lyell--more so, as i believe, than to any other man who ewer lived." the progress of geology [footnote: the text of the two following papers is taken from the 11th edition of lyell's principles of geology, the last edition revised by the author.] i prepossessions in regard to the duration of past time--prejudices arising from our peculiar position as inhabitants of the land-others occasioned by our not seeing subterranean changes now in progress--all these causes combine to make the former course of nature appear different from the present--objections to the doctrine that causes similar in kind and energy to those now acting, have produced the former changes of the earth's surface considered if we reflect on the history of the progress of geology we perceive that there have been great fluctuations of opinion respecting the nature of the causes to which all former changes of the earth's surface are referable. the first observers conceived the monuments which the geologist endeavours to decipher to relate to an original state of the earth, or to a period when there were causes in activity, distinct, in a kind and degree, from those now constituting the economy of nature. these views were gradually modified, and some of them entirely abandoned, in proportion as observations were multiplied, and the signs of former mutations were skilfully interpreted. many appearances, which had for a long time been regarded as indicating mysterious and extraordinary agency, were finally recognised as the necessary result of the laws now governing the material world; and the discovery of this unlooked-for conformity has at length induced some philosophers to infer, that, during the ages contemplated in geology, there has never been any interruption to the agency of the same uniform laws of change. the same assemblage of general causes, they conceive, may have been sufficient to produce, by their various combinations, the endless diversity of effects, of which the shell of the earth has preserved the memorials; and, consistently with these principles, the recurrence of analogous changes is expected by them in time to come. whether we coincide or not in this doctrine we must admit that the gradual progress of opinion concerning the succession of phenomena in very remote eras, resembles, in a singular manner, that which has accompanied the growing intelligence of every people, in regard to the economy of nature in their own times. in an early state of advancement, when a greater number of natural appearances are unintelligible, an eclipse, an earthquake, a flood, or the approach of a comet, with many other occurrences afterwards found to belong to the regular course of events, are regarded as prodigies. the same delusion prevails as to moral phenomena, and many of these are ascribed to the intervention of demons, ghosts, witches, and other immaterial and supernatural agents. by degrees, many of the enigmas of the moral and physical world are explained, and, instead of being due to extrinsic and irregular causes, they are found to depend on fixed and invariable laws. the philosopher at last becomes convinced of the undeviating uniformity of secondary causes; and, guided by his faith in this principle, he determines the probability of accounts transmitted to him of former occurrences, and often rejects the fabulous tales of former times, on the ground of their being irreconcilable with the experience of more enlightened ages. prepossessions in regard to the duration of past time.--as a belief in the want of conformity in the cause by which the earth's crust has been modified in ancient and modern periods was, for a long time, universally prevalent, and that, too, amongst men who were convinced that the order of nature had been uniform for the last several thousand years, every circumstance which could have influenced their minds and given an undue bias to their opinions deserves particular attention. now the reader may easily satisfy himself, that, however undeviating the course of nature may have been from the earliest epochs, it was impossible for the first cultivators of geology to come to such a conclusion, so long as they were under a delusion as to the age of the world, and the date of the first creation of animate beings. however fantastical some theories of the sixteenth century may now appear to us,--however unworthy of men of great talent and sound judgment,--we may rest assured that, if the same misconception now prevailed in regard to the memorials of human transactions, it would give rise to a similar train of absurdities. let us imagine, for example, that champollion, and the french and tuscan literati when engaged in exploring the antiquities of egypt, had visited that country with a firm belief that the banks of the nile were never peopled by the human race before the beginning of the nineteenth century, and that their faith in this dogma was as difficult to shake as the opinion of our ancestors, that the earth was never the abode of living beings until the creation of the present continents, and of the species now existing,--it is easy to perceive what extravagant systems they would frame, while under the influence of this delusion, to account for the monuments discovered in egypt. the sight of the pyramids, obelisks, colossal statues, and ruined temples, would fill them with such astonishment, that for a time they would be as men spell-bound--wholly incapable of reasoning with sobriety. they might incline at first to refer the construction of such stupendous works to some superhuman powers of the primeval world. a system might be invented resembling that so gravely advanced by, manetho, who relates that a dynasty of gods originally ruled in egypt, of whom vulcan, the first monarch, reigned nine thousand years; after whom came hercules and other demigods, who were at last succeeded by human kings. when some fanciful speculations of this kind had amused their imaginations for a time, some vast repository of mummies would be discovered, and would immediately undeceive those antiquaries who enjoyed an opportunity of personally examining them; but the prejudices of others at a distance, who were not eye-witnesses of the whole phenomena, would not be so easily overcome. the concurrent report of many travellers would, indeed, render it necessary for them to accommodate ancient theories to some of the new facts, and much wit and ingenuity would be required to modify and defend their old positions. each new invention would violate a greater number of known analogies; for if a theory be required to embrace some false principle, it becomes more visionary in proportion as facts are multiplied, as would be the case if geometers were now required to form an astronomical system on the assumption of the immobility of the earth. amongst other fanciful conjectures concerning the history of egypt, we may suppose some of the following to be started. 'as the banks of the nile have been so recently colonized for the first time, the curious substances called mummies could never in reality have belonged to men. they may have been generated by some plastic virtue residing in the interior of the earth, or they may be abortions of nature produced by her incipient efforts in the work of creation. for if deformed beings are sometimes born even now, when the scheme of the universe is fully developed, many more may have been "sent before their time scarce half made up," when the planet itself was in the embryo state. but if these notions appear to derogate from the perfection of the divine attributes, and if these mummies be in all their parts true representations of the human form, may we not refer them to the future rather than the past? may we not be looking into the womb of nature, and not her grave? may not these images be like the shades of the unborn in virgil's elysium--the archetypes of men not yet called into existence?' these speculations, if advocated by eloquent writers, would not fail to attract many zealous votaries, for they would relieve men from the painful necessity of renouncing preconceived opinions. incredible as such scepticism may appear, it has been rivalled by many systems of the sixteenth and seventeenth centuries, and among others by that of the learned falloppio, who, as we have seen (p. 33), regarded the tusks of fossil elephants as earthly concretions, and the pottery or fragments of vases in the monte testaceo, near rome, as works of nature, and not of art. but when one generation had passed away, and another, not compromised to the support of antiquated dogmas, had succeeded, they would review the evidence afforded by mummies more impartially, and would no longer controvert the preliminary question, that human beings had lived in egypt before the nineteenth century: so that when a hundred years perhaps had been lost, the industry and talents of the philosopher would be at last directed to the elucidation of points of real historical importance. but the above arguments are aimed against one only of many prejudices with which the earlier geologists had to contend. even when they conceded that the earth had been peopled with animate beings at an earlier period than was at first supposed, they had no conception that the quantity of time bore so great a proportion to the historical era as is now generally conceded. how fatal every error as to the quantity of time must prove to the introduction of rational views concerning the state of things in former ages, may be conceived by supposing the annals of the civil and military transactions of a great nation to be perused under the impression that they occurred in a period of one hundred instead of two thousand years. such a portion of history would immediately assume the air of a romance; the events would seem devoid of credibility, and inconsistent with the present course of human affairs. a crowd of incidents would follow each other in thick succession. armies and fleets would appear to be assembled only to be destroyed, and cities built merely to fall in ruins. there would be the most violent transitions from foreign or intestine war to periods of profound peace, and the works effected during the years of disorder or tranquillity would appear alike superhuman in magnitude. he who should study the monuments of the natural world under the influence of a similar infatuation, must draw a no less exaggerated picture of the energy and violence of causes, and must experience the same insurmountable difficulty in reconciling the former and present state of nature, if we could behold in one view all the volcanic cones thrown up in iceland, italy, sicily, and other parts of europe, during the last five thousand years, and could see the lavas which have flowed during the same period; the dislocations, subsidences, and elevations caused during earthquakes; the lands added to various deltas, or devoured by the sea, together with the effects of devastation by floods, and imagine that all these events had happened in one year, we must form most exalted ideas of the activity of the agents, and the suddenness of the revolutions. if geologists, therefore, have misinterpreted the signs of a succession of events, so as to conclude that centuries were implied where the characters indicated thousands of years, and thousands of years where the language of nature signified millions, they could not, if they reasoned logically from such false premises, come to any other conclusion than that the system of the natural world had undergone a complete revolution. we should be warranted in ascribing the erection of the great pyramid to superhuman power, if we were convinced that it was raised in one day; and if we imagine, in the same manner, a continent or mountain-chain to have been elevated during an equally small fraction of the time which was really occupied in upheaving it, we might then be justified in inferring, that the subterranean movements were once far more energetic than in our own times. we know that; during one earthquake the coast of chili may be raised for a hundred miles to the average height of about three feet. a repetition of two thousand shocks, of equal violence, might produce a mountain-chain one hundred miles long, and six thousand feet high. now, should one or two only of these convulsions happen in a century, it would be consistent with the order of events experienced by the chilians from the earliest times: but if the whole of them were to occur in the next hundred years, the entire district must be depopulated, scarcely any animals or plants could survive, and the surface would be one confused heap of ruin and desolation. one consequence of undervaluing greatly the quantity of past time, is the apparent coincidence which it occasions of events necessarily disconnected, or which are so unusual, that it would be inconsistent with all calculation of chances to suppose them to happen at one and the same time. when the unlooked-for association of such rare phenomena is witnessed in the present course of nature, it scarcely ever fails to excite a suspicion of the preternatural in those minds which are not firmly convinced of the uniform agency of secondary causes;--as if the death of some individual in whose fate they are interested happens to be accompanied by the appearance of a luminous meteor, or a comet, or the shock of an earthquake. it would be only necessary to multiply such coincidences indefinitely, and the mind of every philosopher would be disturbed. now it would be difficult to exaggerate the number of physical events, many of them most rare and unconnected in their nature, which were imagined by the woodwardian hypothesis to have happened in the course of a few months: and numerous other examples might be found of popular geological theories, which require us to imagine that a long succession of events happened in a brief and almost momentary period. another liability to error, very nearly allied to the former, arises from the frequent contact of geological monuments referring to very distant periods of time. we often behold, at one glance, the effects of causes which have acted at times incalculably remote, and yet there may be no striking circumstances to mark the occurrence of a great chasm in the chronological series of nature's archives. in the vast interval of time which may really have elapsed between the results of operations thus compared, the physical condition of the earth may, by slow and insensible modifications, have become entirely altered; one or more races of organic beings may have passed away, and yet have left behind, in the particular region under contemplation, no trace of their existence. to a mind unconscious of these intermediate events, the passage from one state of things to another must appear so violent, that the idea of revolutions in the system inevitably suggests itself. the imagination is as much perplexed by the deception, as it might be if two distant points in space were suddenly brought into immediate proximity. let us suppose, for a moment, that a philosopher should lie down to sleep in some arctic wilderness, and then be transferred by a power, such as we read of in tales of enchantment, to a valley in a tropical country, where, on awaking, he might find himself surrounded by birds of brilliant plumage, and all the luxuriance of animal and vegetable forms of which nature is so prodigal in those regions. the most reasonable supposition, perhaps, which he could make, if by the necromancer's art he were placed in such a situation, would be, that he was dreaming; and if a geologist form theories under a similar delusion, we cannot expect him to preserve more consistency in his speculations, than in the train of ideas in an ordinary dream. it may afford, perhaps, a more lively illustration of the principle here insisted upon, if i recall to the reader's recollection the legend of the seven sleepers. the scene of that popular fable was placed in the two centuries which elapsed between the reign of the emperor decius and the death of theodosius the younger. in that interval of time (between the years 249 and 450 of our era) the union of the roman empire had been dissolved, and some of its fairest provinces overrun by the barbarians of the north. the seat of government had passed from rome to constantinople, and the throne from a pagan persecutor to a succession of christian and orthodox princes. the genius of the empire had been humbled in the dust, and the altars of diana and hercules were on the point of being transferred to catholic saints and martyrs. the legend relates, 'that when decius was still persecuting the christians, seven noble youths of ephesus concealed themselves in a spacious cavern in the side of an adjacent mountain, where they were doomed to perish by the tyrant, who gave orders that the entrance should be firmly secured with a pile of huge stones. they immediately fell into a deep slumber, which was miraculously prolonged, without injuring the powers of life, during a period of 187 years. at the end of that time the slaves of adolius, to whom the inheritance of the mountain had descended, removed the stones to supply materials for some rustic edifice: the light of the sun darted into the cavern, and the seven sleepers were permitted to awake. after a slumber, as they thought, of a few hours, they were pressed by the calls of hunger, and resolved that jamhlichus, one of their number, should secretly return to the city to purchase bread for the use of his companions. the youth could no longer recognise the once familiar aspect of his native country, and his surprise was increased by the appearance of a large cross triumphantly erected over the principal gate of ephesus. his singular dress and obsolete language confounded the baker, to whom he offered an ancient medal of decius as the current coin of the empire; and jamblichus, on the suspicion of a secret treasure, was dragged before the judge. their mutual enquiries produced the amazing discovery, that two centuries were almost elapsed since jamblichus and his friends had escaped from the rage of a pagan tyrant.' this legend was received as authentic throughout the christian world before the end of the sixth century, and was afterwards introduced by mahomet as a divine revelation into the koran, and from hence was adopted and adorned by all the nations from bengal to africa who professed the mahometan faith. some vestiges even of a similar tradition have been discovered in scandinavia. 'this easy and universal belief,' observes the philosophical historian of the decline and fall, 'so expressive of the sense of mankind, may be ascribed to the genuine merit of the fable itself. we imperceptibly advance from youth to age, without observing the gradual, but incessant, change of human affairs; and even, in our larger experience of history, the imagination is accustomed, by a perpetual series of causes and effects, to unite the most distant revolutions. but if the interval between two memorable eras could be instantly annihilated; if it were possible, after a momentary slumber of two hundred years, to display the new world to the eyes of a spectator who still retained a lively and recent impression of the old, his surprise and his reflections would furnish the pleasing subject of a philosophical romance.' [footnote: gibbon, decline and fall. chap, xxxiii.] prejudices arising from our peculiar position as inhabitants of the land.--the sources of prejudice hitherto considered may be deemed peculiar for the most part to the infancy of the science, but others are common to the first cultivators of geology and to ourselves, and are all singularly calculated to produce the same deception, and to strengthen our belief that the course of nature in the earlier ages differed widely from that now established. although these circumstances cannot be fully explained without assuming some things as proved, which it has been my object elsewhere to demonstrate, [footnote: elements of geology, 6th edit., 1865; and student's elements, 1871.] it may be well to allude to them briefly in this place. the first and greatest difficulty, then, consists in an habitual unconsciousness that our position as observers is essentially unfavourable, when we endeavour to estimate the nature and magnitude of the changes now in progress. in consequence of our inattention to this subject, we are liable to serious mistakes in contrasting the present with former states of the globe. as dwellers on the land, we inhabit about a fourth part of the surface; and that portion is almost exclusively a theatre of decay, and not of reproduction. we know, indeed, that new deposits are annually formed in seas and lakes, and that every year some new igneous rocks are produced in the bowels of the earth, but we cannot watch the progress of their formation, and as they are only present to our minds by the aid of reflection, it requires an effort both of the reason and the imagination to appreciate duly their importance. it is, therefore, not surprising that we estimate very imperfectly the result of operations thus unseen by us; and that, when analogous results of former epochs are presented to our inspection, we cannot immediately recognise the analogy. he who has observed the quarrying of stone from a rock, and has seen it shipped for some distant port, and then endeavours to conceive what kind of edifice will be raised by the materials, is in the same predicament as a geologist, who, while he is confined to the land, sees the decomposition of rocks, and the transportation of matter by rivers to the sea, and then endeavours to picture to himself the new strata which nature is building beneath the waters. prejudices arising from our not seeing subterranean changes.--nor is his position less unfavourable when, beholding a volcanic eruption, he tries to conceive what changes the column of lava has produced, in its passage upwards, on the intersected strata; or what form the melted matter may assume at great depths on cooling; or what may be the extent of the subterranean rivers and reservoirs of liquid matter far beneath the surface. it should, therefore, be remembered, that the task imposed on those who study the earth's history requires no ordinary share of discretion; for we are precluded from collating the corresponding parts of the system of things as it exists now, and as it existed at former periods. if we were inhabitants of another element--if the great ocean were our domain, instead of the narrow limits of the land, our difficulties would be considerably lessened; while, on the other hand, there can be little doubt, although the reader may, perhaps, smile at the bare suggestion of such an idea, that an amphibious being, who should possess our faculties, would still more easily arrive at sound theoretical opinions in geology, since he might behold, on the one hand, the decomposition of rocks in the atmosphere, or the transportation of matter by running water; and, on the other, examine the deposition of sediment in the sea, and the imbedding of animal and vegetable remains in new strata. he might ascertain, by direct observation, the action of a mountain torrent, as well as of a marine current; might compare the products of volcanos poured out upon the land with those ejected beneath the waters; and might mark, on the one hand, the growth of the forest, and, on the other, that of the coral reef. yet, even with these advantages, he would be liable to fall into the greatest errors, when endeavouring to reason on rocks of subterranean origin. he would seek in vain, within the sphere of his observation, for any direct analogy to the process of their formation, and would therefore be in danger of attributing them, wherever they are upraised to view, to some 'primeval state of nature.' but if we may be allowed so far to indulge the imagination, as to suppose a being entirely confined to the nether world--some 'dusky melancholy sprite,' like umbriel, who could 'flit on sooty pinions to the central earth,' but who was never permitted to 'sully the fair face of light,' and emerge into the regions of water and of air; and if this being should busy himself in investigating the structure of the globe, he might frame theories the exact converse of those usually adopted by human philosophers. he might infer that the stratified rocks, containing shells and other organic remains, were the oldest of created things, belonging to some original and nascent state of the planet. 'of these masses' he might say, 'whether they consist of loose incoherent sand, soft clay, or solid stone, none have been formed in modern times. every year some of them are broken and shattered by earthquakes, or melted by volcanic fire; and when they cool down slowly from a state of fusion, they assume a new and more crystalline form, no longer exhibiting that stratified disposition and those curious impressions and fantastic markings, by which they were previously characterised. this process cannot have been carried on for an indefinite time, for in that case all the stratified rocks would long ere this have been fused and crystallised. it is therefore probable that the whole planet once consisted of these mysterious and curiously bedded formations at a time when the volcanic fire had not yet been brought into activity. since that period there seems to have been a gradual development of heat; and this augmentation we may expect to continue till the whole globe shall be in a state of fluidity, or shall consist, in those parts which are not melted, of volcanic and crystalline rocks.' such might be the system of the gnome at the very time that the followers of leibnitz, reasoning on what they saw on the outer surface, might be teaching the opposite doctrine of gradual refrigeration, and averring that the earth had begun its career as a fiery comet, and might be destined hereafter to become a frozen mass. the tenets of the schools of the nether and of the upper world would be directly opposed to each other, for both would partake of the prejudices inevitably resulting from the continual contemplation of one class of phenomena to the exclusion of another. man observes the annual decomposition of crystalline and igneous rocks, and may sometimes see their conversion into stratified deposits; but he cannot witness the reconversion of the sedimentary into the crystalline by subterranean heat. he is in the habit of regarding all the sedimentary rocks as more recent than the unstratified, for the same reason that we may suppose him to fall into the opposite error if he saw the origin of the igneous class only. for more than two centuries the shelly strata of the subapennine hills afforded matter of speculation to the early geologists of italy, and few of them had any suspicion that similar deposits were then forming in the neighbouring sea. some imagined that the strata, so rich in organic remains, instead of being due to secondary agents, had been so created in the beginning of things by the fiat of the almighty. others, as we have seen, ascribed the imbedded fossil bodies to some plastic power which resided in the earth in the early ages of the world. in what manner were these dogmas at length exploded? the fossil relics were carefully compared with their living analogues, and all doubts as to their organic origin were eventually dispelled. so, also, in regard to the nature of the containing beds of mud, sand, and limestone: those parts of the bottom of the sea were examined where shells are now becoming annually entombed in new deposits, donati explored the bed of the adriatic, and found the closest resemblance between the strata there forming, and those which constituted hills above a thousand feet high in various parts of the italian peninsula. he ascertained by dredging that living testacea were there grouped together in precisely the same manner as were their fossil analogues in the inland strata; and while some of the recent shells of the adriatic were becoming incrusted with calcareous rock, be observed that others had been newly buried in sand and clay, precisely as fossil shells occur in the subapennine hills. in like manner, the volcanic rocks of the vicentin had been studied in the beginning of the last century; but no geologist suspected, before the time of arduino, that these were composed of ancient submarine lavas. during many years of controversy, the popular opinion inclined to a belief that basalt and rocks of the same class had been precipitated from a chaotic fluid, or an ocean which rose at successive periods over the continents, charged with the component elements of the rocks in question. few will now dispute that it would have been difficult to invent a theory more distant from the truth; yet we must cease to wonder that it gained so many proselytes, when we remember that its claims to probability arose partly from the very circumstance of its confirming the assumed want of analogy between geological causes and those now in action. by what train of investigations were geologists induced at length to reject these views, and to assent to the igneous origin of the trappean formations? by an examination of volcanos now active, and by comparing their structure and the composition of their lavas with the ancient trap rocks. the establishment, from time to time, of numerous points of identification, drew at length from geologists a reluctant admission, that there was more correspondence between the condition of the globe at remote eras and now, and more uniformity in the laws which have regulated the changes of its surface, than they at first imagined. if, in this state of the science, they still despaired of reconciling every class of geological phenomena to the operations of ordinary causes, even by straining analogy to the utmost limits of credibility, we might have expected, at least, that the balance of probability would now have been presumed to incline towards the close analogy of the ancient and modern causes. but, after repeated experience of the failure of attempts to speculate on geological monuments, as belonging to a distinct order of things, new sects continued to persevere in the principles adopted by their predecessors. they still began, as each new problem presented itself, whether relating to the animate or inanimate world, to assume an original and dissimilar order of nature; and when at length they approximated, or entirely came round to an opposite opinion, it was always with the feeling, that they were conceding what they had been justified a priori in deeming improbable. in a word, the same men who, as natural philosophers, would have been most incredulous respecting any extraordinary deviations from the known course of nature, if reported to have happened in their own time, were equally disposed, as geologists, to expect the proofs of such deviations at every period of the past. * * * * uniformity of change ii supposed alternate periods of repose and disorder--observed facts in which this doctrine has originated--these may be explained by supposing a uniform and uninterrupted series of changes--threefold consideration of this subject: first, in reference to the laws which govern the formation of fossiliferous strata, and the shifting of the areas of sedimentary deposition; secondly, in reference to the living creation, extinction of species, and origin of new animals and plants; thirdly, in reference to the changes produced in the earth's crust by the continuance of subterranean movements in certain areas, and their transference after long periods to new areas--on the combined influence of all these modes and causes of change in producing breaks and chasms in the chain of records--concluding remarks on the identity of the ancient and present system of terrestrial changes. origin of the doctrine of alternate periods of repose and disorder.--it has been truly observed, that when we arrange the fossiliferous formations in chronological order, they constitute a broken and defective series of monuments: we pass without any intermediate gradations from systems of strata which are horizontal, to other systems which are highly inclined--from rocks of peculiar mineral composition to others which have a character wholly distinct--from one assemblage of organic remains to another, in which frequently nearly all the species, and a large part of the genera, are different. these violations of continuity are so common as to constitute in most regions the rule rather than the exception, and they have been considered by many geologists as conclusive in favour of sudden revolutions in the inanimate and animate world. we have already seen that according to the speculations of some writers, there have been in the past history of the planet alternate periods of tranquillity and convulsion, the former enduring for ages, and resembling the state of things now experienced by man, the other brief, transient, and paroxysmal, giving rise to new mountains, seas, and valleys, annihilating one set of organic beings, and ushering in the creation of another. it will be the object of the present chapter to demonstrate that these theoretical views are not borne out by a fair interpretation of geological monuments. it is true that in the solid framework of the globe we have a chronological chain of natural records, many links of which are wanting: but a careful consideration of all the phenomena leads to the opinion that the series was originally defective--that it has been rendered still more so by time--that a great part of what remains is inaccessible to man, and even of that fraction which is accessible nine-tenths or more are to this day unexplored. the readiest way, perhaps, of persuading the reader that we may dispense with great and sudden revolutions in the geological order of events is by showing him how a regular and uninterrupted series of changes in the animate and inanimate world must give rise to such breaks in the sequence, and such unconformability of stratified rocks, as are usually thought to imply convulsions and catastrophes. it is scarcely necessary to state that the order of events thus assumed to occur, for the sake of illustration, should be in harmony with all the conclusions legitimately drawn by geologists from the structure of the earth, and must be equally in accordance with the changes observed by man to be now going on in the living as well as in the inorganic creation. it may be necessary in the present state of science to supply some part of the assumed course of nature hypothetically; but if so, this must be done without any violation of probability, and always consistently with the analogy of what is known both of the past and present economy of our system. although the discussion of so comprehensive a subject must carry the beginner far beyond his depth, it will also, it is hoped, stimulate his curiosity, and prepare him to read some elementary treatises on geology with advantage, and teach him the bearing on that science of the changes now in progress on the earth. at the same time it may enable him the better to understand the intimate connection between the second and third books of this work, one of which is occupied with the changes of the inorganic, the latter with those of the organic creation. in pursuance, then, of the plan above proposed, i will consider in this chapter, first, the laws which regulate the denudation of strata and the deposition of sediment; secondly, those which govern the fluctuation in the animate world; and thirdly, the mode in which subterranean movements affect the earth's crust. uniformity of change considered, first, in reference to denudation and sedimentary deposition.--first, in regard to the laws governing the deposition of new strata. if we survey the surface of the globe, we immediately perceive that it is divisible into areas of deposition and non-deposition; or, in other words, at any given time there are spaces which are the recipients, others which are not the recipients, of sedimentary matter. no new strata, for example, are thrown down on dry land, which remains the same from year to year; whereas, in many parts of the bottom of seas and lakes, mud, sand, and pebbles are annually spread out by rivers and currents. there are also great masses of limestone growing in some seas, chiefly composed of corals and shells, or, as in the depths of the atlantic, of chalky mud made up of foraminifera and diatomaceae. as to the dry land, so far from being the receptacle of fresh accessions of matter, it is exposed almost everywhere to waste away. forests may be as dense and lofty as those of brazil, and may swarm with quadrupeds, birds, and insects, yet at the end of thousands of years one layer of black mould a few inches thick may be the sole representative of those myriads of trees, leaves, flowers, and fruits, those innumerable bones and skeletons of birds, quadrupeds, and reptiles, which tenanted the fertik region. should this land be at length submerged, the waves of the sea may wash away in a few hours the scanty covering of mould, and it may merely impart a darker shade of colour to the next stratum of marl, sand, or other matter newly thrown down. so also at the bottom of the ocean where no sediment is accumulating, seaweed, zoophytes, fish, and even shells, may multiply for ages and decompose, leaving no vestige of their form or substance behind. their decay, in water, although more slow, is as certain and eventually as complete as in the open air. nor can they be perpetuated for indefinite periods in a fossil state, unless imbedded in some matrix which is impervious to water, or which at least does not allow a free percolation of that fluid, impregnated, as it usually is, with a slight quantity of carbonic or other acid. such a free percolation may be prevented either by the mineral nature of the matrix itself, or by the superposition of an impermeable stratum; but if unimpeded, the fossil shell or bone will be dissolved and removed, particle after particle, and thus entirely effaced, unless petrifaction or the substitution of some mineral for the organic matter happen to take place. that there has been land as well as sea at all former geological periods, we know from the fact that fossil trees and terrestrial plants are imbedded in rocks of every age, except those which are so ancient as to be very imperfectly known to us. occasionally lacustrine and fluviatile shells, or the bones of amphibious or land reptiles, point to the same conclusion. the existence of dry land at all periods of the past implies, as before mentioned, the partial deposition of sediment, or its limitation to certain areas; and the next point to which i shall call the reader's attention is the shifting of these areas from one region to another. first, then, variations in the site of sedimentary deposition are brought about independently of subterranean movements. there is always a slight change from year to year, or from century to century. the sediment of the rhone, for example, thrown into the lake of geneva, is now conveyed to a spot a mile and a half distant from that where it accumulated in the tenth century, and six miles from the point where the delta began originally to form. we may look forward to the period when this lake will be filled up, and then the distribution of the transported matter will be suddenly altered, for the mud and sand brought down from the alps will thenceforth, instead of being deposited near geneva, be carried nearly 200 miles southwards, where the rhone enters the mediterranean. in the deltas of large rivers, such as those of the ganges and indus, the mud is first carried down for many centuries through one arm, and on this being stopped up it is discharged by another, and may then enter the sea at a point 50 or 100 miles distant from its first receptacle. the direction of marine currents is also liable to be changed by various accidents, as by the heaping up of new sandbanks, or the wearing away of cliffs and promontories. but, secondly, all these causes of fluctuation in the sedimentary areas are entirely subordinate to those great upward or downward movements of land, which will presently be spoken of, as prevailing over large tracts of the globe. by such elevation or subsidence certain spaces are gradually submerged, or made gradually to emerge: in the one case sedimentary deposition may be suddenly renewed after having been suspended for one or more geological periods, in the other as suddenly made to cease after having continued for ages. if deposition be renewed after a long interval, the new strata will usually differ greatly from the sedimentary rocks previously formed in the same place, and especially if the older rocks have suffered derangement, which implies a change in the physical geography of the district since the previous conveyance of sediment to the same spot. it may happen, however, that, even where the two groups, the superior and the inferior, are horizontal and conformable to each other, they may still differ entirely in mineral character, because, since the origin of the older formation, the geography of some distant country has been altered. in that country rocks before concealed may have become exposed by denudation; volcanos may have burst out and covered the surface with scoriae and lava; or new lakes, intercepting the sediment previously conveyed from the upper country, may have been formed by subsidence; and other fluctuations may have occurred, by which the materials brought down from thence by rivers to the sea have acquired a distinct mineral character. it is well known that the stream of the mississippi is charged with sediment of a different colour from that of the arkansas and red rivers, which are tinged with red mud, derived from rocks of porphyry and red gypseous clays in 'the far west.' the waters of the uruguay, says darwin, draining a granitic country, are clear and black, those of the parana, red. [footnote: darwin's journal, p. 163, and edit., p. 139.] the mud with which the indus is loaded, says burnes, is of a clayey hue, that of the chenab, on the other hand, is reddish, that of the sutlej is more pale. [footnote: journ. roy. geograph. soc., vol. iii, p. 142.] the same causes which make these several rivers, sometimes situated at no great distance the one from the other, to differ greatly in the character of their sediment, will make the waters draining the same country at different epochs, especially before and after great revolutions in physical geography, to be entirely dissimilar. it is scarcely necessary to add that marine currents will be affected in an analogous manner in consequence of the formation of new shoals, the emergence of new islands, the subsidence of others, the gradual waste of neighbouring coasts, the growth of new deltas, the increase of coral reefs, volcanic eruptions, and other changes. uniformity of change considered, secondly, in regerence to the living creation.--secondly, in regard to the vicissitudes of the living creation, all are agreed that the successive groups of sedimentary strata found in the earth's crust are not only dissimilar in mineral composition for reasons above alluded to, but are likewise distinguishable from each other by their organic remains. the general inference drawn from the study and comparison of the various groups, arranged in chronological order, is this: that at successive periods distinct tribes of animals and plants have inhabited the land and waters, and that the organic types of the newer formations are more analogous to species now existing than those of more ancient rocks. if we then turn to the present state of the animate creation, and enquire whether it has now become fixed and stationary, we discover that, on the contrary, it is in a state of continual flux--that there are many causes in action which tend to the extinction of species, and which are conclusive against the doctrine of their unlimited durability. there are also causes which give rise to new varieties and races in plants and animals, and new forms are continually supplanting others which had endured for ages. but natural history has been sucessfully cultivated for so short a period, that a few examples only of local, and perhaps but one or two of absolute, extirpation of species can as yet be proved, and these only where the interference of man has been conspicuous. it will nevertheless appear evident, from the facts and arguments detailed in the chapters which treat of the geographical distribution of species in the next volume, that man is not the only exterminating agent; and that, independently of his intervention, the annihilation of species is promoted by the multiplication and gradual diffusion of every animal or plant. it will also appear that every alteration in the physical geography and climate of the globe cannot fail to have the same tendency. if we proceed still farther, and enquire whether new species are substituted from time to time for those which die out, we find that the successive introduction of new forms appears to have been a constant part of the economy of the terrestrial system, and if we have no direct proof of the fact it is because the changes take place so slowly as not to come within the period of exact scientific observation. to enable the reader to appreciate the gradual manner in which a passage may have taken place from an extinct fauna to that now living, i shall say a few words on the fossils of successive tertiary periods. when we trace the series of formations from the more ancient to the more modern, it is in these tertiary deposits that we first meet with assemblages of organic remains having a near analogy to the fauna of certain parts of the globe in our own time. in the eocene, or oldest subdivisions, some few of the testacea belong to existing species, although almost all of them, and apparently all the associated vertebrata, are now extinct. these eocene strata are succeeded by a great number of more modern deposits, which depart gradually in the character of their fossils from the eocene type, and approach more and more to that of the living creation. in the present state of science, it is chiefly by the aid of shells that we are enabled to arrive at these results, for of all classes the testacea are the most generally diffused in a fossil state, and may be called the medals principally employed by nature in recording the chronology of past events. in the upper miocene rocks (no. 5 of the table, p. 135) we begin to find a considerable number, although still a minority, of recent species, intermixed with some fossils common to the preceding, or eocene, epoch. we then arrive at the pliocene strata, in which species now contemporary with man begin to preponderate, and in the newest of which nine-tenths of the fossils agree with species still inhabiting the neighbouring sea. it is in the post-tertiary strata, where all the shells agree with species now living, that we have discovered the first or earliest known remains of man associated with the bones of quadrupeds, some of which are of extinct species. in thus passing from the older to the newer members of the tertiary system, we meet with many chasms, but none which separate entirely, by a broad line of demarcation, one state of the organic world from another. there are no signs of an abrupt termination of one fauna and flora, and the starting into life of new and wholly distinct forms. although we are far from being able to demonstrate geologically an insensible transition from the eocene to the miocene, or even from the latter to the recent fauna, yet the more we enlarge and perfect our general survey, the more nearly do we approximate to such a continuous series, and the more gradually are we conducted from times when many of the genera and nearly all the species were extinct, to those in which scarcely a single species flourished which we do not know to exist at present. dr. a. philippi, indeed, after an elaborate comparison of the fossil tertiary shells of sicily with those now living in the mediterranean, announced, as the result of his examination, that there are strata in that island which attest a very gradual passage from a period when only thirteen in a hundred of the shells were like the species now living in the sea, to an era when the recent species had attained a proportion of ninety-five in a hundred. there is, therefore, evidence, he says, in sicily of this revolution in the animate world having been effected 'without the intervention of any convulsion or abrupt changes, certain species having from time to time died out and others having been introduced, until at length the existing fauna was elaborated.' in no part of europe is the absence of all signs of man or his works, in strata of comparatively modern date, more striking than in sicily. in the central parts of that island we observe a lofty table-land and hills, sometimes rising to the height of 3,000 feet, capped with a limestone, in which from 70 to 85 per cent of the fossil testacea are specifically identical with those now inhabiting the mediterranean. these calcareous and other argillaceous strata of the same age are intersected by deep valleys which appear to have been gradually formed by denudation, but have not varied materially in width or depth since sicily was first colonised by the greeks. the limestone, moreover, which is of so late a date in geological chronology, was quarried for building those ancient temples of girgenti and syracuse, of which the ruins carry us back to a remote era in human history. if we are lost in conjectures when speculating on the ages required to lift up these formations to the height of several thousand feet above the sea, and to excavate the valleys, how much more remote must be the era when the same rocks were gradually formed beneath the waters! the intense cold of the glacial period was spoken of in the tenth chapter. although we have not yet succeeded in detecting proofs of the origin of man antecedently to that epoch, we have yet found evidence that most of the testacea, and not a few of the quadrupeds, which preceded, were of the same species as those which followed the extreme cold. to whatever local disturbances this cold may have given rise in the distribution of species, it seems to have done little in effecting their annihilation. we may conclude therefore, from a survey of the tertiary and modern strata, which constitute a more complete and unbroken series than rocks of older date, that the extinction and creation of species have been, and are, the result of a slow and gradual change in the organic world. uniformity of change considered, thirdly, in reference to subterranean movements.--thirdly, to pass on to the last of the three topics before proposed for discussion, the reader will find, in the account given in the second book, vol. ii., of the earthquakes recorded in history, that certain countries have from time immemorial, been rudely shaken again and again; while others, comprising by far the largest part of the globe, have remained to all appearance motionless. in the regions of convulsion rocks have been rent asunder, the surface has been forced up into ridges, chasms have opened, or the ground throughout large spaces has been permanently lifted up above or let down below its former level. in the regions of tranquillity some areas have remained at rest, but others have been ascertained, by a comparison of measurements made at different periods, to have risen by an insensible motion, as in sweden, or to have subsided very slowly, as in greenland. that these same movements, whether ascending or descending, have continued for ages in the same direction has been established by historical or geological evidence. thus we find on the opposite coasts of sweden that brackish water deposits, like those now forming in the baltic, occur on the eastern side, and upraised strata filled with purely marine shells, now proper to the ocean, on the western coast. both of these have been lifted up to an elevation of several hundred feet above high-water mark. the rise within the historical period has not amounted to many yards, but the greater extent of antecedent upheaval is proved by the occurrence in inland spots, several hundred feet high, of deposits filled with fossil shells of species now living either in the ocean or the baltic. it must in general be more difficult to detect proofs of slow and gradual subsidence than of elevation, but the theory which accounts for the form of circular coral reefs and lagoon islands, and which will be explained in the concluding chapter of this work, will satisfy the reader that there are spaces on the globe, several thousand miles in circumference, throughout which the downward movement has predominated for ages, and yet the land has never, in a single instance, gone down suddenly for several hundred feet at once. yet geology demonstrates that the persistency of subterranean movements in one direction has not been perpetual throughout all past time. there have been great oscillations of level, by which a surface of dry land has been submerged to a depth of several thousand feet, and then at a period long subsequent raised again and made to emerge. nor have the regions now motionless been always at rest; and some of those which are at present the theatres of reiterated earthquakes have formerly enjoyed a long continuance of tranquillity. but, although disturbances have ceased after having long prevailed, or have recommenced after a suspension for ages, there has been no universal disruption of the earth's crust or desolation of the surface since times the most remote. the non-occurrence of such a general convulsion is proved by the perfect horizontality now retained by some of the most ancient fossiliferous strata throughout wide areas. that the subterranean forces have visited different parts of the globe at successive periods is inferred chiefly from the unconformability of strata belonging to groups of different ages. thus, for example, on the borders of wales and shropshire, we find the slaty beds of the ancient silurian system inclined and vertical, while the beds of the overlying carboniferous shale and sandstone are horizontal. all are agreed that in such a case the older set of strata had suffered great disturbance before the deposition of the newer or carboniferous beds, and that these last have never since been violently fractured, nor have ever been bent into folds, whether by sudden or continuous lateral pressure. on the other hand, the more ancient or silurian group suffered only a local derangement, and neither in wales nor elsewhere are all the rocks of that age found to be curved or vertical. in various parts of europe, for example, and particularly near lake wener in the south of sweden, and in many parts of russia, the silurian strata maintain the most perfect horizontality; and a similar observation may be made respecting limestones and shales of like antiquity in the great lake district of canada and the united states. these older rocks are still as flat and horizontal as when first formed; yet, since their origin, not only have most of the actual mountain-chains been uplifted, but some of the very rocks of which those, mountains are composed have been formed, some of them by igneous and others by aqueous action. it would be easy to multiply instances of similar unconformability in formations of other ages; but a few more will suffice. the carboniferous rocks before alluded to as horizontal on the borders of wales are vertical in the mendip hills in somersetshire, where the overlying beds of the new red sandstone are horizontal. again, in the wolds of yorkshire the lastmentioned sandstone supports on its curved and inclined beds the horizontal chalk. the chalk again is vertical on the flanks of the pyrenees, and the tertiary strata repose unconformably upon it. as almost every country supplies illustrations of the same phenomena, they who advocate the doctrine of alternate periods of disorder and repose may appeal to the facts above described, as proving that every district has been by turns convulsed by earthquakes and then respited for ages from convulsions. but so it might with equal truth be affirmed that every part of europe has been visited alternately by winter and summer, although it has always been winter and always summer in some part of the planet, and neither of these seasons has ever reigned simultaneously over the entire globe. they have been always shifting from place to place; but the vicissitudes which recur thus annually in a single spot are never allowed to interfere with the invariable uniformity of seasons throughout the whole planet. so, in regard to subterranean movements, the theory of the perpetual uniformity of the force which they exert on the earth's crust is quite consistent with the admission of their alternate development and suspension for long and indefinite periods within limited geographical areas. if, for reasons before stated, we assume a continual extinction of species and appearance of others on the globe, it will then follow that the fossils of strata formed at two distant periods on the same spot will differ even more certainly than the mineral composition of those strata. for rocks of the same kind have sometimes been reproduced in the same district after a long interval of time; whereas all the evidence derived from fossil remains is in favour of the opinion that species which have once died out have never been reproduced. the submergence, then, of land must be often attended by the commencement of a new class of sedimentary deposits, characterized by a new set of fossil animals and plants, while the reconversion of the bed of the sea into land may arrest at once and for an indefinite time the formation of geological monuments. should the land again sink, strata will again be formed; but one or many entire revolutions in animal or vegetable life may have been completed in the interval. as to the want of completeness in the fossiliferous series, which may be said to be almost universal, we have only to reflect on what has been already said of the laws governing sedimentary deposition, and those which give rise to fluctuations in the animate world, to be convinced that a very rare combination of circumstances can alone give rise to such a superposition and preservation of strata as will bear testimony to the gradual passage from one state of organic life to another. to produce such strata nothing less will be requisite than the fortunate coincidence of the following conditions: first, a never-failing supply of sediment in the same region throughout a period of vast duration; secondly, the fitness of the deposit in every part for the permanent preservation of imbedded fossils; and, thirdly, a gradual subsidence to prevent the sea or lake from being filled up and converted into land. it will appear in the chapter on coral reefs, that, in certain parts of the pacific and indian oceans, most of these conditions, if not all, are complied with, and the constant growth of coral, keeping pace with the sinking of the bottom of the sea, seems to have gone on so slowly, for such indefinite periods, that the signs of a gradual change in organic life might probably be detected in that quarter of the globe if we could explore its submarine geology. instead of the growth of coralline limestone, let us suppose, in some other place, the continuous deposition of fluviatile mud and sand, such as the ganges and brahmapootra have poured for thousands of years into the bay of bengal. part of this bay, although of considerable depth, might at length be filled up before an appreciable amount of change was effected in the fish, mollusca, and other inhabitants of the sea and neighbouring land. but if the bottom be lowered by sinking at the same rate that it is raised by fluviatile mud, the bay can never be turned into dry land. in that case one new layer of matter may be superimposed upon another for a thickness of many thousand feet, and the fossils of the inferior beds may differ greatly from those entombed in the uppermost, yet every intermediate gradation may be indicated in the passage from an older to a newer assemblage of species. granting, however, that such an unbroken sequence of monuments may thus be elaborated in certain parts of the sea, and that the strata happen to be all of them well adapted to preserve the included fossils from decomposition, how many accidents must still concur before these submarine formations will be laid open to our investigation! the whole deposit must first be raised several thousand feet, in order to bring into view the very foundation; and during the process of exposure the superior beds must not be entirely swept away by denudation. in the first place, the chances are nearly as three to one against the mere emergence of the mass above the waters, because nearly three-fourths of the globe are covered by the ocean. but if it be upheaved and made to constitute part of the dry land, it must also, before it can be available for our instruction, become part of that area already surveyed by geologists. in this small fraction of land already explored, and still very imperfectly known, we are required to find a set of strata deposited under peculiar conditions, and which, having been originally of limited extent, would have been probably much lessened by subsequent denudation. yet it is precisely because we do not encounter at every step the evidence of such gradations from one state of the organic world to another, that so many geologists have embraced the doctrine of great and sudden revolutions in the history of the animate world. not content with simply availing themselves, for the convenience of classification, of those gaps and chasms which here and there interrupt the continuity of the chronological series, as at present known, they deduce, from the frequency of these breaks in the chain of records, an irregular mode of succession in the events themselves, both in the organic and inorganic world. but, besides that some links of the chain which once existed are now entirely lost and others concealed from view, we have good reason to suspect that it was never complete originally. it may undoubtedly be said that strata have been always forming somewhere, and therefore at every moment of past time nature has added a page to her archives; but, in reference to this subject, it should be remembered that we can never hope to compile a consecutive history by gathering together monuments which were originally detached and scattered over the globe. for, as the species of organic beings contemporaneously inhabiting remote regions are distinct, the fossils of the first of several periods which may be preserved in any one country, as in america for example, will have no connection with those of a second period found in india, and will therefore no more enable us to trace the signs of a gradual change in the living creation, than a fragment of chinese history will fill up a blank in the political annals of europe. the absence of any deposits of importance containing recent shells in chili, or anywhere on the western coast of south america, naturally led mr. darwin to the conclusion that "where the bed of the sea is either stationary or rising, circumstances are far less favourable than where the level is sinking to the accumulation of conchiferous strata of sufficient thickness and extension to resist the average vast amount of denudation." [footnote: darwin's s. america, pp. 136, 139.] in like manner the beds of superficial sand, clay, and gravel, with recent shells, on the coasts of norway and sweden, where the land has risen in post-tertiary times, are so thin and scanty as to incline us to admit a similar proposition. we may in fact assume that in all cases where the bottom of the sea has been undergoing continuous elevation, the total thickness of sedimentary matter accumulating at depths suited to the habitation of most of the species of shells can never be great, nor can the deposits be thickly covered by superincumbent matter, so as to be consolidated by pressure. when they are upheaved, therefore, the waves on the beach will bear down and disperse the loose materials; whereas, if the bed of the sea subsides slowly, a mass of strata, containing abundance of such species as live at moderate depths, may be formed and may increase in thickness to any amount. it may also extend horizontally over a broad area, as the water gradually encroaches on the subsiding land. hence it will follow that great violations of continuity in the chronological series of fossiliferous rocks will always exist, and the imperfection of the record, though lessened, will never be removed by future discoveries. for not only will no deposits originate on the dry land, but those formed in the sea near land, which is undergoing constant upheaval, will usually be too slight in thickness to endure for ages. in proportion as we become acquainted with larger geographical areas, many of the gaps, by which a chronological table, like that given at page 135, is rendered defective, will be removed. we were enabled by aid of the labours of prof. sedgwick and sir roderick murchison to intercalate, in 1838, the marine strata of the devonian period, with their fossil shells, corals, and fish, between the silurian and carboniferous rocks. previously the marine fauna of these lastmentioned formations wanted the connecting links which now render the passage from the one to the other much less abrupt. in like manner the upper miocene has no representative in england, but in france, germany, and switzerland it constitutes a most instructive link between the living creation and the middle of the great tertiary period. still we must expect, for reasons before stated, that chasms will for ever continue to occur, in some parts of our sedimentary series. concluding remarks on the consistency of the theory of gradual change with the existence of great breaks in the series.--to return to the general argument pursued in this chapter, it is assumed, for reasons above explained, that a slow change of species is in simultaneous operation everywhere throughout the habitable surface of sea and land; whereas the fossilisation of plants and animals is confined to those areas where new strata are produced. these areas, as we have seen, are always shifting their position, so that the fossilising process, by means of which the commemoration of the particular state of the organic world, at any given time, is effected, may be said to move about, visiting and revisiting different tracts in succession. to make still more clear the supposed working of this machinery, i shall compare it to a somewhat analogous case that might be imagined to occur in the history of human affairs. let the mortality of the population of a large country represent the successive extinction of species, and the births of new individuals the introduction of new species. while these fluctuations are gradually taking place everywhere, suppose commissioners to be appointed to visit each province of the country in succession, taking an exact account of the number, names, and individual peculiarities of all the inhabitants, and leaving in each district a register containing a record of this information. if, after the completion of one census, another is immediately made on the same plan, and then another, there will at last be a series of statistical documents in each province. when those belonging to any one province are arranged in chronological order, the contents of such as stand next to each other will differ according to the length of the intervals of time between the taking of each census. if, for example, there are sixty provinces, and all the registers are made in a single year and renewed annually, the number of births and deaths will be so small, in proportion to the whole of the inhabitants, during the interval between the compiling of two consecutive documents, that the individuals described in such documents will be nearly identical; whereas, if the survey of each of the sixty provinces occupies all the commissioners for a whole year, so that they are unable to revisit the same place until the expiration of sixty years, there will then be an almost entire discordance between the persons enumerated in two consecutive registers in the same province. there are, undoubtedly, other causes, besides the mere quantity of time, which may augment or diminish the amount of discrepancy. thus, at some periods a pestilential disease may have lessened the average duration of human life; or a variety of circumstances may have caused the births to be unusually numerous, and the population to multiply; or a province may be suddenly colonised by persons migrating from surrounding districts. these exceptions may be compared to the accelerated rate of fluctuations in the fauna and flora of a particular region, in which the climate and physical geography may be undergoing an extraordinary degree of alteration. but i must remind the reader that the case above proposed has no pretensions to be regarded as an exact parallel to the geological phenomena which i desire to illustrate; for the commissioners are supposed to visit the different provinces in rotation; whereas the commemorating processes by which organic remains become fossilised, although they are always shifting from one area to the other, are yet very irregular in their movements. they may abandon and revisit many spaces again and again, before they once approach another district; and, besides this source of irregularity, it may often happen that, while the depositing process is suspended, denudation may take place, which may be compared to the occasional destruction by fire or other causes of some of the statistical documents before mentioned. it is evident that where such accidents occur the want of continuity in the series may become indefinitely great, and that the monuments which follow next in succession will by no means be equidistant from each other in point of time. if this train of reasoning be admitted, the occasional distinctness of the fossil remains, in formations immediately in contact, would be a necessary consequence of the existing laws of sedimentary deposition and subterranean movement, accompanied by a constant dying-out and renovation of 'species. as all the conclusions above insisted on are directly opposed to opinions still popular, i shall add another comparison, in the hope of preventing any possible misapprehension of the argument. suppose we had discovered two buried cities at the foot of vesuvius, immediately superimposed upon each other, with a great mass of tuff and lava intervening, just as portici and resina, if now covered with ashes, would overlie herculaneum. an antiquary might possibly be entitled to infer, from the inscriptions on public edifices, that the inhabitants of the inferior and older city were greeks, and those of the modern towns italians. but he would reason vary hastily if he also concluded from these data, that there had been a sudden change from the greek to the italian language in campania. but if he afterwards found three buried cities, one above the other, the intermediate one being roman, while, as in the former example, the lowest was greek and the uppermost italian, he would then perceive the fallacy of his former opinion, and would begin to suspect that the catastrophes, by which the cities were inhumed might have no relation whatever to the fluctuations in the language of the inhabitants; and that, as the roman tongue had evidently intervened between the greek and italian, so many other dialects may have been spoken in succession, and the passage from the greek to the italian may have been very gradual, some terms growing obsolete, while others were introduced from time to time. if this antiquary could have shown that the volcanic paroxysms of vesuvius were so governed as that cities should be buried one above the other, just as often as any variation occurred in the language of the inhabitants, then, indeed, the abrupt passage from a greek to a roman, and from a roman to an italian city, would afford proof of fluctuations no less sudden in the language of the people. so, in geology, if we could assume that it is part of the plan of nature to preserve, in every region of the globe, an unbroken series of monuments to commemorate the vicissitudes of the organic creation, we might infer the sudden extirpation of species, and the simultaneous introduction o! others, as often as two formations in contact are found to include dissimilar organic fossils. but we must shut our eyes to the whole economy of the existing causes, aqueous, igneous, and organic, if we fail to perceive that such is not the plan of nature. i shall now conclude the discussion of a question with which we have been occupied since the beginning of the fifth chapter--namely, whether there has been any interruption, from the remotest periods, of one uniform and continuous system of change in the animate and inanimate world. we were induced to enter into that enquiry by reflecting how much the progress of opinion in geology had been influenced by the assumption that the analogy was slight in kind, and still more slight in degree, between the cases which produced the former revolutions of the globe, and those now in every-day operation. it appeared clear that the earlier geologists had not only a scanty acquaintance with existing changes, but were singularly unconscious of the amount of their ignorance. with the presumption naturally inspired by this unconsciousness, they had no hesitation in deciding at once that time could never enable the existing powers of nature to work out changes of great magnitude, still less such important revolutions as those which are brought to light by geology. they therefore felt themselves at liberty to indulge their imaginations in guessing at what might be, rather than enquiring what is; in other words, they employed themselves in conjecturing what might have been the course of nature at a remote period, rather than in the investigation of what was the course of nature in their own times. it appeared to them far more philosophical to speculate on the possibilities of the past, than patiently to explore the realities of the present; and having invented theories under the influence of such maxims, they were consistently unwilling to test their validity by the criterion of their accordance with the ordinary operations of nature. on the contrary. the claims of each new hypothesis to credibility appeared enhanced by the great contrast, in kind or intensity, of the causes referred to and those now in operation. never was there a dogma more calculated to foster indolence, and to blunt the keen edge of curiosity, than this assumption of the discordance between the ancient and existing causes of change. it produced a state of mind unfavourable in the highest degree to the candid reception of the evidence of those minute but incessant alterations which every part of the earth's surface is undergoing, and by which the condition of its living inhabitants is continually made to vary. the student, instead of being encouraged with the hope of interpreting the enigmas presented to him in the earth's structure--instead of being prompted to undertake laborious enquiries into the natural history of the organic world, and the complicated effects of the igneous and aqueous causes now in operation--was taught to despond from the first. geology, it was affirmed, could never rise to the rank of an exact science; the greater number of phenomena must for ever remain inexplicable, or only be partially elucidated by ingenious conjectures. even the mystery which invested the subject was said to constitute one of its principal charms, affording, as it did, full scope to the fancy to indulge in a boundless field of speculation. the course directly opposed to this method of philosophising consists in an earnest and patient enquiry, how far geological appearances are reconcilable with the effect of changes now in progress, or which may be in progress in regions inaccessible to us, but of which the reality is attested by volcanos and subterranean movements. it also endeavours to estimate the aggregate result of ordinary operations multiplied by time, and cherishes a sanguine hope that the resources to be derived from observation and experiment, or from the study of nature such as she now is, are very far from being exhausted. for this reason all theories are rejected which involve the assumption of sudden and violent catastrophes and revolutions of the whole earth, and its inhabitants--theories which are restrained by no reference to existing analogies, and in which a desire is manifested to cut, rather than patiently to untie, the gordian knot. we have now, at least, the advantage of knowing, from experience, that an opposite method has always put geologists on the road that leads to truth--suggesting views which, although imperfect at first, have been found capable of improvement, until at last adopted by universal consent; while the method of speculating on a former distinct state of things and causes has led invariably to a multitude of contradictory systems, which have been overthrown one after the other--have been found incapable of modification--and which have often required to be precisely reversed. the remainder of this work will be devoted to an investigation of the changes now going on in the crust of the earth and its inhabitants. the importance which the student will attach to such researches will mainly depend on the degree of confidence which he feels in the principles above expounded. if he firmly believes in the resemblance or identity of the ancient and present system of terrestrial changes, he will regard every fact collected respecting the cause in diurnal action as affording him a key to the interpretation of some mystery in the past. events which have occurred at the most distant periods in the animate and inanimate world will be acknowledged to throw light on each other, and the deficiency of our information respecting some of the most obscure parts of the present creation will be removed. for as, by studying the external configuration of the existing land and its inhabitants, we may restore in imagination the appearance of the ancient continents which have passed away, so may we obtain from the deposits of ancient seas and lakes an insight into the nature of the subaqueous processes now in operation, and of many forms of organic life which, though now existing, are veiled from sight. rocks, also, produced by subterranean fire in former ages, at great depths in the bowels of the earth, present us, when upraised by gradual movements, and exposed to the light of heaven, with an image of those changes which the deep-seated volcano may now occasion in the nether regions. thus, although we are mere sojourner's on the surface of the planet, chained to a mere point in space, enduring but for a moment of time, the human mind is not only enabled to number worlds beyond the unassisted ken of mortal eye, but to trace the events of indefinite ages before the creation of our race, and is not even withheld from penetrating into the dark secrets of the ocean, or the interior of the solid globe; free, like the spirit which the poet described as animating the universe, ------ire per omnes terrasque, tractusque maris, ccelumque profisndutn. [footnote: "to go through all binds, and the tracts of the ocean, and the boundless heaven."] 