About four weeks after he had to quit work, as his eye again became inflamed and painful, although under treatment, found no relief except in morphine. I saw him on December 7th. Eye inflamed, intense photophobia, a cicatrix on cornea extending to the ciliary body, anterior synechia and the eye-ball very sensitive to the touch. Some intollerance of light in left eye, with unpleasant sensation and some · lachrymation, evidently in sympathy with the right eye. I advised the immediate enucleation of the right eye, to which he consented. The night following he slept more comfortably than he had for two months before. The sympathetic irritation that had taken place in the left eye required months of careful treatment before it was restored to its normal condition. A great responsibility rests upon a surgeon who has charge of a case where an eye has been seriously injured. If a foreign body, such as a piece of iron, percussion cap, or any hard substance has penetrated the eye, and remains there, there is danger of the fellow eye, sooner or later, becoming sympathetically affected. Or if the injury is of such a character as to involve the ciliary body; or if the eyeball is wounded in such a way that in healing the iris or ciliary nerves are included in the cicatrix, then there is great danger of sympathetic trouble being developed in the other eye. But an eye may be seriously injured, the injury involving the cornea, iris and crystalline lens, and even the ciliary body, and yet may, by judicious treatment, be restored to usefulness. An eye with only partial sight is infinitely better than an artificial eye, when the cosmetic effect is not to be taken into consideration. Hence, we should deliberate carefully before determining on enucleation. The following condensed cases will illustrate this point. Mr. G. M.—, æt. 27, Davidson County, on April 19, 1878, was struck on left eye by a stick, the sharp end cutting through the cornea, and sight was almost instantly lost. I saw him about ten hours after the accident. Found a ragged wound in the cornea, almost in the horizontal diameter, extending from a point near the temporal margin across into the sclerotic at the inner angle, the iris lacerated and pressed out into the wound, and the wound filled with clotted blood. Could see light faintly. After a careful examination I concluded I would try to save the eye, but stated that there was a possibility of its having to be enucleated. He stated that he had consulted two other surgeons who advised immediate enucleation. I removed as much of the clotted blood as I could, then snipped off the protruding iris 360 ORIGINAL COMMUNICATIONS-SINCLAIR. and used cold water dressing, and as he was of rather full habit, I ordered two leeches to the temple, gave him a dose of morphine to be taken at bed time, and instilled into the eye a few drops of a solution of atropia sulph. Ordered the patient to be kept quiet in a mod erately darkened room. He made a good recovery with useful vision. I saw him a few months ago, and he has had no trouble with the eye since the accident. Mr. M—, æt. 31, foreman in the Southeastern Railroad shops, while superintending the repairs of an engine, in 1878, was struck on the right eye by a fragment of iron, cutting through the cornea near the sclero-corneal junction, extending to the center of the cornea, then at a slight angle almost to its periphery, lacerating the iris and wounding the capsule of the lens, as was demonstrated in a few days by an opaque lens. The ragged edges of the iris were pressed out into the wound in the cornea, and the anterior chamber filled with blood. Treatment.—The protruding parts of the iris were drawn a little further out and snipped off with the scissors freeing it from the wounds, and as much of the clotted blood removed as was possible. Ordered a few drops of a sol of sulph. atropia to be dropped into the eye every four hours, and cold compress. Patient ordered to be kept quiet in a moderately darkened room. This patient made a good recovery and has had no trouble since the accident. Mr. D. R.—, æt. 36, of Hickman County, a contractor, while superintending the building of a furnace, in October, 1881, was struck on the left eye by a small piece of steel from a hammer that one of his men was using in driving a large spike. It passed through the cornea near the sclero-corneal junction, lacerating the iris and rested upon the capsule of the lens. I found him suffering from severe pain in the eyeball and supra-orbital region. Eye inflamed, lymph thrown out in the pupil so that he had bare perception of light, and iris engaged in the wound in the cornea. Made section with Græfe's knife, entering the knife in the wound at the lower and outer quadrant of the cornea, making a free iridectomy, and removed the foreign body. Found some symptoms of traumatic cataract, but thought best not to remove the lens. Used a four grain sol. atropia and applied a bandage, gave hypodermic injection of morphine, and ordered two pil. cath. co., as his bowels had not been moved for two days. He made a good recovery, except that the lens was removed by absorption. Have seen him several times since I discharged him, and he has never had any trouble. In all these cases of severe injury to the eye the treatment was not antiseptic, and the results will bear favorable comparison with the antiseptic treatment of to-day in like cases. PYÆMIA AND SEPTICEMIA.* BY J. M. ALEXANDER, M.D., OF FLAT CREEK, TENN. As the subject under consideration involves the blood, a short analysis of its normal condition will not be deemed inappropriate. The blood whilst circulating in living vessels consists of two parts, a thin, transparent, (nearly colorless) liquid termed liquor sanguinis, and a number of small bodies called red corpuscles, from which the color of the blood in vertebrated animals derives its peculiar hue; in addition to which is found some white or colorless corpuscles. When the blood is drawn from a living body and let stand for a short time it separates into two parts, by a spontaneous coagulation, forming the crassmentum or clot, and serum. A mean proportion of the ingredients entering into and constituting the clot and serum are thus stated by physiologists : Fibrin, 3 parts; albumen, 80 parts; red corpuscles, 127 parts; water and salts, 790 parts per 1,000. There are also small proportions of fatty matter and extractives. These proportions are snbject to considerable variations within the limits of health. This fluid, the pabulum of life, is sent by the heart to the minutest ramifications of the tissues of the body, laden with nutrient material for the repair of the wasted tissues, and with the broken down or effete matter which has served the purposes of the economy, and is dropped into the stream to be separated and discharged from it by the proper organs. So much by way of introduction to an intelligent understanding of our subject, which embraces the consideration of phenomena arising from the *An essay read before the Bedford County Medical Society and published in the THE SOUTHERN PRACTITIONER by request of the Society. 362 ORIGINAL COMMUNICATIONS-ALEXANDER. introduction into this living stream, products that act as poisons, and change not only its physiological but probably its chemical condition. The morbid products which may enter the blood are of two kinds, viz. : those formed within the body of the person affected, autogenetic; those formed without or in the body of another person, heterogenetic. Pyæmia is a name given by Piorry to one of these products. The name signifies pus in the blood. "Purulent infection" of the blood is a synonymous phrase. It was supposed by those who first investigated the subject, the pus entered the blood without disintegration of its corpuscular constituents, and it was the result of such belief, that after it gained access in this way to the current of the blood, that it was deposited at different points, and that in this way was produced those purulent collections called "metastatic abscesses." After the advent of microscopy in biological and pathological research, it was thought the pus corpuscles were too large to enter the circulation through the coats of the blood vessels, and the only way they could enter the circulation was through rents in the coats of the blood vessels caused by ulceration or wounds. Moreover, it seemed apparent that pus corpuscles and the white corpuscles of the blood were identical, and the name Leucocytes were applied to both. But later researches have demonstrated the presence in the blood of Leucocytes in excessive quantities, as in leucocythemia, but not accompanied by the symptomatic phenomena of pyæmia, therefore these facts do not meet the conditions of the problem and we will have to look elsewhere for the cause of pyæmia. Admitting the white corpuscles of the blood and pus corpuscles to be identical, it is denied that the presence of pus corpuscles in the blood is sufficient to produce pyæmia, or in other words they do not constitute the essential morbid element in pyæmia. As tending to support the doctrine of pyæmia, microscopic observations of a more recent date seem to demonstrate, that abscesses in different situations consist in part of leucocytes or white corpuscles, which under conditions of disease do pass through the coats of the blood vessels without solution of continuity, and are deposited in the surrounding tissues. It is claimed that their passage through the coats of the blood vessels. thus circumstanced has been demonstrated by actual observation, therefore the passage of pus cells, or rather their absorption, should no longer be considered a physical impossibility. That pus corpuscles do enter the circulation through orifices in the blood vessels made either by wounds or ulceration is an admitted fact, and that the phenomena of pyæmia are most apt to follow when the entrance of pus in this way is most apt to occur, viz.: in certain diseases of the bones. Again, while the leucocytes and pus corpuscles are identical, so far as the microscope enables us to discover, it is easy for us to understand that the latter may have acquired toxical properties that do not belong to the former, properties not appreciable by the microscope or chemistry; in these properties may consist their pathogenetic power. In fact, it is not right to consider the corpuscular element as alone constituting pus. The liquor puris is an essential constituent in the purulent liquid as is liquor sanguinis in blood. It is not unlikely, therefore, that liquor puris is the toxic principle. Further, the injection of liquor puris into the blood of lower animals will produce the phenomena of pyæmia in life, and the anatomical characters after death. These facts go far to sustain the inference, that the cause of pyæmia is really purulent infection of the blood. When we come to consider it from a clinical point of view, pyæmia indicates an affection involving a specific morbid condition of the blood, and presents certain distinctive features relative to its causation, its symptoms, its course, and the post mortem appearances. Generally, the causation is distinctly traumatic, most of the cases follow an accidental wound or surgical operation, more especially if the larger bones are involved. It some times follows inflammations that are not traumatic. It is one of the affections included in puerperal fever -that is, it sometimes arises from morbid uterine conditions shortly after parturition. It occurs occasionally as an idiopathic condition, so called. In cases that are typical, it follows consecutively a wound or surgical operation, and does not manifest itself until after several days from receipt of wound or surgical operation, in the mean time the wound becomes tender and painful |