SIR WILLIAM ROBERTS ON DIGESTION.

SIR WILLIAM ROBERTS, of London, the great authority on digestion, says: "The digestive change undergone by fatty matter in the small intestines consists mainly in its reduction into a state of emulsion or division into infinitely minute particles. In addition to this purely physical change, 'a small portion undergoes a chemical change whereby the glycerine and fatty acids are dissociated. The main or principal change is undoubtedly an emulsifying process, and nearly all the fat taken up by the lacteals is simply in a state of emulsion.”

This eminent authority is confirmed in the foregoing view by various experiments by which it has been ascertained that fat foods pass from the lacteals into the circulation by way of the thoracic duct in the form of an emulsion.

Emulsified cod liver oil as contained in Scott's Emulsion appears in a form so closely resembling the product of natural digestion-as it occurs within the body-that it may well be administered as an artificially digested fat food of the very highest type. In combination with the other ingredients mentioned-glycerine being an emollient of inestimable value-Scott's Emulsion offers to the physician a valuable, exquisite and rare accession to his prescription list.

Sanmetto in Cystitis, Urethritis, and in Inflammation of Bladder Neck, also in Impotency.-My experience with Sanmetto has been most satisfactory, from the fact that I have been enabled to get favorable results with my patients. I have used it in a variety of cases during the last ten years, as cystitis, urethritis and inflammation of neck of bladder. As a remedy in impotency I know of nothing of superior efficacy. I do not keep a clinical record of my cases, so am unable to give reports in full detail. I can, however, heartily recommend Sanmetto to the medical profession as a remedy that has no superior where indicated, if faithfully used by the afflicted.-F. M. Abbett, M.D., Indianapolis, Ind.

The Cramer X-Ray Plate. In these days when surgeons employ the cathode rays in many cases of obscure surgery, it should be borne in mind that for purposes of record and illustration of clinical histories, the X-ray plate as made by The Cramer Dry Plate Co., Limited, of St. Louis, Mo., is the plate par excellence. It gives a beautiful print and will be found to accurately represent the condition present. They are not only accurate, but are exceedingly sensitive, though not expensive. A very large number of medical men take amusement out of photography in its different branches. For amateur work the Cramer Crown Plate is one of the very best, is easily handled in the dark-room, gives depth and sharpness to the picture, and will never be found to be specky as some other plates are. The Cramer Banner is also a grand plate, though hardly so fast, and is better suited where long exposure is desired in dull weather. The Cramer Plates were used exclusively at the Pan-American Exposition at Buffalo. The quality of Cramer Plates has been continually improved, till to-day they are better than ever and the demand is ever increasing.

Journal of Medicine and Surgery

A JOURNAL PUBLISHED MONTHLY IN THE INTEREST OF
MEDICINE AND SURGERY

VOL. XVI.

TORONTO, DECEMBER, 1904.

NO. 6.

Original Contributions.

COMPLICATIONS OF FRACTURES AND AMPUTATIONS.

BY THOMAS H. MANLEY, PH.D., M.D.,

Visiting Surgeon to Harlem and Metropolitan Hospitals, New York.

Ir has been my custom in hospital and private practice to endeavor to demonstrate that conservatism is not only the most humane, but the safest course to pursue, when a limb has been so shattered that the question of amputation may arise; and adopt those means by which, when properly utilized, primary amputation may be abandoned altogether in civil life. The mangled limb has been cleansed, hemorrhage subdued, and comfortable dressings applied, and our patient placed in bed. We wait and observe the limb, for, in many cases, time alone will determine its fate. Now, in order to afford our patient the best prospects, not only is it necessary to clearly understand what the phenomena of mortification and gangrene are, but to anticipate their onset; and should they appear be prepared to intelligently interpret the signs which precede them.

It is likewise highly important that the various phases of asphyxiation or decomposition about to set in are early recognized and actively treated, on such lines as the changes in the anatomical elements indicate. Without being thus prepared for the rational and skilful management of such cases, probably our patient's prospects would have been equally as good, or better, had the damaged limb been immediately sacrificed after injury. It may be observed that immediately after a grave injury to a limb, there are no symptoms or signs by which it is possible to estimate with precision the degree of vitality remaining.

The limb in common with the, whole body is cold; after reaction sets in, heat, may return completely or partly. It may remain icy cold. When this frigid state of the limb persists more than forty-eight hours, it is a certain precursor of mortification.

Dupuytren was the first who called attention to the importance of this symptom in prognosis here. He found by the use of the thermometer that the temperature in a limb about to mortify is lower than that in the dead body, and that of the surrounding atmosphere. When along with this abstraction of heat, sensation is lost, a greenish-gray color covers the skin, and a gaseous crepitation is felt under it, the parts are hopelessly mortified, and decomposition is advancing.

Happily in a considerable number this advent of mortification. is not so sudden, the temperature gradually lowers; here and there are other significant symptoms that will warn us of its approach. A gradual diminution in sensation, with changes of color in the skin, especially near the toes, with total loss of power in the damaged limb, is often a forerunner of mortification when the lower extremity is damaged. But it is important to know that the behavior of a gravely traumatized limb, in the beginning, varies; a badly injured limb is much like a grave injury of the body, of which it is but an appendage.

For example, in some instances, one is killed outright; in others, after a varying period, deep shock passes off and the patient recovers; in others, again, full reaction never sets in, but collapse gradually deepens and the patient sinks.

So in some crushes of a limb; it may be killed outright, as it were, animation never returning. In others, the member is but temporarily devitalized; there is a species of "suspended animation," the circulation returning after varying intervals. In another class there is but an imperfect return of the vital processes, and death of the limb sets in. This last type, in my experience, is alarmingly mortal to the tissues and calls for prompt amputation.

Traumatic Gangrene.-This type of diseased action is frequently encountered after nearly every description of serious injury of an extremity or any of its appendages. As it is dependent on a variety of causes, so it presents a considerable diversity of phases. Its fundamental etiological factors are chiefly two: (1) Violence to the tissues, mechanical disorganization; (2) chemicoseptic changes consecutive to injury. As an illustration, great violence being applied to a limb, its main arterial trunk is damaged and the vitality of the parts is imperilled by anemia and impending asphyxia, until the collateral circulation is established, which is not enough, perchance, to preserve and nourish all the distant parts. The too tight application of a splint, in a fracture, may shut off the lumina of the

larger vessels, when the parts supplied by them maintain thereafter a feeble existence or perish. In certain fractures, a spicula of bone crushes through the trunk of a large artery, and thereby so impedes the circulation to parts beyond that the surface tissues may part with their vitality.

In another class, violence favors the development of gangrene by impairing the vitality of the parts on which it falls; vessels are torn open, nerves lacerated and muscles severely contused. Therefore, an injury, per se, is an active cause of gangrene, varying in its effects, according to circumstances.

But in a large member, force is only the proximate cause. The deep parts are opened; a stagnant congested state of the circulation exists over the seat of injury, inflammatory changes have begun. The tissues are but feebly resistant to eccentric influences, and changes of decomposition commence; toxic elements have penetrated from without. There is undoubtedly toxic infection; bio-chemical or microchemical changes are in operation. Whether, indeed, the entrance of some specific germ is the first step in gangrenous changes, or it is brought about through chemical influences stimulated into activity through the action of the atmosphere on feebly vitalized tissues is immaterial.

Modern bacteriological studies would seem to prove that infection of pathogenic germs is alone responsible for the primary pathological changes; but it is well known that the atmosphere plays an important role, as does also the general condition of the patient; above all, in diabetes and in tubercular subjects.

The symptoms which indicate the approach of traumatic gangrene in a limb in serious injuries are general and local. With the onset of those inflammatory changes which precede the sloughing or devitalization of the tissues, a well-marked chill, is experienced, the temperature rises and the pulse quickness; the appetite is lost and thirst is urgent. General debility is marked and the patient sleeps little. These are the usual concomitant disturbances noted, though there are occasional instances in which gangrene sets in, in the most subtle, insidious manner. The day before, the limb may have presented all the signs of a healthy vitality, but, after an interval of twenty-four, or forty-eight hours, on removing the dressings, we are appalled to find an extensive area cold, insensitive and dead. Such cases, however, are very rare indeed; and if we investigate them we discover, as a rule, that some oversight has been committed, that nature's danger signal, great pain, was blunted or destroyed by over-dosing with morphine; that the case was injudiciously treated, or neglected, until too late.

Of the local subjective symptoms, there is one whose significance is of more importance than all the others combined. That symptom is pain, not of a moderate, intermittent description, but