SMITHSONIAN MISCELLANEOUS COLLECTIONS.
300
THE TONER LECTURES
IK8TITTJTED TO ENCOURAGE THE DISCOVERT OF NEW TRUTHS
FOR THE ADVANCEMENT OP MEDICINE.
Lecture V.
ON THE SURGICAL COMPLICATIONS AND SEQUELS OF
THE CONTINUED FEVERS.
WILLIAM W. KEEN, M.D.,
OF PHILADELPHIA.
DELIVERED FEBRUARY 17. 1878.
WASHINGTON:
SMITHSONIAN INSTITUTION.
MARCH, 1S77.
I
ADVERTISEMENT.
The "Toner Lectures" have been instituted at Washington,
D. C, by Joseph M. Toner, M.D., who has placed in charge of
a Board of Trustees, consisting of the Secretary of the Smith-
sonian Institution, tlie Surgeon-General of the United States
Army, the Surgeoji-General of the United States Navy, and
the President of the Medical Society of the District of Colum-
bia, a fund, "the interest of which is to be applied for at least
two annual memoirs or essays relative to some branch of medi-
cal science, and containing some new truth fully established by
experiment or observation."
As these lectures are intended to increase and diffuse knowl-
edge, they have been accepted for publication by the Smith-
sonian Institution in its " Miscellaneous Collections."
The First Lecture of this series was delivered March 28,
18T3, by Dr. J. J. Woodward, "On the Structure of Cancer-
ous Tumors and the Mode in which adjacent parts are invaded."
Published by the Smithsonian Institution, November, 18V3.
44 pp. 8vo.
The Second Lecture was delivered April 22, 1874, by Dr.
C. E. Brown-Sequard, on the " Dual Character of the Brain."
Published by the Smithsonian Institution, Januar}^, 1877. 25
pp. 8vo.
The Third Lecture was delivered May 14, 1874, by Dr. J.
M. Da Costa, on " Strain and Over-Action of the Heart."
Published by the Institution, August, 1874. 32 pp. 8vo.
(iii)
IV ADVERTISEMENT.
The Fourth Lecture was delivered January 20, ISVS, by
Dr. Horatio C. Wood, on " A Study of the Nature and Me-
chanism of Fever." Published by the Institution, February,
1875. 48 pp. 8vo.
JOSEPH HENRY,
Secreta7'y Smithsonian Institution.
Smithsonian Institution,
Washington, April, ISIt.
LECTURE V.
Delivered February 17, 18761
ON THE SURGICAL COMPLICATIONS AND SEQUELS OP THE
CONTINUED FEVERS.
By William W. Keen, M.D.,
OP PHILADELPHIA.
The province of the physician and that of the surgeon are,
in general, sufficiently sharply defined and differentiated, yet
they have many points of contact. "While some diseases belong
exclusively to the province of the one, and some to that of the
other, other diseases may fall with equal propriety under the
care of either practitioner. Still another class of cases, how-
ever, beginning in the domain of Medicine, may terminate in
that of Surgery, and we may lack their complete history from
the very fact of this division of their care and interest.
Among the diseases classed as strictly medical, none deserve
the appellation more definitely than the continued fevers, and
especially T^-phus and Typhoid. Yet I hope to show that
fevers ai'e not infrequently the cause of the gravest and least
expected surgical troubles, mention of which is generally
omitted, even in our best text-books on medicine, still more
rarely noticed in works on surgery, and where noticed, it is
only with the greatest brevity.^
' " The cases of constitutional disease discovered by fever might serve
to illustrate a large part of the convalescence of fever, a subject of the
highest interest and full of promise of utility to one who will carefully
study it. The sequelse of scarlet fever are commonly enumerated ; those
of typhoid fever, especially those seen in surgical practice, are scarcely
less numerous, but seem less known." Just as this is going to press, I
find the above remarks by Sir James Paget, in his extremely interesting
Clinical Lectures and Essays, London, 1875, p. 378.
1 (1)
2 THE TONER LECTURES.
My attention having been called to tlie matter, b}'' several
personal cases, I have been led to study the subject, and I
desire now to record briefly the results of an extensive search
of medical and surgical works as well as the records of indi-
vidual cases, in the hope that by grouping together many
isolated instances, I may be able to contribute somewhat to
our exact knowledge of the surgical complications and sequels
of the continued fevers, both as to their causes, the means of
their early recognition, the best methods of treatment, and if
possible that still higher object, the averting of dangers which
otherwise may prove disastrous to health, and too often to life
itself.
The exanthematous fevers are better known as causes of
surgical troubles, and I have therefore carefully excluded them
as well as a few cases following intermittent fevers.
1 shall omit entirely all well-known results of a semi-surgical
character, such as hemorrhage from the nose and bowels, peri-
tonitis, with or witliout perforation, erysipelas, a not infrequent
complication about the face, or when bedsores exist, and cases
of thrombosis of the veins, which causes a variety of phleg-
masia deserving a more extended study than it has yet received,^
Bedsores and the ordinary abscesses are too well known to
demand other than passing allusions. Much as I regret to do
so, I must also omit, from want of time, the consideration
of the forms of disease which especially interest the ophthal-
mic surgeon. Ulceration and perforation of the cornea are
briefly, but I may say completely, treated by Trousseau.*
Post-febrile ophthalmia or amaurosis, a peculiar retino-choroi-
ditis which follows only relapsing fever, first described by
Hewson in 1814, and Wallace in 182T, has been so carefully
' See Bibliography " Phlegmasia," where I have grouped the most
important references.
2 Clinique Med. de I'Hotel-Dieu, 2d ed., p. 271, and Gaz. des Hop.,
1856, 170.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 3
studied of late by ophthalmic writers, as to leave but little
fiirtlier to be said, and I must refer those who desire to study
it to the appended Bibliograph3^
I shall include only such cases as diseases of the joints,
oedema glottidis and necrosis of the cartilages of the larjaix,
which often require tracheotom}', necrosis of the bones, gan-
grene of the extremities and other parts, fistulce of various
kinds, and tlie like.
The records of many cases are extremely imperfect, some
in fact are mere allusions, and I have been compelled therefore,
in tabulating them, to come as near tlie truth as may be. The
frequency of many symptoms is therefore greater than appears
from my tables. Especially is it difficult to discriminate
between tj-phus and typhoid fevers as causes. The earlier
cases, before the essential abdominal lesion of typhoid was
recognized, are all classed as t^'phus, and even to-da}'' man>'
cases, especially in German books and journals, are briefly
called " typhus," meaning "t^'phus abdominalis," i.e., typhoid.
If any error exist, therefoi'e, it will consist in assigning too
many cases to typhus proper, for I did not feel permitted to go
back of the record unless plainly authorized to do so by the
history or the post-mortem.
I. DISEASES OP THE JOINTS.
Two forms of disease of the joints are found, first a i^oly-
articular inflammation, which may assume either a rheumatic
or a pyemic form ; and, secondly, a monarticular inflammation.
The rheumatic variety I shall at once dismiss. The pyemic
form of inflammation is not ver}^ common, for Murchison, with
his immense experience in the London Fever Hospital, has
seen but one case. It follows the usual course of pyemia,
both in its symptoms and its usually fatal issue. Hnss and
others have referred it to suppurative phlebitis from bedsores,
4 THE TONER LECTURES.
parotitis, etc., but it lias been observed in cases in which no
such complication existed. Pyemic arthritis, like the gangrene
from pressure, parotitis, etc., is most apt to occur in severe
cases, in which the blood change is at its maximum, and the
" typhous crasis," as Stokes has expressed it, possibly becomes
converted into p3'emia.
It is, however, the monarticular form, which will most inte-
rest us. It affects the larger joints, such as the elbow and
shoulder, the ankle and knee, but above all the hip. The
pain is usually slight. The swelling is generally readily
observed in all joints except the hip and the shoulder, where it
is probably obscured by the muscular masses about these
joints combined with the tardy increase in the swelling. Usu-
ally it arises spontaneouslj', but occasionally from periostitis
or necrosis extending into the joint. It rarely produces sup-
purative or fistulous openings. The result is, therefore, gene-
rally a gradual return to usefulness, although in 3 cases I
have found anchylosis. Of 43 cases, the lower extremities
were affected in 39, the upper in only 1, 3 of the cases involv-
ing a joint in both, for occasionally two large joints are affected
at once. Arthritis, therefore, resembles other surgical febrile
affections, such as gangrene, necrosis, etc., in affecting mainly
the lower extremities, as do also thrombosis and the ordinary'-
oedema. The frequency of these joint troubles is not great.
According to Giiter'bock, in a series of years in the Charite
(Berlin) and the Hamburg Hospitals, not a case occurred, and
in the Vienna General Hospital from 1808 to 1871 onl}^ 2 cases
among 3130. Murchison does not even name this complication
at all, nor do any other of our text-books, either on surgery
or practice, except a few lines by Tolkmann, in Pitha and
Billroth's Ilandbuch. Giiterbock and Hellwig are the only
authors who have treated them at all fu-Uy. Yet that they are
of great importance, and demand our utmost attention, will be
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 5
seen at once when we consider that of the 43 cases named,
spontaneous dislocations occiu-red twenty-seven times in the
hip, twice in tlie shoulder, and once in the knee.
These dislocations require more particular notice. From
their similarity to febrile arthritis in the same and other
joints their pathology seems clear, although—in singular
contrast to the strangely fatal laryngeal stenosis I shall soon
consider—not a single death has occurred, and therefore no
post-mortem verification has been possible. They belong to
the class of " Distension-luxations." That the cause is not the
specific poison is evident, since similar results follow other and
dissimilar diseases, such as locomotor ataxia, the exanthe-
matous fevers, hemiplegia, sciatica, and rheumatism, as pointed
out by Stanley in 1841.'
Usually in the period of convalescence, following, therefore,
the prolonged exhaustion, there arises a subacute synovitis
with a gradual serous distension of the capsular ligament,
which, having reached a certain point, may slowly subside, and
no further evil follow. In 3 cases, however, this burst exter-
nallj', producing sinuses, but in none of them was the dis-
charge purulent. The main result is a slow, generally unper-
ceived, elongation of the ligaments, e. g. of the hip, with perhaps
also a swelling of the so-called gland at the bottom of the
acetabulum. This distension will spend its force mainly poste-
riorly, since the inverted Y ligament reenforces the capsular
ligament in front. Given this condition, the slightest force
will dislocate the head of the femur upwards and backwards
on the dorsum of the ilium. In one case a fall to the floor
produced it, in three others turning over in bed, and twice the
lifting of the patient in the arms from one bed to another.
' On dislocation espec. of the hip-joint. Med. Chir. Trans, xxiv. 123.
See also Malgaigne, Fract, and Disloc, Paris, 1855, ii. pp. 218-226,
882-887.
6 THE TOxNER LECTURES.
But in all the other 21 eases no eause was assignable, and it
is, therefore, likely that it was mere muscular contraction which
becomes, at the time when these occur, more vigorous as health
gradually returns. Seitz has recorded one of the most remark-
able cases in which, from extensive bedsores, the abdominal
decubitus was maintained for nearly a month, and he supposes
that this was the immediate cause of the dislocation. But as
in no other case is this posture noted, it cannot be regarded
as correct. Indeed, if posture have any influence, as the dis-
location is generally if not always iliac, the dorsal decubitus
would be the most favorable for its production. In one of the
shoulder cases a subcoracoid luxation was caused by the
patient's assuming the erect posture. Gravity had here
probably some influence, together with the muscular exertion.
The dislocation of the knee also was posterior.
A remarkable case corroborative of the non-specific character
of the lesion and the probable influence of gravity, I have lately
seen in the service of Dr. Wm. G. Porter, at St. Mary's Hos-
pital. The child was about two 3'ears of age, greatly exhausted
from mal-nutrition, and for about six weeks was kept alive by
inunctions of sweet oil, no other nourishment whatever being
given. It had large abscesses in different parts of the body,
and at present has necrosis of the left humerus. Early in the
period of returning strength and before the necrosis appeared,
spontaneous luxation of the left humerus into the axilla oc-
curred. It was easily reduced by manipulation, and has not
since recurred.
Typhoid was noted as the preceding fever in 15 and typhus
in 7 of the hip cases. Sex has a marked predisposing influence
in this, as we shall find in other diseases, for of 23 cases 15
were males and only 8 females. The age at which they occur
is still more noteworthy: 15 were under 15 years, 6 from 15 to
20, 1 was 30, and 1 was 61 years old ; that is, 21 out of 23 were
under 20 years old. The analogy to coxalgia, it will be ob-
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 7
served, is, therefore, ver^- marked. Usually they were single
dislocations, 6 being on the right side and 6 on the left ; but in
3 cases dislocation of both hips occurred.
From the apathetic condition of the patient in some cases,
the subacute nature of the lesion, the absence or slightness of
the pain, the masking of the swelling by even the wasted mus-
cles about the joint, and, above all, the want of knowledge of
cause or probability of the dislocation, and therefore the neglect
to examine the parts thoroughly, it is not surprising that this
threatening evil should have been often unobserved. In 9, that
is, one-third of the cases, it is distinctly stated that the actual
dislocation was the first fact observed, and in most of the others
this is probabl}"" true.
The date at which the dislocation was, at least, observed, was
generally after the third week. One case occurred in the first
week, 4 in the second, and 9 in the fourth week or later, that
is, during distinct convalescence. Pain was experienced in 13
cases. Usually, it was not severe, nor was it always strictly
localized in the hip, but sometimes extended to the entire leg.
In only 2 cases was it referred to the knee, thus differing
markedly from the well-known coxalgic knee-pain. Swelling
is only distinctly stated in 6 cases, though probably present
here as in other joints, but either unobserved or often unre-
corded in the brief statements I have often found. The variety
of the dislocation is not named in 10, but as in all the other IT
it was iliac, there is good reason to believe that this is probably
always the case. Shortening is recorded in 11 cases, and where
the amount is named was generally one and a-half to two
inches. In 5 cases the rotation was inward, in 2 outward, and
in 2 of the 3 double dislocations both legs were rotated in the
same direction, that is, right or left, thus producing a peculiar
deformity when compared with the apparently reversely rotated
body. The head of the bone in 4 cases was freelj^ movable in all
directions. This mobility of the head and the singular diver-
8 THE TONER LECTURES.
sity in the rotation of the limb, are additional reasons in favor
of the distension theory of its pathology. Flexion and adduc-
tion, Dr. Sayre has shown to be the position of the limb which
produces the greatest capacity of the capsular ligament of the
hip, and we ought to see this position, therefore, as a rule in
distension-luxations. But I only find two cases in which there
were adduction and flexion. In the other cases the position is
not stated, except in one in which the limb was extended.
As to treatment, reduction is generally easy when the lux-
ation is discovered early, but if the discovery or treatment be
tardy it is always difficult and often impossible. In 11 cases
reduction was successfully accomplished seven times by mani-
pulation, twice by extension, and twice by both means. In 8
cases reduction was not effected, and in 8 the result is not
stated. Only two cases of recurrence of the luxation are noted,
a rather surprising fact in view of the relaxation of the distended
tissues ; but its possibility should be borne in mind and guarded
against hy the same prophylactic means that I will name
directly. No snap is heard on reduction, all tension and suction-
power of the joint being lost. Even after reduction the leg may
be somewhat longer than the other, owing, probably, to the
distension, to the swollen articular gland, and possibly in old
cases to interstitial changes in the neck of the femur.
The question of prophylaxis is perhaps the most important
of all, and the indications are clear. First, a careful watching
and repeated examination of the hip-joint, especially in children,
to detect any effusion. If any exist, the position of the leg
becomes of the greatest possible importance. As adduction and
internal rotation favor spontaneous dislocation, the leg should
be kept in abduction and external rotation. The first indication
is easily fulfilled by two lateral sandbags which may be bridged
across in front at intervals by a bandage, to keep the leg at rest
between them, or by lateral splints. The foot may be kept in
external rotation by bandages or adhesive plaster fastened to
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 9
the external sandbag or splint. If the effusion threaten to
produce dislocation, it may well be a question whether aspira-
tion would not afford a safe and efficient means of prophylaxis.
II. DISEASES OP THE BONES.
A popular name for necrosis is " fever sore," but, as Nathan
Smith long since pointed out, more because it caused fever than
because it was caused by fever. That it does follow fever and
is caused by it is certainly true, but it is not a very frequent
though a very important sequel. I have collected thus far 50
cases of necrosis proper following continued fevers, but among
these are 19 reported by one single author—Whately—the his-
tories of which are exceedingly brief and unsatisfactory. He
states, indeed, that he has seen 30 cases—an incredible state-
ment, I think, in view of the fact that from all other sources,
after an extended search, I can only gather 31 more. " Fever"
with him, however, may include a A'ery wide range. One
element of unavoidable uncertainty in the history is seen at
once. The osseus disease usually falls under the eye of the
surgeon at a period distinctly subsequent to the fever, and,
knowing nothing personally as to the previous medical history,
he must depend upon the statemeiit of the patient—often a
most unreliable means of information.
Two causes for such necroses and other forms of disease,
such as periostitis and caries, are to be found : first, thrombosis,
or in some cases possibl}^ embolism
;
and secondly, absolute
inanition or want of nutrition.
The role assigned of late to the marrow together witli tlie
spleen as a source of the red corpuscles, would seem to be
confirmed by the similarity of the changes observed by Ponfick'
' Ueber die sympathischen Krankh. des Knochonmarks bei inneren
Krankh. Virchow's Arcliiv, Ivi 534. Cf. also Anatom. Studieu Uber
den Feb. Recurrens, Vircli. Archiv, 1871, Ix. 153.
41
10 TUE TONER LECTURES.
and others in the spleen and marrow in typhoid. In later
convalescence, or shortly after recovery, we find in the marrow
many mother-cells holding numerous blood cells, enormous
masses of large cells filled with pigment in complete analogy
with the observed metamorphoses of extravasated blood. These
are especially seen at the sides of the cavernous veins, and must
retard still further a circulation already impaired in force b}' a
weakened heart. Nutrition is here at its lowest ebb, and as
the vessels, from the nature of the tissue in which they run,
cannot enlarge in proportion to the needs of the circulation
and are themselves more or less involved in fatt}' degeneration,
we may readily understand how the lack of nutrition alone, as
in Dr. Porter's case previously cited, would cause gangrene of
the bone even more readily than in the soft parts in which we
know it to be so common.
That the bones should suflTer from vascular clots, and espe-
cially the bones of the lower extremities, where such clots are
most frequent, as we shall see, in gangrene, is pi'obable both
from analogy and experiment, and from one case in which it
has been actually observed in typhoid.' There is no reason to
suppose, when thrombosis is so frequent elsewhere, that the
bones would escape. Yirchow has shown that in relapsing
fever we frequently have infarctus in the marrow. Yolkmann^
gives an excellent case and illustration of necrosis of the tibia
and talus from embolism, the result of endocarditis. We need
a few similarly exact observations in cases of necrosis from
fever, in which death or amputation aflTords the desired oppor-
tunity to settle the question positively; but generally the
examination, if made at all, is of the most superficial character.
' See Meusel's Case, p. 15.
2 Pitha & Billroth's Handbnch, Bd. ii.. Ahth. ii., Lief, i., p. 287. and
Latifrenbeck's Archiv. 1864. v. 330. See also Molli^re, Lyon M6d., 1870,
pp. 12, 149, 256; 1871, p. 38.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 11
Hartraanu' has shown, experimentally, that obliteration of the
nutritious artery causes necrosis of the inner lamella of bone
a strong point it must be admitted in favor of Whately's theory
that after fever the result is not ordinary necrosis but a central
necrosis of the inner lamella which he limits to the tibia.
Blocking of the veins is evidently not so dangerous in bones
as blocking of the arteries, since the collateral venous circu-
lation especially towards the extremities is abundant, while the
collateral arterial circulation is scant3\
I have found 69 cases of diseases of bone following continued
fevers. Of these, 50 were cases of necrosis, 12 of caries, 3 of
periostitis, and 4 of indeterminate or doubtful nature. Three
cases of necrosis following typhoid and smallpox I have ex-
cluded. Typhoid, as usual, claims the larger share, for of 41
cases 31 followed typhoid and only 4 followed typhus. Males
also are in the preponderance, counting 38, to 14 females. Age
has not a very marked influence, as 19 were under 20 j^ears, 11
from 20 to 30, 11 from 30 to 40, and 5 over 40. Scarcely any
region of the bod}'^ escapes ; 22 cases involved the head, 7 the
trunk, 6 the upper extremities, and 42 the lower, a result
strikingly in accord with the cases of arthritis and gangrene.
In the head I have found 1 2 cases of necrosis of the alveoli and
jaws. Among these perhaps the most remarkable, altliough
somewhat doubtful, case is the one I saw in a soldier at
Frederick, Maryland, in 1862, in which, after typhoid fever
followed by pneumonia, the entire right upper jaw with a part
of the palate bono and the intermaxillary bone necrosed and
separated. The case is remarkable, both from its being a
striking example of the limitation of disease by the embryonic
development,^ and also from the extraordinary series of ope-
' Nekrose herbei^efubrt durch Verstopfung des Foram. nutrit. Yirch.
Archiv, viii. 114.
2 H. Allen, Studies in the Facial Region, Phila., 1875, has sijecially
called attention to this point.
12 THE TONER LECTURES.
rations subsequently done b}- Dr. Gurdon Buck, of New York,*
to remedy the frightful deformity which had been produced.
It is but proper to say that the man was reported to have
talien about 3ij of various mercurials during his preceding
illness ; but from the facts I have stated, as well as his scanty
history, I think it tolerably clear that the fever and not the
mercury caused the necrosis. Mercury or syphilis complicated
two or three of the other cases I have tabulated, but they were
not, apparently at least, the cause of the trouble.
Mr, Salter'' has pointed out the relation of alveolar necrosis
to the eruptive fevers, especially scarlet fever, and believes
that as these structures are dermal in character they partake
with the skin in tlie eruptive mlscliief While this relation
remains undisturbed, yet I do not think the necrosis exists as
a specific sequel of these fevers only. Of the 12 cases cited, T
occurred as follows: one at 16, one at 12, and five at 10 years
of age and under, that is, during the period of dental develop-
ment and growth. That such cases are more frequent in the
exanthemata is natural when we consider the relative infre-
quency of the continued fevers under 15 yeai's of age.
The period at which these diseases of the bones arise varies
greatly. Of 47 cases 10 arose in the first two weeks, 27 in
from three to six weeks, and the remaining 10 followed often
months after the fever. The earlier cases include probably,
most of those from clots, and the later ones those arising from
enfeebled nutrition, whose effects especially in structures which
vary so slowly as the bones may readily extend over such long
periods.
Especially does this enfeebled nutrition show itself in case
where too early strain is put upon the parts and justifies the
remark of Aitken that '^no man can be considered fit for work
' See Bibliocr.
* Holmes's Sjst. Surgery, 1st ed., vol. iv.- p. 50.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 13
or for general military service for three or four months after an
attack of severe typhoid fever." The following case illustrates
the wide-spread mischief that may follow in the osseous sj-stem
when put to tlie test by labor, months and even years after
such a fever.
H. W., a remarkably stout, healthy lad of IG, w^as attacked
Dec. 17, 1871, with typhoid. He was delirious for four weeks,
was in bed four months, and first got out of doors in May,
1S72. Bedsores had formed, but they were kept in check by
incessant care. In the fall of 1872, not yet being strong, he
went to work at riveting in an iron works, which required him
to stand and use a ten pound hammer, the main strain being
naturally on the right arm and leg. His right arm soon began
to swell, and finally four fistulous sinuses formed. After the
removal or discharge of several pieces of bone, this arm
recovered in about a year. Returning then to the same
work, his health being still impaired, his right thigh began
to trouble him, broke out, and healed several times, dis-
charging sevei'al pieces of bone. He came under my care in
Jul}', 1875. He had then a scar and five open sinuses in the
thigh, all leading in the direction of the bone, and in one, just
above the knee, a fragment of dead bone an inch long was
found. This sinus and a second just below the patella, an ofl^-
shoot from it, threatened to invade the knee-joint. Meanwhile,
in the fall of 1874, not having done an^^ work on account of
his right leg, the left thigh broke out, and a sinus in the direc-
tion of the bone was established, but no dead bone was ever
actually found here. In January, 1875, an abscess also
appeared in the left arm, and after the discharge of some bone
finally healed. I enlarged all the existing sinuses in the right
thigh, removed the dead bone, and after treating the case care-
fully for four months all the sinuses liealed. A new one,
however, has appeared of late in the right thigh, but no dead
14 THE TONER LECTURES.
bone is, as yet, to be fouiid.^ His health markedly improved
early iu IS75, aud since my operation he has grown to be
exceedingly robust aud hearty again. His right knee, which
was stitf from the sinuses among the muscles of the thigh and
near the knee-joint, is now as mobile as ever, and he is at work
with ease. The abscesses in the two arms were at or near the
deltoid insertion, in the right leg, the earliest was just below
the insertion of the glutseus maximus, and in the left near the
lesser trochanter, all points at which muscular strain iu stand-
ing and hammering would come.
The symptoms need scarcely be alluded to, for they are
those of ordinary necrosis, although Whately endeavors to
differentiate them. In 13 cases of necrosis of the long bones
other than Whately's, in which the description enables me to
judge, I find only 3 distinct cases of central necrosis,'^ and
these differ in no especial manner from other cases. That it is
limited to the tibia, as assei'ted by Whately, is disproved by
the fact that of seventy-seven bones affected, the tibia was
attacked only thirty times, including in these the 19 reported
by Whately.
' In Feb. 1876, it healed, broke out again in July, and did not heal
until December, after a counter opening had been made. Since then he
has been well (March, 1877).
2 The third of these cases I have had in private practice while the
US. is passing through the press. A. W., a rather feeble girl, aet. 11,
was taken sick with typhoid May 10, 1876. After three to four weeks
in bed she began to walk, but soon had to stop on account of weak-
ness, and especially of pain in her left tibia. After three weeks'
poulticing it broke in two places, and has discharged ever since. I saw
her first in December, 1876, and found two small sinuses which extended
into the bone, but no dead bone had ever been discharged. After build-
ing up her general health by tonics and cod-liver oil, on February 17,
1877, I operated on the bone, using Esmarch's apparatus in the manner
I have suggested {Phila. Med. Times, Sept. 26, 1874), and after making
an opening into the medullary canal with the chisel and gouge, I removed
a small, loose spicula of necrosed bone (central necrosis) seven-eighths of
an inch long. At this date, March 5, 1877, she is doing well.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 15
The results of necrosis vary with the situation. The ordi-
nary sinuses etc., I need not mention further. If in the
sacruui, coccyx, or innominate bone, perineal fistulas may
result, of which I have found 3 cases. If in the mastoid or
petrous bone, the brain and its memln'anes may be involved.
The following resume of the case of Meusel is of especial
interest, as it throws so much light on the cause of the necrosis,
the clot in the meniiigea magna, and is as extraordinary for
tlie audacity of the treatment as for the success of the result.
Fig. 1.
Necrosis of Frontal (A), Parietal (B), and greater win,<j of Sphenoid (C) bones,
following typhoid. In B and C the middle meninsjeal artery and its branches
are seen. Natural size. Meusel, Deutsche Klinilc, 1872, p. 266.
A student in the gymnasium, set. 19, at Easter in 18fi8, had
an attack of typhoid fever, went home when convalescent, but
did not improve, and suffered much from headache. In
August, four months after the fever, he had a large fluctuating
abscess over the right parietal region, which was opened, and
IG THE TONER LECTURES.
dead bono found. By Oct. 1, the bone was loose, and on the
5th, an incision of tliree inches was made and a loose piece of
the frontal was removed. The rest of the dead bone was firm,
but the incision was extended backwards till the whole of the
necrosed portion was exposed. It was then carefully chiselled
loose and separated at the squamous suture. At the anterior
inferior angle the necrosis was there found to extend on the
internal surface only ; with a fine chisel this internal lamella, a
piece 1^x2 c. m., was chiselled away from the great wing of
the sphenoid. In it was a groove in which lay the anterior
branch of the middle meningeal, filled with the detritus of a
clot. The whole piece was 5^x9 cm. The dura mater was
but slightly injected. The scalp and the dura mater united and
in fourteen days he was nearly well, having recommenced his
Latin and Greek with the greatest zest eight daj^s after the
operation. Two small pieces of loose bone afterwards caused
threatening symptoms, but improvement followed immediatel}'
upon their discharge. In March he was entirely well, and
went to Gottingen to study philology at the University. Epi-
leptiform attacks followed during 1869, but then disappeared,
and had not reappeared in I8T2.
As to treatment, the ordinary operation for the removal of
necrosed bone is to be done at the proper time, especial care
being taken to remove any small central sequestrum. Occa-
sionally the disease of the bone may cause extensive disease
in the soft parts, or ma}^ extend to a neighboring joint, though
either complication is rare. Amputation then becomes impera-
tive. Only four such amputations occurred in the eases
rei)orted
;
two died, one recovered, and one was under treat-
ment. About the face not infrequently extensive plastic ope-
rations are required.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. iT
III. DISEASES OP THE LARYNX.
The laryngeal complications are noted very briefly by several
medical writers, such as Murchison, Flint, Liebermeister, Giie-
singer, etc., but it is mainly the laryngeal ulcers themselves
which are treated of, their surgical results being scarcely men-
tioned. Gross and Gray barely allude to typhoid as a cause of
oedema glottidis. Even systematic writers on the larynx
scarcely notice them. Gibb and Riihle refer to two or three
cases. Cohen simply names fever. Tiirck gives, however,
eight valuable cases. I have collected 169 cases, of which at
least 67 (and probably many more) certainly involved the car-
tilages themselves.
The troubles which ma}' demand surgical interference are all
allied, and are the result of a low grade of inflammation. The
entire respiratory mucous membi'ane (as is shown by the fre-
quency of bronchitis) is in a more or less catarrhal condition
like that of the bowels, and occasionally other mucous mem-
branes such as those of tlie gall-bladder, urinary bladder, and
vagina. It is not, therefore, a matter of surprise, that serious
trouble should arise in the larynx, especially as slight varia-
tions in its mechanical condition gravely embarrass so vital a
function as respiration.
Pathologically the troubles may be grouped into three varie-
ties, viz., 1. (Edematous laryngitis. 2. Ulcerative laryngitis.
3. Laryngeal perichondritis. Practically it is often exceed-
ingly difficult to separate these various forms even at the post-
mortem, so far do they overlap each other. (Edema may exist
alone or it may result from either of the others ; ulceration
may march steadily deeper until the cartilages are mvolved ; or
the perichondritis may produce an abscess which will burst,
and so form an ulcer. How much more difficult, na}' often
impossible, then is it, to diagnosticate pi-ecisely the form of
the disease, when, happily, the patient recovers. Dyspnoea,
2
}S THE TONER LECTURES.
suffocation—this is tlie one great overshadowing clinical fact
wiiicli groups tliem all together whatever the form of the dis-
ease, or of the preceding fever.
That simple asthenic oedema may arise just as oedema of the
lower extremities is not only probable, but has been positively
observed by Emmet and Buck. It has also been observed after
diarrhoea, bronchitis, and other diseases. But this is a much
rarer form than those cases in which it is secondary to erysipe-
las, o^ parotiti^s, or larjmgeal ulcers, often of small extent. I
cannot help suspecting also very strongly that more careful
future examinations will sliow in not a few cases that local
ven6us thrombosis has been the cause of the oedema.
Tlie other two forms especially merge into each other.
Rokitanslcy believes that the ulcers are a peculiar form of
typhus, the so-called laryngo-typhus. Others, and I certainly
agree with them, do not believe that they are specific in their
origin, but belong " to the common cortege of septic diseases"
and other allied disorders in wliich the low grade of inflam-
mation readily runs into ulceration, and even into local gan-
grene. How much influence local stasis of the blood or even
clots in the vessels may have, has not been carefull}^ investi-
gated, but I believe them to be no unimportant factors.
These ulcers are sometimes very common. Thus Griesinger
met with them in 31 out of 118 autopsies, Hoffmann in 28 out
of 250, and Louis believes that " if found on the bod}' of one
who has died of an aciite disease, they will establish with
nearly perfect certainty and without going any further, that
the affection is typhoid fever." At other times they are so
rare that in nearly 13,000 typhus cases at the London Fever
Hospital, Murchison records but 21 of lar3'ngitis, of whom 8
died ; and in tyjihoid he has only seen 3 or 4 cases.
Where the cartilages are involved, Moritz-Haller, and others,
believe that it follows the ulceration which detroys the mucous
membrane and eats down to the cartilages, while Sestier has
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 19
gone so far as to declare that the ulcers which accompany
perichondritis are not primary but in all cases secondary.
Both I believe are right, but both go too far. So far as the
history and post-mortem appearances would enable me to judge,
1 have found in 20 cases that the perichondritis preceded the
ulcers and caused them, while in 10 cases the ulceration had
caused the perichondritis. In cases of perichondritis in which
death takes place early, there is no opening in the mucous
membrane, but a submucous abscess will be found surrounding
the necrosed cartilage. If death takes place at a later date a
small opening will exist, through which the probe will enter
into a much larger cavity. In other cases the surface mischief
will be by far the most widely spread, the ulcers being roughly
conical, involving not only the mucous membrane, but eating
deeply down to the cartilages. Similar necrosis of the nasal
cartilages also sometimes results from fever.
Those cases in which there is considerable cough, or the
patient in his delirium has cried aloud, or sung much, or those
in which, after distinct convalescence, there has been exposure
to wet and cold, are predisposed to laryngeal troubles. They
are exceedingly rare in children. In 94 cases in which the age
is recorded, I have found but 6 under 15 years of age, 60 from
15 to 25, and 28 above 25 years. Sex is potent here as in the
other diseases considered. Lisfranc thought them more com-
mon in women than in men, but of 110 cases, I find 86 in men
and only 24 in women, or 3^ to 1.
The cause of the stenosis is various. It may be, 1st, from
oedema; 2d, the swelling produced by the abscess about the
cartilage; 3d, the sides of the glottis may fall together if
the cricoid be destro3'ed and in pieces ; 4th, the permanent
aipproximation of one, or more rarely of both vocal chords
from destruction of tlie fixed points of origin of the muscles
;
5th, as in two remarkable cases given b}'' Hofimann,' shreds of
' Op. cit., pp. 253 and 255.
20 THE TOXER LECTURES.
sloughing tissue on which blood coagulates, may form a sort
of polyp which sullbeates the patient even in spite of trache-
otomy.
Fig. 2.
Laryngeal Ulcer after Typhoid. Polypoid Hrematoma hanging from it and
causing death by suffocation after Tracheotomy, a, upper end of incision. The
smaller cut, b, is a section of the Htcraatoma showing its two layers ; the centre
consisting of shreds of dead tissue hanging from the ulcer, and the outer layer of
clotted blood. Hoffmann, Verand der Organ, beim Abdom. Typhus, Taf. v. Fig. 16.
The seat of the stenosis is threefold. Most frequently (25
cases) it is supra-glottic, that is, in the epiglottis and arj'-epi-
glottidean folds, especially where the oedema is primaiy, or
where it is caused by ulceration, or arytenoid perichondritis.
The next most frequent site is subglottic, i. e., about the cricoid
(22 cases). This is always, I believe, the result of cricoid
necrosis or perichondritis. Russell reports 2 cases following
typhus, which he regards as examples of Gibb's " subglottic
oedema." That the second was a case of ulceration and peri-
chondritis, is quite certain from the history, and most likely
the other was too. The larynx was normal down to the chords,
tracheotomy rescued both wlien suffocation was imminent, and
both were followed by stricture, requiring the permanent use
of the canula. The least frequent site of the osdema is in the
SURGICAL COMPLICATIONS AND SEQUELS OP FEVERS. 21
glottis proper, since oedema of the vocal chords is named but
nine times.
The date of the development is generally here too, in the
later fever, or more frequently in distinct convalescence. Of
102 cases only 4 occurred in the first week, 13 in the second,
19 in the third, and 66 from four weeks to two months. They
follow typhoid far more frequently than typhus, in the propor-
tion of 106 to 49, some of the latter being probably really
typhoid, while 14 arose from other forms of continued fever.
The position of the ulcers in the larynx is noteworthj'.
Wherever they may be, from the arytenoid to the cricoid, they
are almost invariably posterior. Rheiner' has shown that the
posterior wall of the lar^nix is the richest in vessels, and that
ossification begins here often as early as the twentieth year.
Here, then, we should expect the most frequent inflammations
ami thrombosis of the smaller vessels ; and when we add to
this the eflTect of gravity, from the continuous dorsal position,
and the mechanical effects of frequent use of the voice, and,
therefore, repeated movement of the arytenoid cartilages in
some delirious cases, we have a sufficient explanation of the
phenomenon. Emphj'sema of the neck and trunk is an occa-
sional result of such ulcers where thej^ penetrate the mucous
membrane. This was first pointed out by Wilks. Other cases
are reported by Steiner and Loeschner. All three were children.
Necrosis of the cartilages is the most important form to
recognize, in consequence of its excessive gravity, for, of 56
cases in which the result is given,- 54 died. One recovered
after tracheotomy,'^ and one without it.^ We can scarcely agree
with Tiirck, thei'efore, that the prognosis is "doubtful." The
seat of the necrosis in the majority of the cases is the cricoid
' Breitage zur Histologie des Kehlkopfs ; Wiirzburg, 1852.
2 Turck, p. 223.
^ IT6rard. I'Union M6(l., July 14, 18.59. quoted by Trousseau, Cliu.
Med., Syd. Soc. Trans., 2d cd., vol. ii. p. 407.
22 THE TONER LECTURES.
(38 times), next the arytenoids (19 times), while the other car-
tilages were affected but 5 times. In 10 of the cases, the
cricoid and arytenoid were involved simultaneously.
Fig. 3.
Perichondritis laryngea following typhoid. Ulcers on the posterior wall of the
larynx. At a, a piece of the necrosed left arytenoid cartilage shows. Tiirck,
Krankh. des Kehlkopfes, p. 21(5, fig. 78.
It is to be specially observed that probably a number of the
cases which recovered w^ere also really cases of perichondritis,
of which the positive evidence was wanting. Thus, in 8 cases
in which recovery followed tracheotomy, the patients spat up
gangrenous or purulent matter, besides having other symptoms
of cricoid necrosis ; but as the expectoration of any pieces of
necrosed cartilage was not positively observed, I have not
included them in my statistics of necrosis. Were they in-
cluded, the result, and especially the result after tracheotom}-,
would be far more favorable.
Whatever the origin of the necrosis, the cartilage is soon
destro^^ed, either by molecular disintegration or is even broken
in pieces. Sometimes it undergoes ossification ; at others,
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 23
caseous degeneration. The articulations of the cartilages are
also often destroyed, especially those of the cricoid, with the
arj'tenoid or with the thyroid ; and thus again voice is impaired.
The function of the muscles, especiall^^ those which open the
glottis, is impaired or destroyed, from direct implication of the
muscles or from destruction of their cartilaginous attachments,
Fig. 4.
\\\, '^i
Perichondritis laryngea following typhoid ; abscess opened from oesophagus and
seen frora behind, a, b, necrosed and partly destroyed cricoid cartilage ; between
a and b the dark spot indicates the point where the abscess communicated with
the trachea; it did not communicate with the oesophagus; c, crico-aryten. post.
muscle. Tiirck, Krankh. des Kehlkopfes, p. 218, fig. 80.
or of the articulation ; and thus the vocal chord of that side is
immobilized, and altered voice and stenosis of the larynx follow.
If an abscess form about the cricoid, it may not only burst into
24 THE TONER LECTURES.
the larynx but also into the pliarynx, and a fistulous oponing
be establishetl by which food may enter the larynx and trachea.
Fig. 5.
Perichondritis after Typhoid. Opposite a the (Edematous ary-epijrlottidean
folds are seen. Below the vocal chords the larynx was narrowed by thickening
of the connective tissue. Opposite b a movable piece of the destroyed and
broken cricoid, which has perforated the oesophagus, is seen.—EUhle, Kehlkoi)f-
Krankh., p. 178 &. PI. I., Fig. 2.
This, Dittrieh thinks, is the most frequent point of opening
;
but I have only found it recorded in six instances, though such
an abscess would have burst here in several other cases had
life been prolonged. An additional complication may follow,
also in the phaiynx. The cricoid presses upon its posterior
wall, both from swelling and from gravity, and this pressure,
together with the foul purulent discharge, raaj' cause an ulcer
;
or, as in a case recorded by Armstrong, a retro-pharyngeal
abscess. Hoffmann' records another case of retro-pharyngeal
abscess extending from the base of the skull to the diaphragm,
laj'ing bare the left subclavian artery. This, however, did not
result from a laryngeal necrosis.
The earliest S3'mptom of grave lar^-ngeal disease is usuallj''
• Op. cit., p. se
SLRGICAL COMPLICATIONS AND SEQUELS OF FEVEKS. 25
an altered voice. I have only found it distinctly stated as
unaltered in three cases. Generally it is hoarse, sometimes
higher, but usually lower in tone, probabl}" from involvement
of the crico-thyroid muscle. Sometimes complete aphonia sets
in. Stokes' has supposed the hoarseness and deafness both to
be due to the muscular degeneration, to which I shall allude
hereafter; but it is more likely to be due here, at least, to
tedema and inflammatory swelling, and, at a later period, to
the mechanical destruction of the parts involved.
Soon after this hoarseness is observed, the dyspnoea sets in.
This is paroxysmal, the attacks being generally at night.
With each succeeding attack the severity increases, until life
is destroyed ; but even the very first attack may be unexpected,
sudden, and fatal. Especially does this seem to be the case in
tj'phus, and in supra-glottic oedema. Emmet and others have
recorded a number of cases, in which, even witliout the least
previous d^^spnoea, on simply assuming the erect ])osture sud-
den suffocation came on, and life w^as only saved by instanta-
neous lar^-ngotomy. The delay of ''a few minutes" caused
death in one case which otherwise would probabl}^ have re-
covered. Most frequently- the dyspnoea is inspiratorj-, but I
cannot find that this is of an3' decided diagnostic value.
The expectoration, curiously enough, aids us but little ; in
but few cases did it attract sufficient attention even to be
named ; but if it be purulent or gangrenous, it should arouse
instant attention. Pain and tenderness, though often masked
by the mental condition, are generally present, especiall}' in
perichondritis. As we have the resisting verteljral column
behind the cricoid, I would strongly urge that both by direct
and lateral pressure on the cricoid, and also by sliding it side-
wise, we may often elicit pain which might otherwise be over-
looked. Lateral pressure will also often produce dyspnQ?a, or
' On Fevers, riiila., 1876, p. 105.
42
26 THE TONEU LECTURES.
aggravate it, especially if the cricoid be broken, or nearly
broken in two. Dysphagia is noted as present twenty-one times
and absent five times, and is especially present in crico:'d and
arytenoid necrosis. Rarely is there an}- external swelling to
attract attention, for I have onh' found it noted thrice. Nor
can the pharjnx be relied npon to warn us of impending evil,
for in 16 cases in which its condition was observed, it was
normal in 10 and inflamed in only 6.
Most of the cases occurred before the days of the laryngo-
scope, so that I have only thirteen such examinations from
which to draw- any inferences, seven of which are recorded by
Tiirck. In several instances there was nothing whatever ab-
normal down to the vocal chords ; and tlie swelling of a
cricoid abscess on the posterior w^all is not visible. But the
usual facts observed, were the fixation of at least one chord in
tlie middle line, diminished mobility of the other, swelling of
the arj'-epiglottidean folds, stenosis of the larj-nx increased by
lateral pressure, a depression of the mucous membrane in case
of destruction of the arytenoid, and sometimes the opening of
an abscess, usually near the processus vocalis. A few such
positive facts with any additional positive symptoms should
lead to an equally positive treatment.
And first the mortality is so great that the treatment is
of the greatest possible moment. Of 146 cases of all kinds
oi stenosis in which the result is recorded, 101 died and
45 recovered, a mortality of over 69 per cent., but not a
surprising result when we add the laryngeal disease to the
exhausting fever. But when we separate the cases operated
upon from those in which no operation is named, or was
certainly not done, the importance of the treatment becomes
even more appreciable. Of the TO cases not operated on, in
which the result is stated (and, be it observed, I have included
in these the cases of mere scarification), 17 recovered and 59
died, a mortalit}^ of over 71 per cent. Of the 70 cases operated
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 27
on by some form of broncliotomy, 28 recovered and 42 died, a
mortality of 60 per cent. And when it is remembered that in
two of the fatal cases the larvnx was not opened, thongli
tracheotomy was apparently performed ; and a third, in full
recovery thirteen da^^s after the operation, on the removal of
the canula, was suddenly suffocated before it cculd be replaced
;
and in another, the canula got dispjaced in front of the tra-
chea ; that in many, if not in most of the cases, the operation
was deferred till the last possible—that is the most unfavor-
able—moment ; that many cases that might have been rescued
were plainly allowed to die from exhaustion, or even from
positive suffocation, by timid doctors, in which the result could
not have been worse had an operation been performed, the
question of operation would seem to be decided.
Yet I would not be understood as an advocate of rash and
indiscriminate broncliotomy. Its dangers are great, and not
to be undervalued. The question, however, is often between a
dangerous operation and a more dangerous refusal. In case
the attack is sudden and severe, so that life is in immediate
and positive peril, no question can arise as to the propriety of
an operation, wanting which, the patient perishes on the s))ot,
nor any question tliat crico-thyroid larjMigotomy is the easiest,
safest, speediest operation. Delay here means death. Of 14
such operations, 8, orST per cent., recovered, and in such cases
as are recorded by Emmet and Anderson, no words can add
force to the fact, that after life was apparently extinct, larj-n-
gotomy and artificial respiration saved 5, the delay of a few
minutes resulting fatally in the 6th case. A cut throat here is
not over-dangerous, and the operation is so simple, and may
be so Imperative that every medical man, as well as surgeon,
should stand ready to do it in case of impending death.
But it is in the less suddenly threatening cases that judg-
ments may differ, and here I hope to be able to assist in form-
ing a decision. The moment, in a case of typhus or typhoid,
28 THE TONER LECTURES.
that hoarseness, aphonia, dyspnoea, or dysphagia sets in, the
larynx should be examined with the utmost vigilance both
from without and by the laryngoscope. If oedema or ulcera-
tion be found, but the danger be not as j-et severe, leeches,
iodine, ice in rubber bags, or possibly a blister may be used
externally, and astringents, nitrate of silver, etc., internally,
together with proper general treatment. In 1819, Lisfranc
proposed scarification and operated succesfully in six non-febrile
cases, and in 1847, Buck revived the practice and devised an
appropriate knife. The laryngoscope has made such treatment
far more certain, and it should first be tried in suitable cases.
But, should these means fail? Then an early rather than a
late tracheotomy, for otherwise we add to the previous enfee-
bling disease a prolonged battle for breath, with its ensuing
pulmonary congestion and general exhaustion. Especially is
this to be commended in the peculiarly fatal necrosis of tlie
cartilages. Of G7 positive cases, 41 of which occurred in men
and only 10 in women, all died but 2, one with and one with-
out an operation; 22 were operated on, 45 were not. But as
before mentioned, 2 died from displacement of the canula, at
least one of which had practically recovered ; 8 cases of recovery
after tracheotomy are not included, since, though the presump-
tion in favor of necrosis is very strong, yet the evidence is not
positive. Were only these 8 included, and it is certainly fair
to do so, it would stand 30 operations and 10 recoveries, a
mortality of 61 per cent., and 45 not operated and 1 recovery,
a mortality of nearly 98 per cent.
Once, then, that perichondritis is established, death is almost
unavoidable if no operation be done. If bronchotomj' be re-
sorted to, the chances are greatly improved. Indeed, it is pro-
bable that if the dangers which surround such cases be recog-
nized in the future and a prompt attempt at relief be made, far
more favorable results will be obtained. I would, therefore,
join with Sestier in urging an immediale operation the moment
SUllGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 29
that perichondritis is recognized and serious dyspnoea sets in,
without waiting for repeated attacks to exhaust the slight store
of strength, all of which will be needed during the subsequent
separation of the necrosed cartilage, and the sloughing of the
soft parts.
In other cases than those of perichondritis such haste will
not be necessary : } et if the respiratory murmur be progres-
sively enfeebled ; if pulmonary congestion set in; if the parox-
ysms of dyspnoea increase in frequency and severity, especially
if orthopnoea arise ; if the local disease be extensive or rapidly
increasing ; or if the general feebleness be so great that a little
further interference with the respiration will destroy life; then
no time is to be lost. Doubt is certain death.
What operation shall be performed ? If an instant operation
be needful, cricothyroid larj-ngotomj^ is the best ; if time allow,
tracheotom}-. But if the cricoid be involved, with Beck, I
w^ould advise laryngo-ti-acheotomy, i. f., tracheotomy pi'olonged
through the cricoid ; since it would allow readier access to the
seat of the disease for the discharge of pus, the removal of any
loose piece of cartilage, and the treatment of any ulcers or
granulations. These I regard as greater advantages than the
danger of possible collapse of the lateral halves of the cricoid,
which is prevented in part by the canula, and would not imi)ede
the respiration even if it occurred. Unless necessary, it is
liest not to operate during a paroxjj-sra ; since the mechanical
difficulties of the operation are then largely increased, and tlie
danger of entrance of air into the veins is apparentlj"^ mucli
greater- In 36 operations for larjmgeal angina, tvvo such
accidents occurred ; whereas, in 245 non-anginose cases, not a
single similar accident arose (Sestier).
Hemorrhage, as would be supposed from the condition of
the blood, is sometimes a serious complication, both at the
operation and subsequent!}', and caused death in three cases.
A curious and unexpected complication arose in two cases
30 TUE TONER LECTURES.
reported by Mohr' and Laemiec,' the knowledge of which
should guard us against a similar error. The operation having
been apparently achieved and tlie canula inserted, respiration
was not bettered nor did air pass through the canula. In a
few minutes the pj^tients died suffocated. At the post-mortem
it was found that the canula liad entered, not the larynx, but
the abscess around the cricoid. In Mohr's case the vertebrai
were felt through the incision, and a probe and the canula
moved freely about in wliat was naturally believed to be the
trachea but proved to be the abscess cavity.^
In three cases' of oedema the canula was removed in six, eiglit,
and nine days respectively. But after such serious loss of
substance and extensive organic mischief as are involved in
the cases of perichondritis, it is not a matter of wonder that
the stenosis of the larynx is generallj'^ permanent. In It cases
of probable or actual perichondritis, the canula was removetl
in one case after seven months, but in the other 16 cases, when
last seen, the patients were still wearing them. Once, after
seven 3'ears' use, a piece of the canula wore away, broke off,
and fell into the trachea, whence it was successfully removed
by Albers. Busch, Russell, and others have attempted to
dilate the stricture, both from above and below, but without
any success.*
' Casper's Wochenschr., 1842, p. 192. Also in Dittrich, Pmg. Yier-
teljahr., 1850, iii. p. 129.
2 Bayle, Nouveau Journ., t. iv. p. 37.
3 Green, Brit. Med. Journ., Dec. 17, 1870, p. 649. and Marsh, St. Barth.
IIosp. Reports, iii. 368, report cases (not following fevers, however) in
wliich the tube was inserted in the cellular tissue in front of the trachea.
* By the courtesy of Drs. Otis and Woodward, of the Army Medical
Ituseum. the casts and specimens of Dr. Buck's case, p. 18, and of
several cases of laryngeal stenosis, were shown.
SURGICAL COMPLICATIONS AJND SEQULLS OF FEVEKS. 31
IV, GANGRENE.
The cases of gangrene maj' be divided into two classes: A,
those from pressure ; and B, cases of spontaneous gangrene.
A. Those from pressui'e^ or the ordinary bedsores, are not
peculiar to the continued fevers, as is well known, but arise
from any prolonged debilitating disease or accident. They are
more common, therefore, in typhoid fever than in typhus, on
account of its greater duration. But they not infrequently
follow typhus, if it be prolonged by any complication. The only
points in addition to the greater danger of pyifimia, to which I
desire to call attention, are as follows :
—
First, as pointed out by Nelaton,^ Blandin,* and others, if
they penetrate deeply they may destroy the ligaments uniting
the sacrum and coccyx, and so penetrate into the spinal canal
and set up meningitis, etc. This complication, I believe, arises
much more frequently from bed-sores, whatever their cause,
than is generally known. Recently I have had two instances
:
one arising from a bedsore following confinement, the specimen
which I show 3'ou, and which I owe to the courtesy of Dr.
Schell, my colleague at St. Mary's Hospital ; and the other
in a boy who injured his knee and died some weeks after
from tetanus induced probably by this complication. T have
found 6 cases of tetanus recorded ; 4 following typhoid and
2 typhus. Four of them were females. In one it was clearly
caused by a bedsore.' Four of them died, but the two women
who recovered had had menstrual irregularities, which proba-
bly caused the alleged tetanus.*
' Path. Chir., Paris. 1844, i. 256-7.
2 Anat. Top., 2nie ed. p. 437. See also Charcot, Mai. du Syst. Nerveux,
2ine ed., i. 89-90.
" Maclagan's.
• De Laurlere (see Bibl.) reports also a case of hydrophobia, which
became ataxic, following a quotidian fever. He had been bitten by a
32 THE TONER LECTURES.
Secondly, large bedsores, as in two eases reported b}- Chenu
in the Crimea,' may greatly hinder free motion of the legs and
trunk by the extensive cicatrices.
Thirdly, the treatment first proposed, I believe, by Brown-
Sequard, of ice poultices for fifteen minutes, followed b}' hot
flaxseed poultices for two to three hours, often stimulates the
most indolent bedsores to heal with surprising rai)idity. During
and since the civil war I have repeatedly and successfully tried
this plan of treatment.
Sometimes gangrene results from the slighest pressure, as in
a case reported by Stokes,' in which there were thirtj'^ such
spots ; two or three new ones appearing every morning, at
points of such trifling pressure, as where the mammae leaned
on the arm, or one leg on another, and a black hand appearing
where the face had rested on the hand. Strange to say, the
woman recovered after a month's abdominal decubitus. For
such cases Liebermeister recommends an almost continuous
and complete bath, the body resting and reclining on sponges.
B. But the cases of so-called spontaneous gangrene, though
less frequent, are of far greater interest from a surgical point
of view. They vary greatly in frequency. Thus, neither
Flint nor Trousseau ever saw a case ; Nelaton does not name
fever as a cause of gangrene ; Murchison, though he has seen a
few, does not cite a single English post-mortem. Yet Estlan-
der reports 34 eases, and I have collected in all 113 cases.
The frequency varies in proportion to the severity of the case
and of the epidemic, and especially to the preceding conditions
as to bodily nourishment, mental depression, and general mode
of life. In former wars especially, from the time of Thucydides
to that of Nnpoleon, fierce epidemics, especially of typhus, have
healthy dog three months before. R. Reid (Pathol, and Treat, of
Fpver, Trans. Queen's Coll. Phys. Ireland, iii. 41) alludes to the simi-
larity of hydrophobia and the excitable stasfc of fever.
' Rapport, pp. 520, 524. ^ Qu Fever, Phila., 1876, p. 210.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 33
decimated armies and often displayed a most frightful tendency
to gangrene. But of late, whether in civil or military practice,
if we may judge from the scanty gleanings 1 have been ahle to
obtain from the journals and the experience in our own civil
war as well as in the late European wars, the condition of the
sick has been so ameliorated that gangrene is happily a rare
complication.
The history of the extraordinary series of cases reported hy
Estlander, well illustrates these predisposing causes. In Fin-
land, a financial crisis and a series of bad harvests from 18G2,
were followed in 1865-7 b}^ sporadic cases of fever, mainly
typhoid ; but from the thrifty habits of the people and govern-
mental support, the epidemic was at first neither severe nor
extensive. Then came the cold and rainy summer of 186Y,
followed by a very bad harvest. That winter, typhus raged in
almost ever}'^ household, so that often the well were not numer-
ous enough to nurse the sick. The death-rate rose from 2.74
per cent, to 7.69 per cent. Instead of an annual increase in
the population of over 15,000, it deci'eased, in 1868, nearly
94,000; and this in a population of less than 2,000,000. Of
105 doctors, 30 sickened and 8 died. Up to 1868 not a case
of gangrene occurred, but in the first seven months of that
year 28 cases occurred. Then came the bountiful harvest of
1868, and by August the epidemic had almost disappeared.
Yet the lingering effects of the previous want were seen in six
later cases of gangrene. But such an experience is altogether
exceptional. From other writers I have rarely obtained more
than two or three cases.
Estlander's 34 cases were all, except one, from typhus ; but
of the remaining 79 cases, 43 followed typhoid, 22 typhus.
The influence of age is not very marked, as is seen in the fact
that of 67 cases, 8 occurred before 15, 27 from 15 to 25, and
32 after 25 years of age. But sex, as usual, has a marked
3
34 THE TONER LECTURES.
determining influence. Of 81 cases, 56 were males and 25
females. This is the more curious when we consider that the
number of deaths in men, and therefore presumably of cases,
does not hold at all the same relation. In 1868, in Finland,
31,000 males and 28,000 females died; yet of 31 cases of
gangrene of the legs, 25 were males, and only 6 females. The
site of the gangrene is very suggestive also. In 5 cases it was
in the ears, 10 in the nose, 27 in the face, neck, and trunk, 5 in
the arms, 1 in the genitals, and 72 in the legs; that is, of 126
localities, in 77 it was in the extremities, and in 22 more, in
other peripheral districts of tiie vascular system (ears, nose,
genitals).
As far as the pathology of the cases is concerned, they may
be divided into two classes: 1, those with a discoverable clot;
and 2, tliose Avithout such a clot. Murchison believes that all
cases of spontaneous gangrene arise from arterial thrombosis,
but the careful post-mortem examinations of Estlander and
others show, that at least in the larger visible vessels, sometimes
no such thrombus exists.
1. Those with clot. The cause of sneh clots, as Humphrey^
and others have shown, is not the condition of the bloodvessels.
But seldom have I found it stated, that the arterial walls were
diseased ; and when tliey were, it was presumably a secondary
process, the result, and not the cause of the clot. Few, if
any, pathologists will now attribute such results, with Bour-
geois, to a metastasis, especially when arising in convalescence,
as these so frequently do. Gigon has attributed them to chemi-
cal alterations in the blood, which give it an irritative character,
and this, with friction at points of curvature, produces inflam-
mation and coagulation. If so, a fair proportion of cases
should be seen in the upper extremities, where the same irri-
tating blood circulates and similar curves exist. How rare
tills is, we have alread}' seen.
' Brit. Med. Journ., 1859, p. 582.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 35
Although the precise factors in determining the thrombosis
in any individual case may be somewhat doubtful, as also why
it is frequent in one epidemic and rare in another, apparently
frequent in Germany and rare in Britain, and especially in the
United States, yet three causes clearly exist which may vary
inter ae in producing the result: 1, the altered blood; 2, the
weakened heart ; and 3, the mechanical difficulties in carrying
on the circulation, especially in distant parts.
That the blood is profoundly altered, and probably has an
increased coagulability, is conceded. In some cases even air is
found in the veins, as noted by Crisp^ and Lebert.^ That every
such change, besides its depressing effect upon the nutrition,
and therefore upon the vitality of the tissues themselves, would
interfere more or less with its circulation, and consequently
predispose to thrombosis, is most probable. But when we
look at the seat of the cases of gnngrene of both varieties
which are under consideration, I think the conclusion is
inevitable, that the last two causes are the more immediately
determining factors.
The heart, as Stokes showed, is softened in its texture, and
therefore weak. Hayem (see bibliog.) has shown that myo-
carditis is extremelj^ frequent, and not rarely involves the
endocardium. From the sixth to the fourteenth day is its
weakest period, and not onl3' is the general force of tlie circu-
lation diminished at this time, but all the blood not being
squeezed out of its cavity, clots may form in the heart, and
then, or at a later period, when the heart regains somewhat of
its force, be washed into the circulation and lodge as emboli.
Such seems to have been the origin of tlie clot in a remarkable
case related by Patry.^ A decolorized adherent embolus was
' Dis. Bloodvessels, p. 18.
2 Prag. Vierteljahr. 1858, i. 33. Moorehearl, Trans. Med. and Pbys.
Soc. Bombay, 1843, p. 6S, also reports a case.
3 Archiv, (jl6n,, 18G3, i. 144.
36 THE TONER LECTURES.
found high up in the left external carotid, on which a secon-
dary thrombus had formed nearly down to the bifurcation of
tlie primitive carotid. Pain appeared from the jaw to the
temple on the twentieth day of typhoid, two days later the
ear was cold and violet, the arterj^ pulseless, and the gangrene
rapidl^^ extended to the entire left side of the head and face,
involving even the bones. I have found, however, but eight
other cases in which the embolic nature of the primar^^ obstruc-
tion was clear; but often the want of a minute examination of
the clot renders the report useless ; and sometimes probably
the primary' embolus is so overshadowed in size and importance
by the secondary thrombus as to be overlooked.
The third factor, the mechanical difficulties of the distant
circulation, combines almost inextricably with the weakened
heart in i)roducing the spontaneous coagula or thrombi. It is,
nevertheless, clearly the principal factor in precipitating the
gangrene in the lower extremities. Not oi\\}\ however, are the
inferior parts of the body thus involved in gangrene, but the
frequency of venous thrombi, and the resulting phlegmasia in
the same region, is a strong argument in the same direction.
Bouchut* found in 51 cases of non-puerperal venous coagula,
that 44 were situated in the pelvic, femoral, or tibial veins. I
have memoranda of 63 cases of venous coagula following the
continued fevers in which the site is stated. Only two cases
involved the upper extremity alone, and were both followed by
gangrene; one involved both the arm and leg; all the other
60 cases were limited to the lower extremities.^ Both forms
of coagula—the arterial and the venous—form most frequenth",
during or just after the period of greatest cardiac weakness
—
a weakness felt most at such distant points as the legs. Of 18
' Gaz. Med. de Paris, 1845. p. 241.
^ See a very interesting case which got well after a second attack of
typhus thirty years later. Stokes on Fevers, Phila., 1876, p. 249 (repub-
lished in Med. News and Library),
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 37
arterial cases 12, ami of 43 venous eases 24 occurred in the
second and third weeks of the fever. Moreover the preceding
circumstances, such as famine, individual poverty, and the
deprivations of war, are sucli as impair the nutrition and the
circulation in the peripheral districts of tlie body. The
coagulation also takes place at points mechanically favorable
to slowing of the currents, e. g., the bifurcation of arteries and
the valves in the veins.' In the veins at least, as described bj'
Humphrey, the clots are sometimes laminated, the outer Ia3'er3
of decolorized fibrin, and therefoi'e the oldest, and the centre,
a bar-like recent coagulura of dark or black blood.
Once that the obstruction exists in the artery, it extends by
additional coagulation, so that tiie collateral circulation ma}'
be widely and rapidly cut off. The progress of the clot can
often be watched from da}'' to day by the progressive annihi-
lation of the pulse, first, for example in the tibial, then in the
popliteal, then in the femoral or higher ; and by the parallel
progress of the gangrene. In cases of recovery this cessation
of the pulsation and the hard tender cord in the course of the
vessels are of course, the onl}', but sufficient proof of their
occlusion. That gangrene follows so much more frequently
in febrile thrombosis than after the traumatic thrombus which
accompanies ligation, is not surprising, in view of the condition
of the blood, the general enfeeblement, and the moi'e wide-
spread arrest of the collateral circulation. Yet, on the other
hand, pyemia, which has so much to favor it, especially in the
cases of venous thrombi, is a rare sequel. Even when it does
follow, it is in most cases apparently the secondary result
from the septic influences arising from the gangrenous parts.
The circulation in the artery being cut off, it is not strange
that clots should follow in the veins, but even where both are
' See a carefully reported case of Phlegmasia by Cole, Med. Times
and Gaz., 1875, i. 5.
38 THE TONER LECTURES.
obstructed, moist gangrene rarely follows. The foot especially
generally mummifies. But this is not always the case. Occa-
sionally the gangrene is moist from the beginning, from early
obliteration of the vein, or having begun as dry gangrene, e. g.
of the foot from a popliteal clot, suddenly both the femoral
artery and vein may be obstructed, and a moist gangrene of
the leg or thigh be added. Gangrene from venous obstruction
alone is very rare. It is more apt to follow in the arm than
the leg.^
Coagulation of the blood may also be caused occasionally
by direct mechanical causes in fevers, as in a case given by
Jaesche, in which a swollen gland surrounded the common
iliac artery at its bifurcation and caused a clot, probably by
direct pressure or by induced arteritis.
2. The second varietj' of spontaneous gangrene is that in
which no clot apparently exists— certainly no such clot as is
commonly designated either an embolus or a thrombus, that is,
a locnl clot in an arterial trunk of some size which cuts off the
circulation in the tissues supplied by its branches. But oxen
in these cases I believe that the conditions affecting the circu-
lation already so fully considered, will more readil}^ and
rationally explain the causation of the gangrene than any
specific action of the indefinite though undoubted poison of
the fever. Coagulation I believe still to be the cause, but not
in the larger trunks. It begins rather as a blood stasis in the
capillary circulation. The parts in which the often extensive
coagulation takes place are at once struck with gangrene, and,
as the blockaded vessels themselves are all involved in the
general destruction of the gangrenous tissues, all evidence of
the nature of the lesion is thus destroyed. This form of gan-
grene occurs generally in the nose, ears, penis, i^erineum,
' Hueter (Virchow's Archiv, xvii, 48) records, however, a very inte-
resting case of gangrene of the right log following a spontaneous clot
without assignable cause, the vein wall being healthy.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 39
labia, feet, and occasionally the fingers, that is, in parts sup-
plied by no one large vascular trunk, but by many smaller
branches ; not only in parts distant from the centre, such as
the feet, but in parts which lose their heat most readily by
reason of their thinness and small size ; and parts irritated, it
may be by local discharges. Very probabl\', also, it may be
due to the fatty degeneration of the smaller arteries as
observed b^"^ Hoffman, Zenker, and Ponfick. Raymond (and
following him, Fischer and Estlander) ascribes it to a spastic
ischsemia, from contraction of the arterioles. The frequent
bilateral or symmetrical character of this variety, to which
Ka^-mond has called especial attention, would indicate, at least,
the probability of some such central cause. Whether, if it
exist, it be the direct result of irritation of the nerve-centres,
as is seen in the other nervous phenomena of fever, or whether
it be a reflex spasm caused by the circulation of a deteriorated
blood, similar to that to which Dr. George Johnson has
attached so much importance in Bright 's disease, we can at
present only surmise.
The symi)toms of gangrene are marked and characteristic.
Towards the end of the fever, especially in the third week, or
earl}' in convalescence, as weakness is giving place to strength,
and the brightest hopes of speedy recovery are cherished,
sudden, severe, and persistent pain is felt. Usually it is at
the seat of the impending gangrene, though not uncommonly at
the clot itself, radiating thence to the peripher3^ In the lower
extremities it is often felt in the ball of the great toe or in tiie
heel. It is followed by numbness, coldness, loss of sensation,
and sometimes of motion, and in a short time discoloration
and all the other usual evidences of gangrene appear. Some-
times, but not usually, these local symptoms precede the pain.
If the distal vessels be examined, the pulsation will be found
feeble or utterly extinguished, while higher up at the seat of
the obstruction they will l)e changed into moderately firm but
40 THE TONER LECTURES.
tender cords in wliicli we may sometimes differentiate the
artery from tlie vein—an important point in prognosis. Week
by weelv, sometimes day by day, the i)rogress of the coagulum
may be traced upwards by the abolition of the pulsation and
by the upward march of the gangrene. If old cicatrices exist
they will be among the earliest parts to yield. Blebs may
form in the early stages, but most frequently they will dry up
and the parts will mummify, although, as already indicated,
moist gangrene may supervene if a large clot form higher up
or if the veins are extensively obliterated, thus involving great
masses of moist tissue, such as the thigh, in sudden ruin.
Life may be rapidly destroyed, as in a case recorded by
Barker and Cheyne,^ in two and one half liours after gangrene
began in the nose; but more commonly da3's or weeks will
elapse during which nature as usual makes a powerful effort
to rid herself of the dead parts b}^ the establishment of a line
of demarcation. On the establishment of this, the pain often
ceases.
If recovery follow, the circulation is carried on by collateral
branches, or in very rare cases the artery again becomes par-
tially pervious.^ This last result Humphrey has shown to be
not infrequent in veins, and Petres' has recently elucidated its
mechanism through the extension and coalescence of the vasa
vasorum.
In the variety of gangrene without a thrombus, the symptoms
will vary somewhat. It is not so uniformly in the lower
extremity, and is much more frequently symmetrical. If small
in extent, pain is not apt to be a leading feature. The onset
is often earlier, and from the nature of the case its progress is
sharper and its limits much more quickly defined, so that
usuallj'', within a few days at least, the boundary of the gan-
> Yol. i. p. 232. 2 Patry, Archiv. C^n.. lHfi3, i. 136.
8 Ediab. Journ., Aug. 1875, p. 17.5, from Le Progrfes Med.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 41
gi'ene is pi'onouuced, since it does not progress with any
gradually growing thrombus. For the same reason it less
frequently returns in the stump after an amputation. Its area
also is usuall}^ much less than those cases in which a throm-
bus exists, rarely extending in the leg beyond the foot or ankle;
and it rarely involves surrounding parts to a large extent, if it
occur in the nose, ear, genitals, etc. Sometimes, however, it
may extend more widely, as in a case of typhus and starvation,
mentioned by Lj^ons,^ in which the patient walked to the work-
house, and on baring his chest the whole of the right side was
" a dark, olive-green, jell3'-like, tremulous mass." The abdomi-
nal wall is somtimes similarly involved. The probably irregu-
lar area in which the stasis of the blood will take place in this
form, also accounts for the great irregularity generally seen in
the line of demarcation ; whereas, if a clot exists, it is apt to
be fairly even. This sudden history is usually followed by a
speedily decided issue. Death follows quickly, or reaction and
recovery set in within a sliort time, instead of hanging in the
balance for months.
The results of spontaneous gangrene vary much according
to its situation and extent. In the extremities, if life be saved,
the result is usuall}'^ an amputation, either by nature or by the
surgeon. In the nose, it may perforate the septum or destroy
the entire organ to a greater or less extent. During some
civil, as well as military, epidemics of typhus, this seems to
have been a favorite spot for its beginning, so that the disease
was popularly known early in this century as the " Blue Nose" f
and inspired terror whenever it appeared. In 1834, Mauthner
says, it was an extremely common result, seen in all the
military hospitals, and "all hope was gone as soon as this
dreadful symptom was seen." Another not infrequent form is
' On Fever, p. 191.
2 See Mauthner, Kraft, Gutbcrlet, Wendelstadt, and Barker and
Cheyne. i. 232.
43
42 THE TONER LECTURES.
noma, or cancrnra oris. This is especially frequent in children
and in the arm}-. Murchison speaks of it in the Crimea, as
frequent and invariably fatal ; Ch^nu, however, in his report
does not name it. Its ravages are extremely extensive, often
involving even the bones.
The ear, also, and the e3^elids are sometimes destroyed.
From each of these, singly or all together, the most frightful
deformities often follow, which require the utmost ingenuit}' in
the plastic operations necessary to remedy them. In many
cases the gangrene is local and subcutaneous, producing ne-
crobiotic masses of tissue, which are, I believe, often, if not
generally, the cause of the abscesses so commonly seen in all
parts of the bod}^ Sometimes even the mediastina are opened,
the anterior from the chest wall, the posterior from the deep
tissues of the neck ;' unless, by a timely surgical operation, the
danger be averted.
The male genitals are occasionally destro3"ed to a greater or
less extent. Except the organic destruction, no special result
follows, except, possibly, hemorrhage, for one case is recorded
of death from a hemorrhage of fl^xxx from the scrotum.^
That the perineum and the female genitals are not more
frequently the seat of gangrene, is rather surprising, when we
consider the neglected condition of many of the patients and
the constant soiling of the parts, as a result of unconscious and
unavoidable discharges, especially in females. The troubles of
the female generative organs ai'e either distinct external gan-
grene, or gangrenous ulcers in the vagina. I have found 9
cases, 8 from typhoid and one from typhus ; all in j'oung per-
sons from IT to 2 Y years of age, except one of 34. In 6 of the
cases there was gangrene of the labia, extending sometimes to
the perineum and the thigh. At least one case was followed b}^
' See Bibliog'. Fraentzel, Werner, and Hoffman, p. 388.
2 Murohison. n. 194.
^— ^ Q .
c , p.
SURGICAL COMPLICATIONS AND SEQUELS OP FEVERS. 43
contraction of the v+ilva.^ In another, reported by Gueneau de
Mussy, there was complete occlusion of the vagina and men-
strual retention, necessitating puncture, with a fatal result.
The ulcers are generally on the posterior wall of the vagina,
and in three cases recto-vaginal fistula? have resulted. One is
reported by Lebert, in which, when convalescent in the seventh
week, chill, fever, and diarrhoea set in, and four weeks later
the fistula was discovered by injection. It was situated in
front of the h^nnen, and was as large as a 5-centime piece.
A month later she died of pelvic peritonitis. A second is
reported by Liebermeister.^ It was caused by the sloughing
of a large piece of the recto-vaginal septum, in mass. The
large fistula thus produced healed without operation. The
third case has been under my own observation, in St. Mary's
Hospital, for three years past, and is the only case I have
found of both recto-vaginal and vesico-vaginal fistulas. Up to
March, 1872, she was perfectly healthy, when, at the age of
thirty-four, she had a severe attack of t^q^hoid, for four months,
following exhaustive nursing during her husband's fatal
illness. About the fourth week the labia sloughed away
to a large extent, and both water and feces passed b}^ the
vagina. In October 1812, she was admitted to the hospital,
under the care of my colleague. Dr. Grove, having two large
vesical openings (separated by a slight bridge of tissue),
which destroyed the posterior part of the urethra and all the
floor of the bladder up to the uterus ; and one rectal opening
an inch in diameter, one and a half inches above the anus.
Dr. Grove operated on her three times unsuccessfully ; once on
the rectal opening bj^ the rectum, when he divided the sphincter,
and twice by the vagina. From Dec. 1873 to Dec. 1875, I
have done nine operations. Thrice unsuccessfully I attacked
the fistulae proper, when, becoming convinced that the attempt
* Russell, Glasgow Med. Journ., 1864-5, xii. 165.
* Ziemssen's Cyc, Amer. ed., vol. i. p. 184.
44 THE TONER LECTURES.
to close them was hopeless, I proceeded to close the vagina.
At fir«t 1 attempted to preserve and utilize the remnant of tlie
urethra, which gave me great trouble and necessitated several
operations ; but at the last operation, Dec. 28, 1875, I gave up
the attempt, excised the useless urethra, and closed the entire
vulval aperture by ten wire sutures. The operation has been
a complete success. At present, after nearly seven weeks, she
defecates, menstruates, and micturates entirely by the rectum,
and without the slightest trouble. She rises usually once,
sometimes twice, in the night, and micturates only five or six
times during the day. My greatest fear has been that the
softened feces would pass into the vagina or bladder and give
trouble, but thus far at least, none has arisen, and she is
happily rid of the annoyance of four years.^ In the last four
operations, instead of the usual sigmoid female catheter to
empty the bladder, I inserted the curved branch of a pocket
case male catheter into the vagina and bladder, by the recto-
vaginal fistula, thus draining these cavities, while I drained
the rectum below the eye of the catheter, by an ordinary drain-
age tube inserted into the rectum, lest the feces should be
softened and then pass into the vagina. They answered admi-
rably. The difficulty in obtaining a cure, I believe lay
partly in the inherent difficulty of the case, and partly in her
deteriorated health ever since the fever.
The perineum suffers mostly in males as 8 to 3, while in 2
cases the sex is not stated. Typhoid was the cause in 11,
typhus in 2. Although not all cases of gangrene, they may
be surgically grouped together, since all but one produced
perineal fistulse. The exception^ was a case fatal from a large
' Soon after this was written, a small fistulous opening appeared in
the cicatrix, caused probably by the feces. This healed after a thir-
teenth operation, and now (May, 1877} she has remained entirely well
for over fifteen months. The rectum has answered perfectly both for
the urine and the menstrual discharire, as stated above.
2 De Change, Arch. Belg. de M6d. Mil., 1861, xxviii., 126.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 45
abscess around the membranous urethra. Three fistulte were
caused by necrosis of the pelvic bones or sacrum, and nine by-
gangrenous ulcers, whii-h sloughed not onl}' externally, but in
five, certainly communicated with the rectum, and probably
did so in others. Except two cases of 21 and 22 years of age,
they all occurred (when the age is stated) from 39 to 74 years
of age, later in life than most of the other sequels. They
arose from the third to th'e seventh week, that is, during dis-
tinct convalescence, and to this is probabl}^ due the fact tliat
10 recovered and 2 died, one from the peri-urethral abscess,
the other from hemorrhage upon sloughing into tlie rectum.
The question of treatment of gangrene is, after all, the most
important in a practical point of view, and is divided naturally
into the preventive and remedial. The general supporting
treatment of the disease is, of course, the most important
preventive. Next, a careful and repeated examination of the
body, especially the parts most likely to be attacked. If gan-
grene is specifically threatened, stimulation of the circulation,
both at the centre and at the threatened spot, is imperative.
To stimulate the centre, alcohol in liberal doses is the best
remedy, and two extremely instructive cases are given by
Stokes.^ In one, "the surface was cold, and tlie pulse imper-
ceptible. From the middle of the calf of each leg downwards
over both feet, the surface was black, the skin hanging in loose
wrinkles, giving an appearance as if the i)atient had on a pair
of black socks." Sixteen ounces of brandj^ in the first eight
hours saved his life. Digitalis might also possibly be used
with advantage. The peripheral circulation must be stimulated
bj' such means as will assist the threatened circulation by
inducing alternate dilatation and contraction of the arterioles.
Permanently wrapping up the part in cotton, and other similar
means, will but assist permanent vascular dilatation and stasis.
' On Fever, Pliila., 1876, p. 205.
46 THE TONER LECTURES.
The alternation of the two is the condition of health, and its
artificial production will tend to restore healthful reaction.
Chapman's ice and hot-water bags to the spine, alternate
heat and cold directly to the parts, with proper friction and
stimulating liniments, at once commend themselves, to us.
The constant current battery also may prove an extremely
useful aid, since it dilates the deep as well as the superficial
vessels, and will aid the collateral circulation.
But suppose gangrene actually occurs, what then ? Est-
lander gives most judicious counsel here. We must remember
that good results follow both to life and limb loithout opera-
tion, especially if the gangrene be limited and the patient not
too exhausted. "We must not, therefore, be rash in our inter-
ference. If amputation has to be done, the question as to
where it should be done, depends on the probable extent of
the gangrene ; as to when, on the line of demarcation. In the
non-thrombotic cases, as the line of demarcation is usually
established within two or three weeks, and the disease is not
then likely to be progressive, the amputation may be done but
little above or even through it. It is, therefore, usually best
to wait for its formation. In the thrombotic cases, the clot and
the gangrene are apt to be progressive. Until the line of
demarcation forms, therefore, it is impossible to say precisely
where the disease will stop. Yet we can gain some idea of the
probabilities of the case from past experience.
If the clot extend no further than the popliteal, the limb
may escape gangrene altogether, and if it follow, I have found
it limited in 9 cases, to the foot 4 times and to the upper calf
in 5 ; if the clot extend into the femoral, I find the gangrene
extended to the upper calf in 6 and to the thigh in 4 ; if the
clot extend above Poupart's ligament, I find in 10 cases it was
limited to the foot in one, the calf in 3, and extended above the
knee in 6. ' The results of amputation are good, giving 21
recoveries to 21 deaths, but the recoveries are largely after
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 47
amputations in the foot. Before demarcation was established,
5 out of 8 died ; after demarcation, 12 out of 22, a mortality,
respectively, of 63 and 55 per cent. As a rule, therefore, wait
for the line of demarcation, but amputate soon after its appear-
ance ; but if danger of septic poisoning, or of speedy exhaus-
tion should appear, amputate at once, at or aboA-e the probable
limitation of the disease, which, if tiie femoral be free, will not
be, in the majority of cases, above the tubercle of the tibia;
but if the femoral be involved, amputation would probably be
more dangerous than the expectant treatment. As dead parts
slough, they should be removed to prevent septic poisoning.
Fortunately there is but little danger of hemorrhage, either
primary or secondarj-, in the thrombotic cases, since the
arteries are all plugged securely.
Of course, the ordinaiy treatment of the gangrenous ulcers
and abscesses, especiall}' of the perineum and genitals, should
be pursued, but I would especially urge the importance of free
incision, especially in abscesses in the Aicinity of the anus, and
the use of detergent and stimulating washes in the vagina in
case of sloughing of the labia, in order to prevent in both cases
the establishment of fistulse.
V. H^MATOMATA.
The muscular sj'stem suffers, in typhus and typhoid fevers,
in common with almost every other tissue of the body,
undergoing a peculiar form of degeneration, resulting some-
times in rupture and the formation of hsematomata. These,
although not so strictl}' surgical as some of the other diseases
noted, yet, as their proper surgical treatment is so important,
I shall notice briefl}'.
Apparentl}^, tlie first published case was observed b}^ that
shrewd surgeon Yelpeau, in 1819, in the post-mortem exami-
nation of a soldier at Tunis. " Rupture of the muscles of the
48 THE TONEU LECTURES.
belly," saj's he, " is not siir[)risiiig. The organs become so
fragile in advanced stages of putrid fever that tlieir rupture is
a phenomenon which is easily conceived when the patient in
his delirium moves so irregularly." In 1844 Rokitansky
noted their relation to typhoid. Yirchow studied them also in
1857. In 1SG4, however, Zenker first studied the subject
thorougldy. Since then, but especially within the last five
years, they have been frequently observed or studied, mostlj',
however, from a pathological standpoint.
The muscular changes to be described are so frequent as to
be almost an essential part, at least, of tj'phoid. Yet they are
not peculiar to these fevers. They are said to have been met
with in phthisis, scurv}^, scarlet fever, cholera, pneumonia,
dj^senterj', measles, tetanus, Bright's disease, cerebro-spinal
nicningitis, muscular traumatism, and I have seen a similar
change in the muscles of the abdomen, in cases of large
ovarian tumors.
There are two independent forms: 1, a granular degenera-
tion of the muscular fibres, which is least frequent ; and 2, a
waxy change, which is by far tlie commonest. In the micro-
scope the muscular tissue presents a glass^^, translucent,
slightly opalescent, shin}' appearance, the fibres being swollen
to eA'en double their usual size, and changed to fragile
cjdinders. Sometimes the muscular tissue resembles even the
flesh of fish. The nature of the change is as yet greatly
disputed. Erb, Bernheim, and others attribute it simply to
post-mortem imbibition ; Haj'em, to proliferation of the tunica
intima, which, with granulo-fatty change in the arterial walls,
produces an obstructive arteritis ; Zenker ascribes the degene-
ration to the disturbance of a centre which regulates the
nutrition of the muscles; Waldeyer, Hoffman, Ranvier, and
Weihl believe that it is a coagulation of the myosin ; and
Liebcrmeister that it is due to the long-continued high tempe-
rature. Whatever the cause, the muscles become extremely
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 49
fragile, and when the}'- are called into play by the distension
from meteorisin, b}' the efforts at coughing and other violent
respiratory acts, b}' defecation, rising in bed, the movements
of the legs, etc., they rupture with the greatest ease. Spasm
or direct violence does not seem to have been noticed in any
case. The arteries, which have also undergone an analogous
change, are involved in this rupture, and muscular hemorrhages
result. These assume three forms, according to their size and
mechanical limitation: 1, ecchymoses ; 2, difluse infiltration
into the muscular tissue, soaking it with blood; or, 3, distinct
hoematomata, the last being the most important and probably
the most frequent. The effused clot, at first hard, well defined,
and sharply limited, graduall}^ softens and not infrequently
suppurates, thus producing serious abscesses which, unless
opened, may even burst into the peritoneal cavity.^ Meanwhile
the swollen muscular fibres gradually undergo re-absorption,
until, finall}', they disappear entirel}^, and a new formation of
cells takes place in the perimysium, which, accordino- to
Hoffmann, first become spindle-shaped, then coalesce endwise
with one another, and gradually assume the appearance of
striated muscular fibre. Complete repair is then effected.
The resemblance of these spindle-shnped cells, which are nascent
muscular fibres, to tlie muscular fibre-cells is most striking,
and seems to form a link connecting the two forms of muscular
tissue, the striated and non-striated, such as I have long
taught to be probable.
Almost all of the muscles may be thus invaded, but
the favorite seats both for the degeneration and the hoemato-
mata are in the recti abdominis and the adductors of tlie thigh,
tlien in the pectorals, and, as Hoffmann has noticed in 16
cases out of 22, in the diaphragm. The influence of the
phrenic lesion in enfeebling tlie respiration is, perhaps, more
' "VVenzel Gruber in Jacops' Thesis, p. 42.
4
50 THE TONER LECTURES.
serious than has been recognized. Zenker gives the adductors
the first i^lace, and Hoffmann reports the adductors involved
in the degenerative changes in '15 out of 107, tlie recti in 87
out of 127. While this may be true of the degenerative
process, yet the hfematomata are certainly most frequent in
the recti. Of sixty positions in cases I have collected from
every side, they were in the recti in 27, and the "abdominal
muscles" in 9, in the adductors but 5 times, and the upper
extremities but twice.^ If in the adductors, they may buiTOW
so as even to strip off the periosteum from the bone. Hjema-
tomata are even found in the inter-ventricular septum of the
heart itself.
Stokes suggests that febrile deafness and hoarseness may
result from a similar degeneration of the muscles of the ear
and the larj-nx. There are no post-mortem examinations on
which to found such an hypothesis, and the fact that hoarse-
ness and deafness are so often not seen, and that, as I have
shown,^ other and sufficient causes are found at least in the
larjMix, render the idea scarcely tenable.
Typhoid was the preceding fever in 44 out of 46 cases, but
the severity of the fever seems to have but little influence.
Nineteen out of 25 cases occurred from 15 to 25 j'ears of
age, and 22 were males as against 8 females. They rarely
appear befm'e the third week, since the muscular fragility is
then at its height. Of 23 cases I find 19 arose in the third,
fourth, and fifth weeks of the fever. Regeneration of the
muscles usually begins at the third or fourth week, and is
accomplished by the seventh, after which time they do not
appear. Their period of development is therefore quite sharply
defined by the anatomical history.
As in dislocation of the hii>joint, the symptoms are often
' In the recti they are, I believe, invariably below the navel, possibly
on account of the absence of the support derived from the liueaj traus-
versae.
2 Ante, p. 25.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 51
nil. Indeed, of 47 cases, I find 10 were wholly unsnspccted
until revealed at the post-mortem. The position of the tumor
accounts in part for this. Both in the thigh and in the
abdominal wall they are almost alwaj's in the posterior part of
the muscle—a position due probably, to the effect of gravit}^
in the recumbent posture. Often, indeed, they are so deep as
to extend to the pelvic and iliac muscles, and in two cases,
under the serous coat of the bladder. Hence there is usually
little or no discoloration of the skin, though Foucault reports
a case with ecchymosis in the h3q30gastrium, extending later
to the scrotum, thighs, and buttocks Swelling is only
reported 13 times, and fluctuation but 10 times. Suppuration
and softening are but rarely attended with any special fever.
Pain is mentioned in 14 cases, j^'lexion of the legs to relax
the abdominal wall, which we would suppose to be frequent, is
named but once. Tlie size of these blood tumors varies from
that of a bean to that of an orange. If small, they may be
obscured by mcteorism ; the symptoms then being so indeci-
sive, as in many of these surgical sequels, the necessity for
frequent and rigid physical examinations is at once apparent.
If a sudden and fixed pain exist in the recti below the navel,
or even if movements be onl}^ hindered or uneas}^ and painful,
a close examination should be made, and if a tumor or onl}^
hardness be found, it should be carefully scrutinized, from
day to day, especially for the pasty feel and other signs of
oedema, and of fluctuation. The differential diagnosis is not
usually very dilTicult. The most likely error, if in tlie rectus,
is that of mistaking it for a distended bladder, but the
catheter will at once unmask this error. If in the right iliac
region, it may be mistaken for perityphlitis ; or in the adduc-
tors, for a simple abscess ; but, as in point of practice, the
treatment of all three would be more or less similar, the error
is of less moment than might be supposed. From aneurism,
an abdominal tumor, and peritonitis, the differential diagnosis
is sufficiently easy.
52 THE TONER LECTURES.
The treatment is important, especially when we consider
the results. Of 13 cases opened by incision, only 2 died; of
34 in which there is no mention of an operation, all died. If
small, they will either be overlooked until the post-mortem
reveals their existence, or if recovery take place, absorption
of tlie clot, and regeneration of the muscle will follow, inde-
pendent of treatment. If large, every possible effort should
be made by poultices, etc., to bring about early softening, and
as soon as softened, the}'^ should be opened. That the aspi-
rator ma^^ be of service, is probable, but as yet it is, I believe,
untried.
VI. PAROTITIS.
Parotitis is occasionally an exceedingly important surgical
complication, whose onset is always to be dreaded, lest it
bring in other evils worse than itself. Murchison believes
with Graves that the inflammation begins in the areolar tissue
between the lobules of the gland itself, but Hoffmann has
unquestionably shown tliat, at least in typhoid, the pancreas
and all the salivary glands are in a state of rapid cell prolife-
ration in nearly every case, and that parotitis proper is merely
"an exaggeration of the changes that usually take place in this
gland during typhoid fever, and bears the same relation to
these changes that ulceration and perforation of the intestine
do to the infiltration of the intestinal follicles." This exagge-
ration he believes to be due to the dense parotid fascia which
compresses the gland. But this is not the only role this dense
investing fascia plays. The compression of the swollen tissues
not rarely produces gangrene, so that the entire gland may
slough out in great masses like tow. In a case related to me
by Dr. Grove, it involved both glands and proceeded so far
that the fingers could almost meet behind the phar3'nx.
The compression also is very favorable to thrombosis, which
may extend to the brain by the diploic veins or even to the
internal jugular itsel£ Necrosis and septicaemia not rarely
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 53
follow in its track. In two cases I have found facial pais}',
from involvement of the seventh nerve. Facial deformity and
anchylosis of the jaw are sometimes seen. In none does
hemorrhage from the carotid appear to have followed.
The death-rate is largely increased in such cases, since of
352 cases, 125 died and 227 recovered, a mortality of nearly
one-third. The sex is named in onlj' 19 cases, of which 14 were
niales. Contrary to the fact in other complications, except in
perineal fistulfe, this disease is most common after 30. Of
211 cases, the average age, according to Murchison, was 3H.
It is certainlj^ very rare in children, for I have found but 2
cases under 15. Typhus was the preceding fever in 352 cases,
and t^^phoid in only 26. Most cases do not go on to suppu-
ration, for of 101, I find 40 suppurated and 61 did not. The
abscesses generally discharge by one or often by several
openings, the external meatus being frequently one of them.
As Ndlaton has pointed out, even where it has thus opened,
if we would avoid burrowing and other subsequent troubles,
we must open it still more freely, in order to divide the parotid
fascia.
CONCLUSIONS.
If now, by way of review, we cast our eyes back over the
general results of all the complications and sequels we have
studied, we may arrive at some useful and important con-
clusions.^
1. T3'phoid, probabl}' from its usuall}- longer duration, is by
far the more prolific source of such surgical troubles except
parotitis, especially when we consider that many cases tabu-
lated as typhus are really typhoid. Of 433 cases, typhoid was
the preceding fever in 252, typhus in 119, and other forms of
continued fever in 62.
' In this summary I have not included the cases of parotitis in the
figures.
54 THE TONER LECTURES.
2. The surgical troubles to be apprehended in typhus are
mainly restricted to gangrene and laryngeal stenosis, 103 out
of the 119 cases being due to these two classes of disease,
while typhoid bears in its train any and all of the forms
of disease described.
3. The age is about the usual age of greatest frequence of
these fevers.' From 15 to 25 years is by far the most fre-
quent decade, counting 133 cases against 129 at all other
periods of life. One singular exception is to be made, viz.,
the articular troubles, and especially dislocation of the hip, 21
out of 23 cases being under 20 years of age, of which 15 were
in children under 15—in striking analogy to the frequency of
coxalgia in children.
4. Sex is an unexpected and important factor in the predis-
position to febrile surgical troubles. Of 303 cases in which
the sex is named, 218 are males and 85 are females, or over
two and a half to one. What is the normal proportion of the
sexes in fever, it is difficult to determine. In nearly 6000
cases of t^'phoid, Murchison gives the proportions as precisely
equal, and in over 18,000 cases of typhus the females were in
a decided majority (8871-920*7). Estlander's figures would
give us a slight preponderance of males, while Liebermeister,
in over 2000 cases of t3'phoid, gives 1300 males and 750 females.
Unfortunately, I omitted to tabulate the number of cases
arising in military practice, which I am sure is not inconsider-
able ; but while this will account to some extent for the
predominance of males, it could not be adduced in the cases
of arthritis and dislocation, since most of the patients were
children, yet the males were in the preponderance,
' Leibermeister gives the ages in typhoid, as follows: 15-30, 1310;
30-71,- 394, total 1704. None under 15 were admitted. In typhus,
15-30, 39 per cent.
Murchison gives in typhoid : 15-25, 2752 ; all other ages. 3159. total
5911; and in typhus, 15-25, 5332; all other ages, 12,800, total 18,138.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 55
5. The period of development is not the initial period of the
fever, but first, from its height to its close, that is, the compli-
cations, especially gangrene and stenosis of tlie larynx ; and,
secondly and most freqiientlj^, during convalescence, that is,
the sequels. Of 240 cases, only 12 arose in the first week, 38
in the second, and 48 in the third, a total of 98. Jf we may
assume that convalescence, on the average, begins at the end
of the third week, then 142 occurred during convalescence,
when health is apparently in the near future.
6. The lower half of the body is tlie especial seat of such
surgical troubles. Vv'itii the exception, of course, of the
laryngeal cases and parotitis, of 307 cases 216 occurred in the
pelvic region and legs, as agains.t 91 in all other parts of the
body. Moreover, the diseases attacking the upper half of the
bod}' are limited almost entirely to local gangrenes and caries
and necrosis, and they are usually far less severe in type and
more limited in extent than those in the lower half. Here,
whole limbs are blighted by gangrene, here occur most of the
dislocations, the hsematomata, the fistulas, here the severest
necroses and largest abscesses, and were we to add the long
catalogue of bedsores and phlegmasise, the preponderance of
the lower half of the body in importance would be still further
increased.
T. The diagnosis is, in general, moderately eas}^ The
danger is not that difliiculty of diagnosis may obscure the case,
but that the diseases may be entirely overlooked. The}' occur
most frequently in parts of the body covered by the bedclothes,
parts whicli require time and trouble to expose and examine
in the routine of an ordinary visit. Moreover, the patient
is frequently so apathetic and insensible to pain, that he does
not complain, or, if he do so, it is ascribed to the ordinar}^
pains so frequent in the belly and legs in such fevers, or
else to delirium itself.
Hence the most important hint I can give in the diagnosis
66 THE TONER LECTURES.
and where indeed does the same rule not hold good ?—^^is, that
time and trouble must be taken, and that no patient, suffering
from a continued fever, and especially from typhoid, should
escape frequent, minute, complete, physical examinations, in
which every pai't of the body from head to foot should
be questioned. Especially should the physical condition of
the larynx, the bell}', the legs, and the toes, and in children,
the hip-joint, be exactly ascertained. This shonld be done
at least .every second day, and that too, not only in severe,
but in mild cases, and not only during the fever, but especially
in early convalescence, for it is in just such mild and con-
valescent cases that the wariness of the doctor is the patient's
surest reliance. Particularly should attention be paid to hoarse-
ness or even the slightest change in the voice, and the larynx
be examined at once with the greatest care from day to day,
by the eye, the finger, and the laryngoscope, lest sudden
CBdema or the more insidious and more fatal necrosis of
the cartilages be impending. The eye should seize upon
an}' hindered movements, even without discomfort, and no
complaint of pain should fall upon a deaf ear, especially if it
be in the throat, the belly-wall, the buttock, the hip-joint, the
legs, or the toes. True, it may mean nothing. It may be
the vagary of a wandering mind. But it may also be, as we
have seen, the herald of the gravest dangers whose attack may
be entirely repelled or their force broken by heeding this timely
warning.
8. The prognosis is naturally unfavorable, yet not to the
extent w^e would suppose from the addition or sequence of
such serious disease. Of 383 cases in which tlie result is
named, 220 died and 163 recovered, a mortality of 57^ per cent.
9. Still more clearly I think, after such a review, do we see
the powerful influence of mechanical causes as the proximate
factors in the production of such troubles, working in conjunc-
tion with the profoundly vitiated blood. With the exception,
SURGICitL COMPLICATIONS AND SEQUELS OF FEVERS. 57
perhaps, of the almost constant muscular degeneration, and
its not infrequent subsequent haematomata, these surgical
results are not usually primar}^ but secondary processes ; not
dependent directly on the fever-poison, but its indirect and
often distant results ;• not constantly seen, but incidental,
indeed, often rare ; not parts of the fever, but its complications
and sequels.
Pathologically all these results may be grouped into two
categories, viz.: 1. Those in "which a clot exists; 2. Tliose
without any clot.
1. Those in which emboli of cardiac origin, or more fre-
quently local thrombi exist, are unquestionablj" most of the
cases of extensive gangrene and phlegmasia. In many other
cases in which such a clot is at present unsuspected, I believe
that more careful examination will reveal its presence in tlie
smaller vessels, and prove that if venous, it may be a cause
of oedema glottidis, and if arterial, of the local "necrobiotic
processes, which result in necrosis^of the bones, and probably
of the cartilages of the lar3^nx, and gangrene of the soft parts
with its abscesses, fistuloe, etc.
2. Those in which no clot exists, and yet oedema glottidis,
drops}', and dislocation of the hip, gangrene, ulcers, necroses,
perichondritis, and other similar troubles occur. These are
especially often ascribed to the fever-poison itself, acting
locally and producing, for instance, the so called laryngo-
typhus, the abscesses and ulcers in the skin and subcutaneous
tissues etc., which are regarded as specific. While not denying
this view outright, and especially in some cases, I feel still
more strongly'' disposed to look upon them as allied disorders,
the immediate results, as in the case of the pneumonia of
fevers, of mechanical conditions, which produce a local stasis
of the blood followed by a?dema, low forms of inflammation
or gangrene. True, these results of fever are most frequent
in severe cases and severe epidemics, in which the poison
44
58 THE TONER tECTURES.
would be the most virulent, but it must also be remembered
that such epidemics and such cases are themselves, as a rule,
the result of exceptionally depressing pre-existing causes,
such as famine and war, want and sorrow. Even simple
inanition alone will produce identical results in many cases.
But it is especially when we consider the position of the
troubles that this mechanical factor is apparent. Their
posterior position, as is seen in the laryngeal ulcers, the peri-
chondritis, the vaginal ulcers, the fistulse, and in the hsemato-
mata the posterior surface of the recti and adductors, is most
significant. Likewise is the fact that all such complications
as we have seen, are especially frequent in the lower extremi-
ties, that is, in parts mechanically unfavorable to a ready
return of the blood and eminently favorable, if not to throm-
bosis, at least to stasis.
10. The treatment must be bold, but not rash; conservative,
but not timid.
]S;-oTK.—After the portion on Diseases of the Joints was stereotyped. I
received a letter from Dr. V. P. Gibney, of the Hospital for Rnptured
and Crippled, New York City, giving the results in 860 cases of disease
of the joints. The following is the only case which followed any con-
tinned fever, and it is not tabulated with the others.
" William H
,
fet. 12, presented himself at the out-door department
of the Hospital for Ruptured and Crippled, May 2, 1876. His general
condition was good. The right hip was anchylosed with the thigh, abducted,
semiflexed, and rotated inward, the trochanter carried upward, and the
pelvis tilted to the right side. There was apparent shortening of the limb,
but the real shortening was not ascertained. The thigh was atrophied
three inches. Immense cicatrices of bedsores were found, one over each
posterior superior spine of the ilium, one over the right natis, and one
over each trochanter major, that over the right being the deeper, and
covered by a scab one and three-fourths by one and a half inches.
" Prior to October, 1875, he was in perfect health, but was taken that
month with typhoid fever, and lay very ill for six weeks, during which
illness, the bedsores formed, and during convalescence the deformity at
the hip was observed. This history I obtained from the mother, who
was very intelligent. At the time I saw him, the disease was practically
arrested."
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 59
BIBLIOGRAPHY.'
I. WORKS REFERRING MORE OR LESS BRIEFLY TO SEVERAL DISEASES.
Flint, Clin. Rept. on Continued Fever, Pliila., 1855.
Hoffmann, Untersuch. liber die Patliolog. Anatom. Verander. der Organe
beim Abdominal Typhus, -Leipzig, 18G9.
Liebcrmeister, Ou Acute Infectious Diseases, Ziemssen's Cyc. Pract.
Med., N. Y., 1874, vol. i.
Murchison, Ou the Continued Fevers of Great Brit., 2d ed., London,
1873.
Trousseau, Cliuique Med. de I'Hotel-Dieu, 2d ed., Paris, 1865.
n. DISEASES OF THE JOINTS.
JBarth, Bull. Soc. Anat., 1853, p. 80.
JBillroth, Chirurg. Erfahr. Langenbeck's Archiv, x. 763.
JBoyer, Maladies Chirurg., iv. 316.
Capelle Quelques Consid. sur les Luxat. du Femur Survenues dans la
Cours de la Fifevre Typhoide epidem., Jouru. de Med. Chirurg., etc.,
Bruxelles, 1861, p. 456.
JDittel, Wien. Med. Wochen., 1861, p. 200; also in Journ. fur Kinder-
kraukh. 1861, p. 31, and in Gurlt's Jahresbericht, Langenbeck's
Archiv, iii. 183.
Graves, Clin. Med., 2d ed., pp. 201-2.
Giiterboek, Ueber Spontan. Luxat. und einige ander. Gelenkkraukh.
bei Ileotyphus, Langenbeck's Archiv, xvi. 58.
*Hellwig, Ueber die Affect, des Hliftgelenk. bei Typhus, Marburg, 1856.
Hliter, Klinik der Gelenkkrankh., pp. 686-7.
JLorinser, Wien. Med. Wochen., 1853, p. 353.
Roser, Die Lehre, v. d. Spontan. Yerrenk. des Oberschenkels, Schmidt's
Jahrbb., 1857, xciv. 120.
JSchotten, Archiv physiol. Heilkund, 1854, xiii. 118.
tSeitz, Deutsche Klinik. 1864, p. 109.
1 In the preparation of this contribution to the Bibliography of the subject, I
must acknowledsce my very great indebtedness to the card catalogues of the
National Medical Library, and of the private library of Dr. .T. M. Toner, and my
personal indebtedness for many facilities to both Drs. Toner and Billings.
Works marked t I have not been able to consult.
Those marked t are cases whose titles are omitted to save space.
Those marked * are Theses or Inaugural Dissertations.
60 THE TONER LECTURES.
fStromeyer, Hiindb. dor Cliirurg., 1844, p. 496.
Volkmauu, Pitlia & Billroth's Haiidb., Bd. ii., Abth. ii., Lief, i., 502-3.
III. DISEASES OF THE BONES.
fArniieux, Fifevre Typhoide, Osteite de rHumerus droit, Erysipfele, Mort.
R6v. Med. de Toulouse, 1875, pp. 42-3.
fBetz, Typhus mit Periostitis u. Synovitis, ]S[emorabil. Heilbronn, 1872,
pp. 497-501.
JBigelow, Boston Med. and Surg. Journ., 1867, p. 395, and private letter
giving subsequent amputation and fatal result.
Birkett, Necrosis of Condyle, etc., of Lower Jaw after Typhus, Trans.
Path. Soc. Lond., 1855-56, p. 283.
*tBruant, Consid. sur quelques cas d'Osteo-Periostite h, la suite de
* * Fifevres Graves, Paris, 1873.
JBuck, Trans. N. Y. State Med. Soc, 1864, p. 173; Circ. No. 6, S. G. 0.
Surg. Sec, Spec 557, p. 53; Med. and Surg. Hist. War of the Rebel.,
Pt. i., Surg, vol., pp. 375-7, and Buck on Reparative Surgery.
JDurham, Guy's Hosp. Rep., 1870, p. 521.
Englisch, Beitrage zur Lchre von den Nachkrankh. des Typhus, Wien.
Med. Presse, 1867, pp. 1199, 1259.
JGairdncr, Glasgow Med. Journ., xii. 408.
JGay, Trans. Path. Soc London, xx. 290.
JGuy's Hosp. Mus. Catal., 1026^0.
JM. Hall, Edinb. Med. Journ., 1819, p. 552.
JLailler, Gaz. Hebdom., 1867, p. 652, and Med. Times and Gaz., 1867,
ii., 521.
ILebert, Anat. Pathol., ii. 579, pi. clxiv.. Fig. 9, and Prag. Viertelj.,
1858, i., 40-2.
JMartin, Moniteur des Sci. M6d., 1859, p. 371.
Meusel, Beitrag zur Kentniss der Nachkrankh. von Typhus, Thrombose
der Art. Mening, Med., Schadelnekrose, Resection, Heilung, Deutsche
Klinik, 1872, pp. 265-7.
JMurchison, Acute Necrosis of Sternum. Ilium, and Acromion, Trans,
Path. Soc. Lond., xv. 181. (Doubtful case.)
IPatry, Archiv. G4n., 1863, i. 150-1.
JRobinson, Buff. Med. Journ., 1853, viii. 736.
Stanley. On the Bones, Amer. ed., pp. 76, 117, 118.
JSt. Geo.'s Hosp. Museum Catal., ser. ii. 95, and iii. 76.
tWarren, Boston Med. Journ., 1863, Ixviii. 500.
JWarren Museum, Catalogue of, No. 1323, p. 246.
Whatcly, Descrip. of an Affection of the Tibia, induced Ijy Fever, etc.,
London, 1810.
Whately, Pract. Observ. on Necrosis of the Tibia, and a defence of a
Tract entitled " Description, etc.," London, 1815.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS, 61
IV. DISEASES OF THE LARYNX.
Albers, Tracheot. bei Glottis-CEdom im Folge von Typlius, Langenbeck's
Arcliiv, 1867, viii. 176.
JAnderson, A., Ten Lectures on Fever, London, 1861, p. 4G.
Armstrong, Pract. Illustr. Typhus F., London, 1819, p. 399.
JBarthez, Ann. de Chir. FranQ., iii. 92.
Bayle, Sur I'CEdfeme de la Glotte, Nou%'eau Journ., iv. 1.
JBeck, Laryngot. bei einem Typhus Ki'anken., Verhandl. Phys. Medic.
Gesellsch., Wurzburg, 1868, i. 27.
JBergeron, Bull. Soc. Anat., 1857, p. 119.
JBlondeau, Bull. Soc. Anat., 18.58, xxxiii. 151.
fBonorden, Abdom. Typhus, CEdem der Glottis, Tracheot., Med. Zeit.,
1838, 156.
Buck, On CEdemat. Laryngitis successfully treated by scarif. of the
Glottis and Fpigl.. Trans. Ainer. Med. Assoc, 1848, p. 135.
Charcot et Dechambre, Des Affect. Laryngees dans la Fifevre Typhoide,
Gaz. Hebdom., 1859, vi., 465, 497, 706.
JOornil, Trav. Soc. M6d. d'Observ., Paris, 1859-63, ii. 769.
JCoues, Catalogue Army Med. Mus., Washington, Med. Sec, Spec. no.
207, p. 56.
fDeBroen, Presse Med., xxi. 20.
fDeLasiauve, Laryngitis Oildem., Ann. de Chir., Nov. 1844, and March,
1845.
JDinstl, Zeitschr. k. k.. Gesellsch. Aertzte Wien, 1853, no. 5, p. 472.
Dittrich, Ueber Perichondritis lai'yngea u. ihre Verhalt. zu ander. Krank-
heits-Proc, Prag. Viertelj., 1850, iii. 117.
JP^lster, Casus Earior Febr. Nervos. cum Abscessu Laryngis Compile,
Lips., 1829.
Emmet, On ffidema Glottidis, resulting from Typhus Fever, Amer. Journ.
Med. Sci., July, 1856, xxxii., 63-81.
*Farssac, De Certains Accidents qui compliquent la Convalec. de la
Fifevre Typhoide, Paris, 1872, p. 36.
JFieber, Die luhalat. Medic. Fliissigk., p. 44, quoted in Cohen, on Inha-
lation, p. 60.
Foot, Enteric Fever, compile during convalesc. with Acute (Edem. Glot.
terminating in Abscess of the I^arynx, Irish Hosp. Gaz., 1874, p. 211.
Frey, Uebcr Anwendung d. Laryngot. bei Typhosen Kehlkopfsleiden,
Henle & Pfeuffer's Zeitsch. f. rat. Med., 1847, vi. 1-11.
Genouville, Bull. Soc. Anat., 1859, xxxiv. 81. (Trousseau quotes this
as a case of typhoid, but it was not. See Report of Vidal, which
follows the case.)
Gibb, Diseases of the Throat and Windpipe, 2d ed., pp. 292-4.
tGilliard, Presse M6d., xxi. 20.
62 THE TONER LECTURES.
Griesihger, Iiifectionskraiikli., Virch. Haudb. Pathol., Erlangen, 1857,
Bd. ii., Abth. ii., S. lGO-2.
JGuersaiit, Bull. Soc. Chirurg., 1857-8, p. 586.
tOuyot, Bull. Soc. Anat., 1858, xxxiii. 151.
tH6rard, L' Union M6d., July 14, 1859.
Jenner, On Fevers, Med. Times and Gaz., xxi. 135 et seq.
JLacaze-Duthiers, Bull. Soc. Anat., 1848, xxiii. 149.
JLawrence, London Med. Gaz., 1844-5, i. 307, and St. Bartli. Hosp.
Museum, iii., ser. 25, no. 19. (Doubtful case.)
JLawrence, Med.-Chir. Trans., vi. 232.
Lisfranc, Mem. sur I'Angine Laryng. Q2d6m., Jouru. Gen., 1823,
Ixxxiii. 289.
Litten, Deutsch. Archiv Klin. Med., 1874, xiii. 298.
Loscliner, Klin. Beobacht. des Ileotyphus mit brandigem Kehlkopf u.
weitverbreitetes Eniphysem, Prag. Vicrteljahr., 1856, iv. p. 23.
Minnich, Typhus, Perichondr. Metastat., Glottis-ffidem, Laryngotomie,
Besserung, Wien. Med. Presse, 1874, 816-8.
JMohr. Casper's Wochenschr., 1842, p. 19?.
Moritz-Haller, Des Ulcer, du Larynx dans la Fifevie Typho'ide, Journ.
Med. de Bordeaux, 1856, p. 758, from Oesterr. Zeitschr. prakt. Heilk.,
1856, no. 19.
fObedenare, De la Tracheot. dans I'CEdferae de la Glotte et de la Laryn-
gite Necrosique, Paris, 1866.
JPachmayr, Zwei Falle von Typhus mit seltenen Complicationen, Yer-
handl. Phys. Medic. Gesellsch., "VYiirzburg, 1868, i. 2.
JPfeuffer, Zeitsch. f. Rat. Med., 3d ser., bd. v., uos. 2 and 3, quoted in
Amer. Journ. Med. Sci., July, 1861, p. 268.
JPorter, Catalogue Army Med. Mus., Washington, 1866, Surg. Sec.
Spec, no. 836, p. 483.
Ruhle, Die Kehlkopfs-Krankh. Berlin, 1861, pp. 151 and 257, and fig. 2.
Russell, J. B., On Subglottic ffidcma and Permanent Stricture of the
Larynx following Typhus, Glasgow Med. Journ., Feb. 1871, p. 209.
JRyland, Diseases and Injur. Larynx and Trachea, Phila., 1838, p. 78.
fSchiele, Obs. d'Abscfes au Larynx k la Suite d'une Fifevre Typli-i -A-U-
nuaire par Noirot, 1859, 214.
JSecond-Ferr^ol, Bull. Soc. Anat., 1858, xxxiii. 145.
Sestier, La Bronchotomie dans le cas de I'Angine Laryngee OEdem.
Archiv. Gen., 1850, 4me ser., xxiii. 385; xxiv. 35, 297, 441.
Sestier, Traite de I'Angine Laryngee (Edem., Paris, 1852.
tSpencer, Catalogue Army Med. Mus., Washington, Med. Sec, Spec.
no. 301, p. 30.
JSteiner, Dis. Children, London, 1874, p. 363.
*Szenic, Typhus Abdom. u. ihre Folgezustande, Berlin, 1869.
Turck, Kliuik der Krankh. des Kehlkopf., Wien, 1866, 215-235.
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 63
fTurck, Ueber Perichondritis Laryiigea, Wien. Med. Zeit., 18G1, no. 50.
JUlricli, Laryngo-Typlius, Laryiigotomie, Archiv. Gen., 1870, xvi., 3G6,
from Berlin, Klin. Woclien., 1869, no. 45.
Wilks, Remarks on Ulcer, of the Larynx and Emphysema in Typhoid
F., Med. T. and Gaz., 1862, ii. 276, and Trans. Path. Soc. Loudon,
1857, ix. 34.
V. GANGRENE.
^Andrews, Proc. Path. Soc. Phila., ii. 177.
JAshhurst, Proc. Path. Soc. Phila., ii. 153.
JBabington, Dublin Med. Journ., xxi. 45.
Barker and Cheyne, Ace. of the Fever lately Epidemic in Ireland, London,
1821, i. 232-9.
Behier, Rapport sur M. Bourgeois' Note sur la Gangrene, etc., L'Union
Med., June 13,*1857 and 18G1, pp. 145, 292.
JBell, Edinb. Med. Journ., July, 1875, p. 72.
JBillroth, Langenbeck's Archiv, x. 783.
*Blumm, Ueber Gangriln uach Typhus, Wiirzburg, 1872.
JBourdeau, Archiv. MM. Belg., 1874, 3d ser., vi., 73.
Bourgeois, Des Gangrenes des J^xtrem. dans la Fifevre Typhoide, Archiv.
Gen., Aug. 1857, p. 149, and L'Union Med., 1861, xii. 80 and 249.
Bourguet, Gangrfene Spontan6e de la Jambe, Gaz. Hebdom., 1861, 350.
Estlander, Ueber Brand in den Unter. Extrem. bei Exauthera. Typhus,
Langenbeck's Archiv, 1870, pp. 453-517.
JFabre, Gaz. M6d. de Paris, 1851, p. 539.
JFinlay, W. A., Edinb. Med. Journ., May, 1876, p. 1023.
Fischer, Zur Lehre vom Brande, Langenbeck's Archiv, xviii. 338.
fFranQois, Essai sur la Gangrfene Spontanee, Mons, 1832.
JGay, Trans. Path. Soc. London, xx. 290.
Gaz. Hebdom., 1867, p. 651 ; and also Med. Times and Gaz., 1867, ii.
521.
Gigon, Note sur le Sphacfele et la Gangrfene Spontanee dans la Fifev.
Typhoide, L'Union M6d., 1861, t. xi. 577, 611 ; t. xii. 127.
i'Grimm, Darstel. u. Eriirt. Eines Falles von Spontan. Gangriin, Bern,
1850.
Gutberlet, Die Blaue Nase bei dem Typhus Bellicus, Hufeland's Journ.,
1816, xlii., vi. 101.
JHayem, Edinb. Med. Journ., May, 1876, p. 1023.
Hayem, Legons Clin, sur les Manifest. Cardiaques de la Fifevre Typhoide,
Paris, 1875, lect. iv., v., p. 49 et seqq.
JHudson, On Fever (Gangrene of Nose), Eng. ed., p. 27.
JJaesche, Langenbeck's Archiv, 1865, vi. 701.
Kraft, Ueber Typhus Bellicus u. die Blaue Nase, Hufeland's Journ., 1851,
xii. 81.
64 THE TONER LECTURES.
Massei-oll, Eiii Fall von Sponfdner Gungraa nacli Abdom. Typhus,
Deutsch Arch. Klin. Med., 18G9, v. 445.
Muutlmer, Ueber das Typhose Fieber rait Nasenbrand, Ilufeland's Journ.,
1834, Ixxviii. 46.
Obre, On Gangrene of the Face, Ediub. Med. Journ., 1844, i. 105.
t*0schvvak1, Ueber den Brand., Bern, 1840.
JPachmayr, Zwoi Falle von Typhus mit seltenen Coniplicationen., Yer-
handl., Phys. Med. Gesell., Wurzburg, 1868, i. 1-26.
Pappelbaum, De Febre Malig. per Gangren. Pedis Dextri * * Critice
Soluta, Gutting. 1643.
Patry, De la Gangrfene des Membres dans la Fifevre Typhoide, Arch.
Gen., 1863, 129-52, 549-61.
t*Raynaud, De I'Asphyxie locale et de la Gangrfene symmetrique des
Extrem., Paris, 1862.
Roger, Sur le Rhino-Necrose, L'Union M6d., 1860, p. 468.
Russell, 300 cases of Typhus, Glasgow Med. Jouru., 1864-5, xii. 165.
JSquintani, quoted by Dechambre, Gaz. Hebdoni., 1859, p. 706.
JStokes, Med. Times and Gaz., 1849, xix. 251, and 1854, new series,
viii. 424.
Stokes, On Fevers, Phila., 1876, p. 210.
Suchanek, Die Typhus Epidemie in Schlesien, Prag. Viertelj., 1849, i. 115.
JVirchow, Yirchow's Archiv, ii. 200, 329, 346.
"VVendelstadt, Die Blaue Nase beim Typhus Bellicus, Hufeland's Journ.,
1816, xliii., v. 131.
VI. H^MATOMATA.
fBernheim, De I'Etat dit Cireux des Muscles, Gaz. M6d. de Strasb.,
1870, no. 7.
JBesnier, Bull. Soc. Med. des Hopit., 1869, p. 213.
JBuchanan, Trans. Path. Soc. London, 1865, p. 274.
*Chaparre, Etude sur les Hemorrhag. Muscul. dans la Fifevre Typhoide,
Paris, 1872.
JDauv6, L'Union M6d., 1865, p. 317, and Centralbl., 1865, no. 48.
Erb, Ueber die Sogenannt. Wachsartig. Degeuerat. der Quergestr. Musk.,
Virch. Arch., 1868, xliii. 108.
JFoucault, Bull. Soc. Anat., 1869, p. 498.
Hayem, Alt6rat. des Muscles Partic. dans la Variole, Gaz. M6d. de
Paris, 1866, p. 698, and M6m. Soc. de Biol., 1866, p. 93.
Hoffmann, Ueber die Neubild. der Quergestreif. Muskelfas. beim Typhus
Abdom., Virch. Archiv, 1867, xl. 505.
*Jacops, Etude Clinique sur les Abcfes Muscul. qui surviennent pendant
la Convalesc. de la Fifevre Typhoide, Paris, 1873.
*Jankowski, Typhus Abdom. Compile, mit Ruptur. der Geraden Bauch-
Muskeln., Berlin, 1869. Resum6 in Canstatt Jahresb., 1870, ii. 217.
SURGICAL COMPLICATIONS AND SEQUELS OP FEVERS. &5
fKlob, Pathol. Anat. Mittheil. liber Exaiith. Typhus, Wochenbl. Zeit-
schr. Gesell. Aertz. Wien, 1866, p. 331.
Kraft-Ebiiig, Ueber Muskelvereiter. bei Typhus Abdom., Deutsch. Arch.
Klin. Med., 1871, viii. 613.
*Labuzc, Des Abcfes Develop, daus la Gaiiie des Muse. Grand Droits
do I'Abdomen, Paris, 1871.
JLiouville, Bull. Soc. Anat., 1869, p. 501.
Litten, Deutsch. Arch. Klin. Med., 1874, xiii. 150.
Martini, Beitrage zur Pathol. Histol. der Quergestr. Musk., Deutsch.
Arch. Klin. Med., 1868, iv. 505.
JMurchison, Trans. Path. Soc. London, 1865, p. 275.
Popoif, Ueber die Yerand. des Muskelgeweb. bei Einigen Infections-
krankh. Virch. Arch., 1874, Ixi. p. 322.
Kussell, 300 Cases of Typhus, Glasgow Med. Journ., 1864-5, xii. 151.
Velpeau, Diet, en trente vol., article. Abdomen, Rupture de 1', quoted by
Jacops.
Yirchow, Wiirzb. Yerhandl., vii., and Yirch. Archiv, iv.
fWagener. Yerhalten der Muskeln in Typhus, Schultze's Arch. Mikros.
Anat., 1874, p. 311.
Waldeyer, Die Yerand. des Quergestr. Muskelfas. bei Abdom. Typhus
Centralbl., Med. Wisseusch., 1865, p. 97, and Yirch. Archiv., 1865,
xxxiv. 470.
Weihl, Ueber Wachsart. Degen. der Quergestr. Muskeln, Yirchow's
Archiv, 1874, Ixi. 253.
Zenker, Ueber die Yerand. der Willklirl. Muskeln im Typhus Abdom.,
Leipzig, 1864. See also Archiv. Gen6r., 1865, pp. 143, 290, and a
r6sum6 in Trousseau, Clin. Med., Eng. ed., ii. 334.
VII. DISEASES OF THE EYE.
Ch^nu, Rapport, Paris. 1865, pp. 520-3.
Dubois, Relapsing Fever and Ophthalmitis Post-Febrilis in N. Y., Trans.
Amer. Med. Assoc, 1848, p. 373.
fEstlander, Ueber Choroiditis nach Feb. Typhos. Recur., Archiv f. Oph-
thal., 1869, Bd. xv. Abth. ii. 108.
JGillespie, Edinb. Med. Journ., May, 1870, p. 964.
Haenisch, Die Complicat. u. Nachkrankh. der * * Typhus Recurrens,
Deutsch. Archiv Klin. Med., 1874, xv. i. 53.
fHewson, Obs. on History and Treat, of Yener. Ophthal., London, 1814.
Huss, Statist, et Trait, du Typhus et de la Fifev. Typhoide, Paris, 1855.
English ed., London, 1855.
Jacob, On Internal Inflammation of the Eye following Typhus Fever.
Trans. Queen's Coll. Phys., Ireland, v. 1828.
JJenner, Med. Times and Gaz., xx. 456.
5
66 THE TONER LECTURES.
Litten, Deutsch Arcli. Klin. Med., 1874, xiii. 308.
tLogestschiiikow, Uebcr Eiitzund. des Vorder. Abschnit. des Choroidea
als Nacbkrankh. des Feb. llecurr., Archiv f. Opbthalin., 1870, xvi. i.
353.
Lyons, On Relapsing Fever, p. 152.
Mackenzie, Post-Febrile Opbthahnitis in Remittent Fever, Lond. Med.
Gaz., 1843, p. 225.
*Munier, Cousid. sur les Malad. de I'CEil Consec. a la Fifevre Typhoide,
Paris, 1874.
Peltzer, P]rkrank. des Choroidal Tractus nach Febris Recurrens, Berlin.
Klin. Woch., 1872, p. 444.
Reid, Clin. Obs. ou * * Fever of 1826, Trans. Queen's Coll. Phys., Ireland,
V. 1828.
Trousseau. De la Fonte de la Cornee dans les Fifevres Putrides, Gaz. des
Hop., 1856, 170, and Cliniq. M4d. de I'Hotel-Dieu, 2d ed., p. 271.
Wallace, On a Peculiar Inflam. Disease of the Eye as a Sequel of Fever.
Med. Chir. Trans., 1828, xiv. 290.
VIII. PHLEGMASIA.
JBaginsky, Yirch. Archiv, xlix. 522.
JBaumler, Deutsch. Archiv Klin. Med., 1867, iii. 532.
Begbie, The Swelled Leg of Fevers Ediub. Med. Journ., Sept. 1872,
p. 249.
Bennett, Med. Times and Gaz., April, 1857, p. 410.
Bouchut, Gaz. M6d. de Paris, 1845, p. 241.
JCole, Case of Typhoid Fev. with Thrombosis of Left Innom. Vein, Med.
Times and Gaz., 1875, i. 5.
fCurrier, Phlebit. foil. Typhoid F., Vermont Med. Journ., 1874, i. 43-7.
JDriver, Boston Med. Journ., 1872, 306.
JEichhorst, Deutsch. Arch. Klin. Med., 1874, xii. 223.
JFergusson, Amer. Med. Times, 1860, p. 366.
JGairdner, Glasgow Med. Journ., xii. 395, 402.
Gigon, Vide under " Gangrene."
Graves, Clin. Med., 2d ed., p. 198.
Graves and Stokes, Dubl. Hosp. Repts., 1830, v. 29-32.
Humphrey, Formation of Clots in Veins during Life, Brit. Med. Journ.,
1859, 582-3.
JJameson, Provinc. Med. and Surg. Journ., 1842, v. 207.
JLeMaistre, Bull. Soc. Anat., 1848, p. 159.
Litten, Deutsch. Arch. Klin. Med , 1874, xiii. 307.
Martin, Journ. de Med. Chir. et Pharm., Bruxelles, 1853, p. 405.
JMoore, Irish Hosp. Gaz., 1873, i. 32L
I
SURGICAL COMPLICATIONS AND SEQUELS OF FEVERS. 67
JPaget, Cliu. Lects. and Essays, Loudon, 1875, p. 307, and St. Barth.
Hosp. Rep., ii. 82.
tPerry, Observ. on the present Epidera. of Typhus, Glasgow, 1866.
JRichardsou, Penna. Hosp. Repts., 1869, p. 287.
JRussell, Glasg. Med. Jouru., 1869, p. 270.
Stewart, Phleg. Del. after Typhus, Med. Times and Gaz., May 2, 1857.
Stokes, On Fevers, Amer. ed., 1876, p. 245.
Tweedie, Obs. on a Peculiar Swelling of the Lower Extrem. after Fever,
Edin. Med. Journ., 1828, xxx. 258.
JYogel, Deutsch. Archiv Klin. Med. viii., 342.
IX. MISCELLANEOUS,
JAndrew, Typhoid with Abscess of Prostate, Lancet, 1871, ii. 712.
JAstbury, Case "with Trismus aud Amaurosis, Edinb. Med. Journ., 1818,
pp. 158-163, and Lond. Med. Surg, and Pharm. Repos., 1818, pp. 71-3.
JChalot, Typhoid, Perineal Fistula, Gaz. Med. de Paris, 1875, p. 575.
JDaCosta, Typhus with Opisthotonos, Amer. Journ. Med. Sci., Jan.
1866, p. 44.
Dechange, Typhoule, compliqn^e d'Abscfes k la Region sous-pubienne,
Archiv. Belg. de M6d. Mil., 1861, p. 126.
Delairifere, Observ. d'une Fifevre Ataxique qui s'est Termini par une
Hydrophobie, Journ. de M6d. Chir. et Pharm., Paris, xiii. an. 15, p.
19. Cf. also R. Reid, Pathol, and Treat, of Fever, Trans. Queen's
Coll. Phys., Ireland, iii. 41.
JEuglisch, Typhoid, Perineal Fistulas, Wien. Med. Zeit., 1867, viii. 1201,
1259.
*Farssac, Tj'phoid, Abscess in Hands, etc., Paris, 1872, p. 230. (See
under Larynx.)
J Friedreich, Typhoid, Thyroid Abscess, Wlirzb. Verhandl., 1855, xv. 314.
JFraentzel, Ein Fall von Acuter Eiteriger Mediastinitis in Yerlauf eines
Ileotyphus, Berl. Klin. Woch., 1874, xi. 97.
J(Tibbs, Case with Trismus, Western Lancet, 1855, xvi. 465.
Gu^neau de Mussey, Case of Gangrene of Vulva followed by Complete
Occlusion of Vagina, Gaz. Hebdom., 1867, p. 652.
JHillier, Dis. .Children, 'J'yphoid with Abscess in Perineum, Amer. ed.,
p. 340.
JHughes, Typhoid with Abscess of Labium, Med. Times and Gaz., 1851,
ii. 355.
fjanzion, Obser. sur une Fifevre Maligne ou Ataxique ayant le Pria-
pisme pour Principale Symptome pendent la Duree du Redoublement,
Ann. Soc. de INl^d. de Montpel., iv. 1. 146.
JLebert, Case of Typhoid with Recto-Vaginal Fistula, Anat. Pathol., ii.
307, and pi. ex v.
JLouis, Ou Typhoid Fever, Case with Tetanic Symptoms, ii. 321.
68 THE TONER LECTURES.
JMaclagan, Case followed by Tetanus, Edinb. Med. Journ., 1867. p. 297
JMoutault, Case of Typhoid with Emprosthotouus, Jourii. Universel et
Hebdom., 1833, p. 516.
JPaulicki, Case of Typhoid with Spasm of Interossei of Hands and Feet,
Memorabil. Heilbroun., June 24, 1869, p. 60.
tSeidler, Typhoid with Rectal Fistula, Rust's Mag.. 1838, li. 541.
JSiredey, Typhoid, Abscess Lab. Maj., Journ. de M^d. et de Chir. prat..
1873, p. 486.
tSteinbbmer, Fall von Wiederholt. auftret. Embolien nach Typhus Ab-
dom. an Sich Selbst Beobachtet, Zeitschr. f. prakt. Heilk., 1866, pp.
109-116.
tSteinthal, Typhoid with Perineal Fistula, Deutsch. Klinik, 1858, p. 111.
Werner, Verbreitet. sinuose Geschwiire auf der Brust, Perfor. vorder.
Mittelfellraum, Plotzlich. Tod an Verblutung, Typhose Geschwiire im
Darm, Med. Corresp. Wurttemb. Aertzl. Verein, Stuttgart, 1859,
xxix. 76.
JWolff, Gangrene Ext. Genitals, Annal. Charite Krankeuh. Berlin, iii.
Jahrgang 1852, p. 97.