In a letter to the reader, dated April 22, 1901, Dr. Charles McBurney says that since resorting to his method of preventing hemorrhage, namely, direct pressure of the common iliac by the finger of an assistant through what is known as his gridiron incision, he has had no loss of blood and no patient has died as the result of the operation, or soon afterward from any cause. Several have died months later from recurrence of sarcoma. The advantages claimed for his method are: "The whole operative field is perfectly free from incumbrance of any kind. Cases requiring a very high anterior incision can be most satisfactorily handled. It is the only method applicable to amputation for extensive tubercular disease about the hip-joint and upper part of the femur, and the method has no disadvantages."

The special dangers which render amputations at the hip-joints such a formidable operation are from hemorrhage and shock. According to Lunning, "5 per cent of all patients operated on do not survive the operation, and 70 per cent of deaths occur within the first five days." Various methods have been suggested for preventing hemorrhage during the operation. Larrey advised preliminary ligation of the femoral artery; Pancoast, Lister, Esmarch, and others, instrumental compression of the abdominal aorta; Gross and McEwen, digital compression, by an assistant, of the same vessel; and J. J. Buchanan, of Pittsburgh, in 1888, in a paper read before the Pennsylvania Railway Surgeons' Convention, suggested "the opening of the abdomen and direct digital compression of the aorta through the incision," and Dr. Neal Hardy, of Sandusky, Ohio, used this method in a successful case in November, 1890. Woodbury, of Philadelphia, and Van Buren, of New York, advised digital compression of the common iliac, by the hand of an assistant, in the rectum; and R. Davie, of London, used for the same purpose a long rod with a knob on its end, known as the Davie lever. McBurney, of New York, in 1894, called the attention of the New York Surgical Society to his method of direct compression of the common iliac artery by the finger of an assistant, through what is known as his gridiron incision. W. L. Estes, of Bethlehem, Pa., practiced gradual dissection, in which the femoral vessels are first exposed, tied, and divided between two sets of ligatures. "The flaps are then formed as may be indicated, and the soft parts divided as for any operation of the body where a tourniquet can not be employed, all known vessels being secured before they are divided, and all others caught with forceps as soon as severed."

Jordan Lloyd, in 1883, used an Esmarch bandage in figure-of-8 turn around the hip and trunk, placing a roller bandage as a pad beneath it for pressure on the external iliac. Richard Valkman, in 1874, reports three cases in which, after driving the blood out of the limb into the body with an Esmarch bandage, he "placed an elastic loop in the femoral (scrolure commissure?), drawing the ends upward and outward, the anterior passing parallel with Poupart's ligament, the posterior near the gluteal fold, in which position it was held by an assistant. To further secure it in position, loops of roller bandage were thrown beneath the rubber tourniquet in front and behind, and upon these, during the operation, upward traction was also made by an assistant."

Trendelenburg devised a steel rod to be passed through the soft parts in front of the joint, and a rubber tube to be wound around its protruding ends in figure-of-8 turns. After the anterior flap is made the vessels are secured, and the rod is then placed through the soft parts behind the joint in a similar manner before the posterior flap is made.

Wyeth's method consists of two mattrass needles, one introduced one inch below and slightly to the inner side of the anterior superior spinus process of the ilium, passing beneath superficial muscles and emerging on the outer side of the hip about three inches from and on a level with the point of entrance. The other enters an inch below the level of the crotch, internal to the saphenous opening, passing through the adducta muscles and coming out an inch below the tuberosity of the ischium. The points of the needles are shielded with corks to prevent injury to the operator. A thick pad of gauze is placed over the femoral vessels. Above these needles a piece of strong rubber tubing is wound around the limb over the pad six or eight times and tied.

Senn first disarticulates the head of the femur through a long perpendicular incision over the trochanter, and then, with a long pair of forceps introduced into this incision and passed through the limb to the inner side, where a counter opening is made for them to emerge, he grasps a piece of rubber tubing in its center and pulls it through the limb. The tubing is then divided, and one part of it is tied anteriorly around the anterior portion of the thigh; the other is passed around the posterior portion of the thigh, and then brought around the anterior portion and tied, thus doubly securing the flap containing the femoral vessels.

As to the different methods of prevention of hemorrhage, I believe with Rudolph Matas that "none can compare with Wyeth's in

their general application, thoroughness, simplicity, and wide range of usefulness." Hot salt solution has played a very important part in lowering the death-rate of this as well as of other big operations. While it is of incalculable value in shock from loss of blood, it is also very beneficial in surgical shock without hemorrhage. The best effect is secured when the saline solution is given by intravenous infusion. The temperature of the solution should be from 101° to 115°, and it should be injected slowly at about the rate of a pint in fifteen minutes. Dawbarn suggested the idea that to introduce the hot salt water directly into the blood-current would bring the heat immediately into the heart, and thereby stimulate the heart and respiratory center of the medulla, and when administered in this way would also increase the circulating fluid much more quickly. The quantity of the saline to be used will depend, of course, upon the condition of the patient, the amount necessary varying from one half to as much as four pints. In cases of injury, where the shock is slight and the loss of blood trifling, amputation can be done at once. Salt solution, while not absolutely necessary, can do no harm, and should be used as a safeguard.

In cases of inquiry, where the shock is marked, either from loss of blood or the nature and extent of the injury, we should endeavor, by the use of saline solution, warmth to the surface of the body, elevation of the foot of the bed, together with atropia, strychnine, and small doses of morphine given hypodermatically, to bring about reaction. before attempting to operate.

"Amputation should not be deferred too long; after perhaps six hours, each hour increases the danger of infection. In the majority of cases, if the patient is to recover at all from the shock, some signs should be seen in from four to six hours."

I myself have operated upon two cases, both of which recovered. These cases have been reported to our local societies. The first one was an old hip case. The patient was thirty-five years of age, a very small, thin woman. She had had hip disease since early childhood, and ankylosis had taken place with the femur almost at right angles to the pelvis. The limb was greatly atrophied, and there were a number of fistular tracts. Dr. Ap Morgan Vance, who assisted me, by pressure with his thumb on the femoral artery, and at the same time almost encircling the limb with his hands, so completely controlled all vessels as to render the operation practically bloodless. Of course the Esmarch was used to drive the blood from the limb into the body first. The

second case was one of railway injury. The patient, a negro man, aged thirty-one, fell from the platform of a Pennsylvania train, and his left thigh was run over at the middle third. The bone was crushed and soft structure lacerated nearly to the hip-joint. There was a rent in the skin over the femoral vessels extending near to Poupart's ligament. When he reached the hospital, about three hours after receipt of injury, his pulse was only 84 and fair as to volume, temperature 98° F. So the operation was done at once. As the soft structures were so badly contused and lacerated, it was decided to do a preliminary ligation of the femoral high up, and then make the pass slowly, catching the vessels as they were divided.

Dr. Thomas L. Butler assisted me in the operation. The amount of blood lost was very trifling. The man made a good recovery. We were afraid- from the amount of contusion of the tissues-that the flaps would slough, but they did not. There was, however, some suppuration.

LOUISVILLE.

SUBSTANCE, OR CELL LIFE, AND THE GERM CONSIDERED FROM THE STANDPOINT OF NATURAL PHENOMENA.*

BY U. V. WILLIAMS, A. M., M. D.

Carlyle has most tersely said, "The universe is the Great God's fact," and that all its phenomena are not a matter of "just happened so;" neither is nature governed by stratagem nor special providence, but by inexorable law, fixed and unalterable, with no "variableness or shadow of turning," as is the nature of "Thou First great Cause least understood." The time has gone by to search for living organism by a spontaneous aggregation of molecules in vegetable or other infusions, or from a layer of formless primordial slime dispersed over the bed of the ocean. Living matter, during our epoch, has been and continues to be derived from pre-existing living matter, even when it possesses the simplicity of the structure of a bacterium and the morphological unit of a cell. When we consider the cell as the point of organic tissue building, as the primordial, we assume the beginning to be within that cell and capable of nucleus and nucleola ad infinitum,

* Read before the Kentucky State Medical Society, Louisville, May, 1901.

beyond the limits of the most powerful microscope and the infinity of further possibilities. We must reach an imaginative point in its genesis, where it ceases to be a solid, a substance, and for want of a nicer subdivision we will call it a gas. So with the infinity of the genesis of the germ. Starting with the cocci, which Dorland defines as "any individual organism or spheroid and bacterial cell-form of a group including macrococcus, micrococcus, gonococcus, streptococcus, etc., and then when we have of the single variety of streptococcus seventyone elaborately classified divisions," we are lost in an impenetrable maze, unless we assume a common origin and let the environment determine the differentiative. Any other form is capable of the same infinite classification, only limited by the number of observers and the power of human endurance to comprehend and classify. Rather is it the part of wisdom and convenience to classify as one common starting-point that we are endowed with a divine organism; constitutional defects and heredity play but a secondary part in etiology. The favorable soil for a disease is a soil made so by defect, usually an acquired one of the normal resisting power, and that starting-point is substance, and let environment determine the variety. Such will be the object of this paper, and, as on former occasions, let us begin with the Great God's fact of Carlyle, Nature, admitting that abiogenesis of cell life can not be refuted, neither can it nor has it been proven.

Substance is defined as "the material of which an organ is made up." Thus we have "Dottel substance," "Substance of Nissl," "Rolando's gelatinous substance," "Rollet's secondary substance," "Sommering's tigroids," and as many others as there are scientists delving in any especial department. All are like the cell, or the coccus, a something whose characteristics and adaptation wholly, like those, depend upon invironment, or catabiotic genesis, the cell plasm lying in its periphery substance. All scientists are joining with Prof. Thurston to-day in asking, What is this real character, the mighty world wonder which the realistic scientist calls nature, or the universe, the idealist philosopher calls substance or cosmos, the religionist calls God? We must admit we know little of its essence. There remains beneath all an apparent unknowable. Haeckel throws no light upon this eternal sphinx-life. The realist, the idealist, and the Christian each once affirmed the possibilities of spontaneous generation, the production of living organism from non-living matter, but they have abandoned that theory. Now they all affirm that living matter is only derived from