first employed this remedy, and has written with much emphasis on its efficacy, has stated that the best plan is to continue applying it until an insensible, dark-coloured, dry slough is formed upon the whole surface of the sore, and the patient becomes relieved of pain.

Various other substances have been occasionally employed. Bromine, in its pure liquid form as well as in combination with bromide of potassium, was largely employed during the United States war, and is described as having proved beneficial in arresting the disease. Dr. Goldsmith, U. S. Vols., to whom its introduction as an agent for the control of this disease is stated to have been chiefly due,34 directs that the parts are first to be dried by the application of charpie; then the sloughs, if thick, should be trimmed out with forceps and scissors as much as possible, for the thinner the slough the more effectual is the remedy. The parts having again been dried, the solution is applied by means of a mop, or a pointed stick of wood, in quantities sufficient to saturate the sloughs. If the sloughs undermine the skin, or dip down into intermuscular spaces, the solution must be made to follow, with the pointed stick, or by means of a glass syringe. The remedy should be reapplied every second hour as long as any odour of putrefaction is present, or as long as the sloughs appear to be diffluent.

The actual cautery was largely employed during the late Franco-German war by German surgeons. The reports regarding its use tended to show that hospital gangrene might be arrested by this form of remedy with more certainty than by any other. The irons were applied at a red or even white heat. In using the cautery, as with all other caustics, it must be remembered that the object is to penetrate completely the gangrenous parts, and to destroy a layer of the sound tissues beneath. If any poisoned portion be allowed to remain untouched, the disease will probably spread from that point. The surgeon must have a full conviction of the necessity for a complete destruction of the diseased structures to enable him resolutely to burn them to the requisite depth. As the iron, though red-hot when applied, soon becomes cooled by acting on the moist pulpy substance, which is more resisting to the burning action of the cautery than might at first be supposed, it is necessary to have several cauterising irons ready for use in each case. They should be applied while the patient is narcotised by chloroform or ether. In cases where a large surface has to be cauterised, it is convenient to remove as much as possible of the pulpy gangrenous tissues previously, and then to dry the surface as far as practicable with some carbolised tow. Portions of the edges, if much undermined, may also be cut away with advantage before the cauterising irons are applied.

It is only right to state, on the other hand, that, according to reports by Dr. Reeb respecting the treatment of hospital gangrene in the French Military Hospital at Strasburg, and by Dr. Bongard respecting its treatment in Belgium during the war of 1870-71, quoted by Dr. Chenu,35 the actual cautery did not in their hands arrest its progress. Both of these surgeons have reported that they had better success with simple lemon-juice applied by pads of charpie two or three times a day. The use of the actual cautery is also stated to have been attended with but little success at Paris, where hospital gangrene extensively prevailed during the siege.

Whatever caustic applications may be used, when the charred tissues and sloughs are detached, and a granulating surface obtained, the wound may then be treated with any of the usual antiseptic dressings; its previous condition of disease appears to exercise no influence upon its future progress when once the morbid action has been fully checked.

The constitutional treatment must vary with the varying states of patients. Some surgeons have strongly advocated the administration of an emetic on the first signs of an attack of hospital gangrene being observed.36 The necessity for giving an active purgative in the outset has also been generally noticed. The careless habits of soldiers frequently render a thorough evacuation of the bowels necessary before resorting to other remedies. The excretions, as well as secretions, are particularly liable to be very irregular in this disease, and their regulation becomes a necessary part of the treatment. The administration of iron, quinine, or one of the mineral acids, is generally serviceable. Pain must be alleviated, excitement allayed, and sleep procured by opium in some of its forms, or by other remedies having a sedative tendency.

Venesection combined with antiphlogistic remedies was formerly stated to be very beneficial. The removal of a moderate amount of blood may be occasionally useful when men with slight wounds happen to be attacked by the gangrene, and when the disease manifests itself in an active form, with accompanying high fever; but other means, as antimonial preparations, and medicines of a like character, are generally preferred by modern surgeons for lessening the constitutional and local excitement. Certainly no one would now practise venesection as it was recommended by Staff-Surgeon Dr. Boggie,37 whose advice and example seem to have led to bleeding being a favourite treatment among many surgeons of the Peninsular period.38 Hennen has recorded that the practice of venesection, introduced by Dr. Boggie at one period, became general in the treatment of the Bilbao hospital gangrene, and that it was regarded both by surgeons and patients as very advantageous. To modern surgeons it seems only reason

able to conclude that the greatly lessened ratio of mortality in hospital gangrene of late years, compared with what the records. show it to have been during the Peninsular war, may be greatly due to the abandonment of the practice of bleeding for its relief.

The records of the disease and its treatment handed down to us from the time of the Peninsular war seem to warrant the inference that hospital gangrene was of a much more inflammatory and sthenic type then than it has been during later wars. It was remarked in Germany that most of the severely wounded Germans, and still more the wounded French prisoners, especially if they had been long in the field before receiving their wounds, reached the country in a condition of great general debility. The fatigues of the campaign, the effects of their wounds, the hospital confinement, the insufficient attention after battles which left overwhelming numbers of wounded in the hands of the surgeons, reduced the physical powers of the men so rapidly and seriously that they generally arrived in a very sickly and depressed state. Suitable nutrient support, with a moderate amount of stimulants, cautious nursing, and tonic remedies, were what was most urgently demanded. When patients in the depressed state just described happen to be attacked by hospital gangrene, the morbid action, the intense pain, and the loss of appetite with which it is usually accompanied, quickly reduce them to a still lower ebb; and it requires the greatest skill and the most unremitting attention to support them through the terrible ordeal to which they are then subjected. It will sometimes become an anxious matter for a surgeon to decide, when life seems in danger from increasing gangrene taking place in a wounded limb, whether amputation may not hold out a better prospect of saving the patient's life than allowing the strain on the powers of his constitution to continue. Too frequently, however, when the question is discussed, the state of the patient has become such as to prevent any reasonable prospect of success from the operation.

Treatment of pyæmia after gunshot wounds. From all that was said in describing this complication, and the circumstances under which it has been chiefly observed, it is obvious that preventive measures are of the first importance to wounded patients. If surgeons are still in uncertainty as to the explanation of some of the phenomena of pyæmia, at any rate a knowledge of the conditions which are generally found to lead to the production of this fatal disease enables them to become aware of the precautionary treatment which will best serve to prevent its occurrence. Strictly antiseptic treatment of the wounds concerned is forcibly indicated, because it has been proved by experience that when it is practised, pyæmia hardly ever occurs, even though it may have been previously rife in the same building when it was not followed. If a low degree of vital energy predisposes patients to

the reception of pyæmic poisoning, regular and sufficient nutritious diet, cheerful occupation of the mind, adequate clothing, and a proper amount of rest, are indicated to fortify the constitution against the effects of exposure to it. If miasmata arising from patients with suppurating wounds tend to the production of pyæmia, we can counteract their deleterious effects by taking steps to remove the emanations as fast as they arise, before they have time to become corrupt, and by separating patients with such wounds as far apart from one another as practicable. As a rule, tents in suitable weather, and next to them temporary huts, have shown themselves to be more favourable means of shelter for men under treatment for suppurating wounds than fixed solid buildings, because they admit of more thorough ventilation. Attention to all the sanitary precautions which were mentioned when describing the preventive treatment of hospital gangrene are equally necessary for averting this complication. The general excitement in time of war, the circumstances of battles, the frequent occurrence of death from causes so much more obvious to the commonest senses than that arising from the slow poison of an infected atmosphere, the sudden admission into hospitals of many wounded men together, the many demands on the time and exertions of attendants, are apt to render persons in the midst of such scenes careless as to what appear to be comparative trifles; and among the other duties of surgeons in warding off this complication, not the least important is personal observation to ascertain that the directions given on hygienic matters are really carried into execution. Surgeons can rarely rely securely on the statements of subordinates in respect to such subjects.

But when pyæmia is threatened in any given case, the special attention of the surgeon should at once be directed, firstly, to the state of the wound, and, secondly, to the patient's general condition. Both local and general treatment must be resorted to without delay.

Local treatment.-If purulent discharges have become scanty, the wound should be well fomented, warm dressings applied, and any steps taken that may appear calculated to restore free action in the suppurating surface without exciting irritation in it. On the other hand, if any collections of pus are discovered, the pus should be at once evacuated under antiseptic precautions, and steps taken to prevent future accumulations. If the wound be deeply seated, complete removal of discharges, by drainage or otherwise, should be diligently attended to. Topical applications, which may hold out a hope of improving the tone of the secreting surfaces, and neutralising any tendency to septicity in the discharges, should be employed. Weak solutions of the permanganate of potash, and also of perchloride of mercury, have appeared most beneficial in this respect. The perchloride of iron was much used

in the Italian campaign of 1859, as an application to wounds in cases where commencing signs of pyæmia were exhibited, and the effects were stated to be exceedingly satisfactory. If the suppurating wound be connected with fracture of bone in one of the limbs, and all reasonable hope of union seems to be frustrated, the question of amputation will arise. It is a question that can only be decided after a complete investigation of all the circumstances, local and general, of each particular case. As a general rule, however, if pyæmia have really commenced, and especially if it has assumed an acute character, the patient is no longer in a fit condition to be subjected to amputation. The shock of the operation will be more than he can bear with impunity; and even if the first dangers should be escaped from, a healthy reparative action cannot be anticipated. Sir James Paget has, however, pointed out in his clinical lectures that in chronic pyæmia, when an injured part is manifestly useless, or is a source of irritation or of exhaustion to a patient, amputation may be a very proper operation to be performed.

When joints are found to contain pus, they should be treated as pus in joints under other circumstances, especially by easy support, rest, and the maintenance of an equable temperature about them by means of cotton-wool. The fluid, if excessive, should be removed, either by the aspirator, or by incision with strict antiseptic precautions.

Constitutional treatment.-The general indications are-to remove the patient out of any building in which the septic influence may have been exerted into a fresh atmosphere, into a clean tent on suitable ground, if practicable; to try by appropriate remedies, or by exciting some of the excretory organs, to get rid of any injurious products which may exist in the blood; to support the strength of the patient to the fullest practicable extent by nutritious food in a form likely to be assimilated readily, combined with the moderate use of stimulants; and lastly, by the administration of quinine in full doses, with mineral acids. The remedies last named appear to be useful in checking the copious perspirations with which the disease is usually attended. If nervous irritability be a prominent symptom, opium is the remedy which can be most relied on for allaying it. It has been recommended to encourage pyæmic patients to take tepid drinks copiously, with a view to maintaining fulness of the vessels, so as to render them less likely to absorb matters of a noxious character into the system. Whether this injunction has any practical value is very doubtful.

Just as the perchloride of iron has been strongly praised as a local application, so also the beneficial influence of its internal administration has been highly extolled by some surgeons. It is given in rather full doses of twenty minims every three or four