Chapter XIV: Miscellaneous Surgical Anomalies (2)

Syphilis from a Flea-bite.--Jonathan Hutchinson, in the October, 1895, number of his unique and valuable Archives of Surgery, reports a primary lesion of most unusual origin. An elderly member of the profession presented himself entirely covered with an evident syphilitic eruption, which rapidly disappeared under the use of mercury. The only interest about the case was the question as to how the disease had been acquired. The doctor was evidently anxious to give all the information in his power, but was positive that he had never been exposed to any sexual risk, and as he had retired from practice, no possibility of infection in that manner existed. He willingly stripped, and a careful examination of his entire body surface revealed no trace of lesion whatever on the genitals, or at any point, except a dusky spot on one leg, which looked like the remains of a boil. This, the doctor stated, had been due to a small sore, the dates of the appearance and duration of which were found to fit exactly with those of a primary lesion. There had also been some enlargement of the femoral glands. He had never thought of the sore in this connection, but remembered most distinctly that it followed a flea-bite in an omnibus, and had been caused, as he supposed, by his scratching the place, though he could not understand why it lasted so long. Mr. Hutchinson concludes that all the evidence tends to show that the disease had probably been communicated from the blood of an infected person through the bite of the insect. It thus appears that even the proverbially trivial fleabite may at times prove a serious injury.

Snake-bites.--A writer in an Indian paper asserts that the traditional immunity of Indian snake-charmers is due to the fact that having been accidentally bitten by poisonous serpents or insects more than once, and having survived the first attack, they are subsequently immune. His assertion is based on personal acquaintance with Madari Yogis and Fakirs, and an actual experiment made with a Mohammedan Fakir who was immune to the bites of scorpions provided by the writer. The animals were from five to seven inches long and had lobster-like claws. Each bite drew blood, but the Fakir was none the worse.

The venom of poisonous snakes may be considered the most typical of animal poisons, being unrivaled in the fatality and rapidity of its action. Fortunately in our country there are few snake-bites, but in the tropic countries, particularly India, the mortality from this cause is frightful. Not only are there numerous serpents in that country, but the natives are lightly dressed and unshod, thus being exposed to the bites of the reptiles. It is estimated by capable authorities that the deaths in India each year from snake-bites exceed 20,000. It is stated that there were 2893 human beings killed by tigers, leopards, hyenas, and panthers in India during the year 1894, and in the same year the same species of beasts, aided by snakes, killed 97,371 head of cattle. The number of human lives destroyed by snakes in India in 1894 was 21,538. The number of wild beasts killed in the same year was 13,447, and the number of snakes killed was 102,210.

Yarrow of Washington, who has been a close student of this subject, has found in this country no less than 27 species of poisonous snakes, belonging to four genera. The first genus is the Crotalus, or rattlesnake proper; the second is the Caudisona, or ground-rattlesnake; the third is the Ancistrodon, or moccasin, one of the species of which is a water-snake; and the fourth is the Elaps, or harlequin snake. There is some dispute over the exact degree of the toxic qualities of the venom of the Heloderma suspectum, or Gila monster. In India the cobra is the most deadly snake. It grows to the length of 5 1/2 feet, and is most active at night. The Ophiophagus, or hooded cobra, is one of the largest of venomous snakes, sometimes attaining a length of 15 feet; it is both powerful, active, and aggressive. The common snakes of the deadly variety in the United States are the rattlesnake, the "copperhead," and the moccasin; and it is from the bites of one of these varieties that the great majority of reported deaths are caused. But in looking over medical literature one is struck with the scarcity of reports of fatal snake-bites. This is most likely attributable to the fact that, except a few army-surgeons, physicians rarely see the cases. The natural abode of the serpents is in the wild and uninhabited regions.

The venom is delivered to the victim through the medium of a long fang which is connected with a gland in which the poison is stored. The supply may be readily exhausted; for a time the bite would then be harmless. Contrary to the general impression, snake-venom when swallowed is a deadly poison, as proved by the experiments of Fayrer, Mitchell, and Reichert. Death is most likely caused by paralysis of the vital centers through the circulation. In this country the wounds invariably are on the extremities, while in India the cobra sometimes strikes on the shoulder or neck.

If called on to describe accurately the symptoms of snake-venom poisoning, few medical men could respond correctly. In most cases the wound is painful, sometimes exaggerated by the mental condition, which is wrought up to a pitch rarely seen in other equally fatal injuries. It is often difficult to discern the exact point of puncture, so minute is it. There is swelling due to effusion of blood, active inflammation, and increasing pain. If the poison has gained full entrance into the system, in a short time the swelling extends, vesicles soon form, and the disorganization of the tissues is so rapid that gangrene is liable to intervene before the fatal issue. The patient becomes prostrated immediately after the infliction of the wound, and his condition strongly indicates the use of stimulants, even if the medical attendant were unfamiliar with the history of the snake-bite. There may be a slight delirium; the expression becomes anxious, the pulse rapid and feeble, the respiration labored, and the patient complains of a sense of suffocation. Coma follows, and the respirations become slower and slower until death results. If the patient lives long enough, the discoloration of the extremity and the swelling may spread to the neck, chest and back. Loss of speech after snake-bite is discussed in Chapter XVII, under the head of Aphasia.

A peculiar complication is a distressing inflammation of the mouth of individuals that have sucked the wounds containing venom. This custom is still quite common, and is preferred by the laity to the surer and much wiser method of immediate cauterization by fire. There is a curious case reported of a young man who was bitten on the ankle by a viper; he had not sucked the wound, but he presented such an enormous swelling of the tongue as to be almost provocative of a fatal issue. In this case the lingual swelling was a local effect of the general constitutional disturbance.

Cases of Snake-bite.--The following case illustrative of the tenacity of virulence of snake-venom was reported by Mr. Temple, Chief Justice of Honduras, and quoted by a London authority. While working at some wood-cutting a man was struck on a heavy boot by a snake, which he killed with an axe. He imagined that he had been efficiently protected by the boot, and he thought little of the incident. Shortly afterward he began to feel ill, sank into a stupor, and succumbed. His boots were sold after his death, as they were quite well made and a luxury in that country. In a few hours the purchaser of the boots was a corpse, and every one attributed his death to apoplexy or some similar cause. The boots were again sold, and the next unfortunate owner died in an equally short time. It was then thought wise to examine the boots, and in one of them was found, firmly embedded, the fang of the serpent. It was supposed that in pulling on the boots each of the subsequent owners had scratched himself and became fatally inoculated with the venom, which was unsuspected and not combated. The case is so strange as to appear hypothetic, but the authority seems reliable.

The following are three cases of snake-bite reported by surgeons of the United States Army, two followed by recovery, and the other by death: Middleton mentions a private in the Fourth Cavalry, aged twenty-nine, who was bitten by a rattlesnake at Fort Concho, Texas, June 27, 1866. The bite opened the phalangeal joint of the left thumb, causing violent inflammation, and resulted in the destruction of the joint. Three years afterward the joint swelled and became extremely painful, and it was necessary to amputate the thumb. Campbell reports the case of a private of the Thirteenth Infantry who was bitten in the throat by a large rattlesnake. The wound was immediately sucked by a comrade, and the man reported at the Post Hospital, at Camp Cooke, Montana, three hours after the accident. The only noticeable appearance was a slightly wild look about the eyes, although the man did not seem to be the least alarmed. The region of the wound was hard and somewhat painful, probably from having been bruised by the teeth of the man who sucked the wound; it remained so for about three hours. The throat was bound up in rancid olive oil (the only kind at hand) and no internal remedy was administered. There were no other bad consequences, and the patient soon returned to duty.

Le Carpentier sends the report of a fatal case of rattlesnake-bite: A private, aged thirty-seven, remarkable for the singularity of his conduct, was known in his Company as a snake-charmer, as he had many times, without injury, handled poisonous snakes. On the morning of July 13, 1869, he was detailed as guard with the herd at Fort Cummings, New Mexico, when, in the presence of the herders, he succeeded in catching a rattlesnake and proving his power as a sorcerer. The performance being over and the snake killed, he caught sight of another of the same class, and tried to duplicate his previous feat; but his dexterity failed, and he was bitten in the middle finger of the right hand. He was immediately admitted to the Post Hospital, complaining only of a little pain, such as might follow the sting of a bee or wasp. A ligature was applied above the wound; the two injuries made by the fangs were enlarged by a bistoury; ammonia and the actual cautery were applied; large doses of whiskey were repeated frequently, the constitution of the patient being broken and poor. Vomiting soon came on but was stopped without trouble, and there were doubts from the beginning as to his recovery. The swelling of the hand and arm gradually increased, showing the particular livid and yellowish tint following the bites of poisonous snakes. A blister was applied to the bitten finger, tincture of iodin used, and two ounces of whiskey given every two hours until inebriety was induced. The pulse, which was very much reduced at first, gained gradually under the influence of stimulants; two grains of opium were given at night, the patient slept well, and on the next day complained only of numbness in the arm. The swelling had extended as far as the shoulder-joint, and the blood, which was very fluid, was incessantly running from the wound. Carbolic acid and cerate were applied to the arm, with stimulants internally. On the 15th his condition was good, the swelling had somewhat augmented, there was not so much lividity, but the yellowish hue had increased. On the 16th the man complained of pain in the neck, on the side of the affected limb, but his general condition was good. Examining his genitals, an iron ring 3/4 inch in diameter was discovered, imbedded in the soft tissues of the penis, constricting it to such a degree as to have produced enormous enlargement of the parts. Upon inquiry it seemed that the ring had been kept on the parts very long, as a means of preservation of chastity; but under the influence of the snake's venom the swelling had increased, and the patient having much trouble in passing water was obliged to complain. The ring was filed off with some difficulty. Gangrene destroyed the extremity of the bitten finger. From this date until the 30th the man's condition improved somewhat. The progress of the gangrene was stopped, and the injured finger was disarticulated at the metacarpal articulation. Anesthesia was readily obtained, but the appearance of the second stage was hardly perceptible. Le Carpentier was called early on the next morning, the patient having been observed to be sinking; there was stertorous respiration, the pulse was weak and slow, and the man was only partly conscious. Electricity was applied to the spine, and brandy and potassium bromid were given, but death occurred about noon. A necropsy was made one hour after death. There was general softening of the tissues, particularly on the affected side. The blood was black and very fluid,--not coagulable. The ventricles of the brain were filled with a large amount of serum; the brain was somewhat congested. The lungs were healthy, with the exception of a few crude tubercles of recent formation on the left side. The right ventricle of the heart was empty, and the left filled with dark blood, which had coagulated. The liver and kidneys were healthy, and the gall-bladder very much distended with bile. The intestines presented a few livid patches on the outside.

Hydrophobia.--The bite of an enraged animal is always of great danger to man, and death has followed a wound inflicted by domestic animals or even fowls; a human bite has also caused a fatal issue. Rabies is frequently observed in herbivorous animals, such as the ox, cow, or sheep, but is most commonly found in the carnivore, such as the dog, wolf, fox, jackal, hyena, and cat and other members of the feline tribe. Fox reports several cases of death from symptoms resembling those of hydrophobia in persons who were bitten by skunks. Swine, birds, and even domestic poultry have caused hydrophobia by their bites. Le Cat speaks of the bite of an enraged duck causing death, and Thiermeyer mentions death shortly following the bite of a goose, as well as death in three days from a chicken-bite. Camerarius describes a case of epilepsy which he attributed to a horse-bite. Among the older writers speaking of death following the bite of an enraged man, are van Meek'ren, Wolff, Zacutus Lusitanus, and Glandorp. The Ephemerides contains an account of hydrophobia caused by a human bite. Jones reports a case of syphilitic inoculation from a human bite on the hand.

Hydrophobia may not necessarily be from a bite; a previously-existing wound may be inoculated by the saliva alone, conveyed by licking. Pliny, and some subsequent writers, attributed rabies to a worm under the animal's tongue which they called "lytta." There is said to be a superstition in India that, shortly after being bitten by a mad dog, the victim conceives pups in his belly; at about three months these move rapidly up and down the patient's intestines, and being mad like their progenitor, they bite and bark incessantly, until they finally kill the unfortunate victim. The natives of Nepaul firmly believe this theory. All sorts of curious remedies have been suggested for the cure of hydrophobia. Crabs-claws, Spanish fly, and dragon roots, given three mornings before the new or full moon, was suggested as a specific by Sir Robert Gordon. Theodore De Vaux remarks that the person bitten should immediately pluck the feathers from the breech of an old cock and apply them bare to the bites. If the dog was mad the cock was supposed to swell and die. If the dog was not mad the cock would not swell; in either case the person so treated was immune. Mad-stones, as well as snake-stones, are believed in by some persons at the present day. According to Curran, at one time in Ireland the fear of hydrophobia was so great that any person supposed to be suffering from it could be legally smothered.

According to French statistics, hydrophobia is an extremely fatal disease, although the proportion of people bitten and escaping without infection is overwhelmingly greater than those who acquire the disease. The mortality of genuine hydrophobia is from 30 to 80 per cent, influenced by efficient and early cauterization and scientific treatment. There is little doubt that many of the cases reported as hydrophobia are merely examples of general systemic infection from a local focus of sepsis, made possible by some primitive and uncleanly treatment of the original wound. There is much superstition relative to hydrophobia; the majority of wounds seen are filled with the hair of the dog, soot, ham-fat, and also with particles of decayed food and saliva from the mouth of some person who has practiced sucking the wound.

Ordinarily, the period of incubation of hydrophobia in man is before the end of the second month, although rarely cases are seen as many as six months from the reception of the bite. The first symptoms of the disease are melancholia, insomnia, loss of appetite, and occasionally shooting pains, radiating from the wound. There may be severe pain at the back of the head and in the neck. Difficulty in swallowing soon becomes a marked symptom. The speech assumes a sobbing tone, and occasionally the expression of the face is wild and haggard. As regards the crucial diagnostic test of a glass of water, the following account of a patient's attempt to drink is given by Curtis and quoted by Warren: "A glass of water was offered the patient, which he refused to take, saying that he could not stand so much as that, but would take it from a teaspoon. On taking the water from the spoon he evinced some discomfort and agitation, but continued to raise the spoon. As it came within a foot of his lips, he gagged and began to gasp violently, his features worked, and his head shook. He finally almost tossed the water into his mouth, losing the greater part of it, and staggered about the room gasping and groaning. At this moment the respirations seemed wholly costal, and were performed with great effort, the elbows being jerked upward with every inspiration. The paroxysm lasted about half a minute. The act of swallowing did not appear to cause distress, for he could go through the motions of deglutition without any trouble. The approach of liquid toward the mouth would, however, cause distress." It is to be remarked that the spasm affects the mechanism of the respiratory apparatus, the muscles of mastication and deglutition being only secondarily contracted.

Pasteur discovered that the virulence of the virus of rabies could be attenuated in passing it through different species of animals, and also that inoculation of this attenuated virus had a decided prophylactic effect on the disease; hence, by cutting the spinal cord of inoculated animals into fragments a few centimeters long, and drying them, an emulsion could be made containing the virus. The patients are first inoculated with a cord fourteen days old, and the inoculation is repeated for nine days, each time with a cord one day fresher. The intensive method consists in omitting the weakest cords and giving the inoculations at shorter intervals. As a curious coincidence, Pliny and Pasteur, the ancient and modern, both discuss the particular virulence of saliva during fasting.

There is much discussion over the extent of injury a shark-bite can produce. In fact some persons deny the reliability of any of the so-called cases of shark-bites. Ensor reports an interesting case occurring at Port Elizabeth, South Africa. While bathing, an expert swimmer felt a sharp pain in the thigh, and before he could cry out, felt a horrid crunch and was dragged below the surface of the water. He struggled for a minute, was twisted about, shaken, and then set free, and by a supreme effort, reached the landing stairs of the jetty, where, to his surprise, he found that a monstrous shark had bitten his leg off. The leg had been seized obliquely, and the teeth had gone across the joints, wounding the condyles of the femur. There were three marks on the left side showing where the fish had first caught him. The amputation was completed at once, and the man recovered. Macgrigor reports the case of a man at a fishery, near Manaar, who was bitten by a shark. The upper jaw of the animal was fixed in the left side of the belly, forming a semicircular wound of which a point one inch to the left of the umbilicus was the upper boundary, and the lower part of the upper third of the thigh, the lower boundary. The abdominal and lumbar muscles were divided and turned up, exposing the colon in its passage across the belly. Several convolutions of the small intestines were also laid bare, as were also the three lowest ribs. The gluteal muscles were lacerated and torn, the tendons about the trochanter divided, laying the bone bare, and the vastus externus and part of the rectus of the thigh were cut across. The wound was 19 inches in length and four or five inches in breadth. When Dr. Kennedy first saw the patient he had been carried in a boat and then in a palanquin for over five miles, and at this time, three hours after the reception of the wound, Kennedy freed the abdominal cavity of salt water and blood, thoroughly cleansed the wound of the hair and the clots, and closed it with adhesive strips. By the sixteenth day the abdominal wound had perfectly closed, the lacerations granulated healthily, and the man did well. Boyle reports recovery from extensive lacerated wounds from the bite of a shark. Both arms were amputated as a consequence of the injuries. Fayrer mentions shark-bites in the Hooghley.

Leprosy from a Fish-bite.--Ashmead records the curious case of a man that had lived many years in a leprous country, and while dressing a fish had received a wound of the thumb from the fin of the fish. Swelling of the arm followed, and soon after bullae upon the chest, head, and face. In a few months the blotches left from this eruption became leprous tubercles, and other well-marked signs of the malady followed. The author asked if in this case we have to do with a latent leprosy which was evoked by the wound, or if it were a case of inoculation from the fish?

Cutliffe records recovery after amputation at the elbow-joint, as a consequence of an alligator-bite nine days before admission to the hospital. The patient exhibited a compound comminuted fracture of the right radius and ulna in their lower thirds, compound comminuted fractures of the bones of the carpus and metacarpus, with great laceration of the soft parts, laying bare the wrist-joint, besides several penetrating wounds of the arm and fore-arm. Mourray gives some notes on a case of crocodile-bite with removal of a large portion of omentum. Sircar speaks of recovery from a crocodile-bite. Dudgeon reports two cases of animal-bites, both fatal, one by a bear, and the other by a camel. There is mention of a compound dislocation of the wrist-joint from a horse-bite. Fayrer speaks of a wolf-bite of the forearm, followed by necrosis and hemorrhage, necessitating ligature of the brachial artery and subsequent excision of the elbow-joint.

Injuries from Lightning.--The subject of lightning-stroke, with its diverse range of injuries, is of considerable interest, and, though not uncommon, the matter is surrounded by a veil of superstition and mystery. It is well known that instantaneous or temporary unconsciousness may result from lightning-stroke. Sometimes superficial or deep burns may be the sole result, and again paralysis of the general nerves, such as those of sensation and motion, may be occasioned. For many years the therapeutic effect of a lightning-stroke has been believed to be a possibility, and numerous instances are on record. The object of this article will be to record a sufficient number of cases of lightning-stroke to enable the reader to judge of its various effects, and form his own opinion of the good or evil of the injury. It must be mentioned here that half a century ago Le Conte wrote a most extensive article on this subject, which, to the present time, has hardly been improved upon.

The first cases to be recorded are those in which there has been complete and rapid recovery from lightning-stroke. Crawford mentions a woman who, while sitting in front of her fireplace on the first floor of a two-story frame building, heard a crash about her, and realized that the house had been struck by lightning. The lightning had torn all the weather-boarding off the house, and had also followed a spouting which terminated in a wooden trough in a pig-sty, ten feet back of the house, and killed a pig. Another branch of the fluid passed through the inside of the building and, running along the upper floor to directly over where Mrs. F. was sitting, passed through the floor and descended upon the top of her left shoulder. Her left arm was lying across her abdomen at the time, the points of the fingers resting on the crests of the ilium. There was a rent in the dress at the top of the shoulder, and a red line half an inch wide running from thence along the inside of the arm and fore-arm. In some places there was complete vesication, and on its palmer surface the hand lying on the abdomen was completely denuded. The abdomen, for a space of four inches in length and eight inches in breadth, was also blistered. The fluid then passed from the fingers to the crest of the ilium, and down the outside of the leg, bursting open the shoes, and passing then through the floor. Again a red line half an inch wide could be traced from the ilium to the toes. The clothing was not scorched, but only slightly rent at the point of the shoulder and where the fingers rested. This woman was neither knocked off her chair nor stunned, and she felt no shock at the time. After ordinary treatment for her burns she made rapid and complete recovery.

Halton reports the history of a case of a woman of sixty-five who, about thirty-five minutes before he saw her, had been struck by lightning. While she was sitting in an outbuilding a stroke of lightning struck and shattered a tree about a foot distant. Then, leaving the tree about seven feet from the ground, it penetrated the wall of the building, which was of unplastered frame, and struck Mrs. P. on the back of the head, at a point where her hair was done up in a knot and fastened by two ordinary hair-pins. The hair was much scorched, and under the knot the skin of the scalp was severely burned. The fluid crossed, burning her right ear, in which was a gold ear-ring, and then passed over her throat and down the left sternum, leaving a burn three inches wide, covered by a blister. There was another burn, 12 inches long and three inches wide, passing from just above the crest of the ilium forward and downward to the symphysis pubis. The next burn began at the patella of the right knee, extending to the bottom of the heel, upon reaching which it wound around the inner side of the leg. About four inches below the knee a sound strip of cuticle, about 1 1/2 inches, was left intact. The lightning passed off the heel of the foot, bursting open the heel of a strongly sewed gaiter-boot. The woman was rendered unconscious but subsequently recovered.

A remarkable feature of a lightning-stroke is the fact that it very often strips the affected part of its raiment, as in the previous case in which the shoe was burst open. In a discussion before the Clinical Society of London, October 24 1879, there were several instances mentioned in which clothes had been stripped off by lightning. In one case mentioned by Sir James Paget, the clothes were wet and the man's skin was reeking with perspiration. In its course the lightning traveled down the clothes, tearing them posteriorly, and completely stripping the patient. The boots were split up behind and the laces torn out. This patient, however, made a good recovery. Beatson mentions an instance in which an explosion of a shell completely tore off the left leg of a sergeant instructor, midway between the knee and ankle. It was found that the foot and lower third of the leg had been completely denuded of a boot and woolen stocking, without any apparent abrasion or injury to the skin. The stocking was found in the battery and the boot struck a person some distance off. The stocking was much torn, and the boot had the heel missing, and in one part the sole was separated from the upper. The laces in the upper holes were broken but were still present in the lower holes. The explanation offered in this case is similar to that in analogous cases of lightning-stroke, that is, that the gas generated by the explosion found its way between the limb and the stocking and boot and stripped them off.

There is a curious collection of relics, consisting of the clothes of a man struck by lightning, artistically hung in a glass case in the Museum of the Royal College of Surgeons, London, and the history of the injury, of which these remnants are the result, is given by Professor Stewart, the curator, as follows: At half past four on June 8, 1878, James Orman and others were at work near Snave, in Romney Marsh, about eight miles from Ashford. The men were engaged in lopping willows, when the violence of the rain compelled them to take refuge under a hedge. Three of the men entered a shed near by, but Orman remained by the willow, close to the window of the shed. Scarcely were the three inside when a lightning-stroke entered the door, crossed the shed, and passed out the window, which it blew before it into the field. The men noticed that the tree under which Orman stood was stripped of its bark. Their companion's boots stood close to the foot of the tree, while the man himself lay almost perfectly naked a few yards further on, calling for help. When they left him a few moments previously, he was completely clad in a cotton shirt, cotton jacket, flannel vest, and cotton trousers, secured at the waist with leather straps and buckles. Orman also wore a pair of stout hobnail boots, and had a watch and chain. After the lightning-stroke, however, all he had on him was the left arm of his flannel vest. The field was strewn for some distance with fragments of the unfortunate man's clothing. Orman was thrown down, his eyebrows burned off, and his whiskers and beard much scorched. His chest was covered with superficial burns, and he had sustained a fracture of the leg. His strong boots were torn from his feet, and his watch had a hole burned right through it, as if a soldering iron had been used. The watch-chain was almost completely destroyed, only a few links remaining. Together with some fused coins, these were found close by, and are deposited in a closed box in the Museum. According to Orman's account of the affair, he first felt a violent blow on the chest and shoulders, and then he was involved in a blinding light and hurled into the air. He said he never lost consciousness; but when at the hospital he seemed very deaf and stupid. He was discharged perfectly cured twenty weeks after the occurrence. The scientific explanation of this amazing escape from this most eccentric vagary of the electric fluid is given,--the fact that the wet condition of the man's clothing increased its power of conduction, and in this way saved his life. It is said that the electric current passed down the side of Orman's body, causing everywhere a sudden production of steam, which by its expansion tore the clothing off and hurled it away. It is a curious fact that where the flannel covered the man's skin the burns were merely superficial, whereas in those parts touched by the cotton trousers they were very much deeper. This case is also quoted and described by Dr. Wilks.

There was a curious case of lightning-stroke reported at Cole Harbor, Halifax. A diver, while at work far under the surface of the water, was seriously injured by the transmission of a lightning-stroke, which first struck the communicating air pump to which the diver was attached. The man was brought to the surface insensible, but he afterward recovered.

Permanent Effect of Lightning on the Nervous System.--MacDonald mentions a woman of seventy-eight who, some forty-two years previous, while ironing a cap with an Italian iron, was stunned by an extremely vivid flash of lightning and fell back unconscious into a chair. On regaining consciousness she found that the cap which she had left on the table, remote from the iron, was reduced to cinders. Her clothes were not burned nor were there any marks on the skin. After the stroke she felt a creeping sensation and numbness, particularly in the arm which was next to the table. She stated positively that in consequence of this feeling she could predict with the greatest certainty when the atmosphere was highly charged with electricity, as the numbness increased on these occasions. The woman averred that shortly before or during a thunder storm she always became nauseated. MacDonald offers as a physiologic explanation of this case that probably the impression produced forty-two years before implicated the right brachial plexus and the afferent branches of the pneumogastric, and to some degree the vomiting center in the medulla; hence, when the atmosphere was highly charged with electricity the structures affected became more readily impressed. Camby relates the case of a neuropathic woman of thirty-eight, two of whose children were killed by lightning in her presence. She herself was unconscious for four days, and when she recovered consciousness, she was found to be hemiplegic and hemianesthetic on the left side. She fully recovered in three weeks. Two years later, during a thunder storm, when there was no evidence of a lightning-stroke, she had a second attack, and three years later a third attack under similar circumstances.

There are some ocular injuries from lightning on record. In these cases the lesions have consisted of detachment of the retina, optic atrophy, cataract, hemorrhages into the retina, and rupture of the choroid, paralysis of the oculomotor muscles, and paralysis of the optic nerve. According to Buller of Montreal, such injuries may arise from the mechanic violence sustained by the patient rather than by the thermal or chemic action of the current. Buller describes a case of lightning-stroke in which the external ocular muscles, the crystalline lens, and the optic nerve were involved. Godfrey reports the case of Daniel Brown, a seaman on H.M.S. Cambrian. While at sea on February 21, 1799, he was struck both dumb and blind by a lightning-stroke. There was evidently paralysis of the optic nerve and of the oculomotor muscles; and the muscles of the glottis were also in some manner deprived of motion.

That an amputation can be perfectly performed by a lightning-stroke is exemplified in the case of Sycyanko of Cracow, Poland. The patient was a boy of twelve, whose right knee was ankylosed. While riding in a field in a violent storm, a loud peal of thunder caused the horse to run away, and the child fell stunned to the ground. On coming to his senses the boy found that his right leg was missing, the parts having been divided at the upper end of the tibia. The wound was perfectly round and the patella and femur were intact. There were other signs of burns about the body, but the boy recovered. Some days after the injury the missing leg was found near the place where he was first thrown from the horse.

The therapeutic effect of lightning-stroke is verified by a number of cases, a few of which will be given. Tilesius mentions a peculiar case which was extensively quoted in London. Two brothers, one of whom was deaf, were struck by lightning. It was found that the inner part of the right ear near the tragus and anti-helix of one of the individuals was scratched, and on the following day his hearing returned. Olmstead quotes the history of a man in Carteret County, N.C., who was seized with a paralytic affection of the face and eyes, and was quite unable to close his lids. While in his bedroom, he was struck senseless by lightning, and did not recover until the next day, when it was found that the paralysis had disappeared, and during the fourteen years which he afterward lived his affection never returned. There is a record of a young collier in the north of England who lost his sight by an explosion of gunpowder, utterly destroying the right eye and fracturing the frontal bone. The vision of the left eye was lost without any serious damage to the organ, and this was attributed to shock. On returning from Ettingshall in a severe thunder storm, he remarked to his brother that he had seen light through his spectacles, and had immediately afterward experienced a piercing sensation which had passed through the eye to the back of the head. The pain was brief, and he was then able to see objects distinctly. From this occasion he steadily improved until he was able to walk about without a guide.

Le Conte mentions the case of a negress who was struck by lightning August 19, 1842, on a plantation in Georgia. For years before the reception of the shock her health had been very bad, and she seemed to be suffering from a progressive emaciation and feebleness akin to chlorosis. The difficulty had probably followed a protracted amenorrhea, subsequent to labor and a retained placenta In the course of a week she had recovered from the effects of lightning and soon experienced complete restoration to health; and for two years had been a remarkably healthy and vigorous laborer. Le Conte quotes five similar cases, and mentions one in which a lightning-shock to a woman of twenty-nine produced amenorrhea, whereas she had previously suffered from profuse menstruation, and also mentions another case of a woman of seventy who was struck unconscious; the catamenial discharge which had ceased twenty years before, was now permanently reestablished, and the shrunken mammae again resumed their full contour.

A peculiar feature or superstition as to lightning-stroke is its photographic properties. In this connection Stricker of Frankfort quotes the case of Raspail of a man of twenty-two who, while climbing a tree to a bird's nest, was struck by lightning, and afterward showed upon his breast a picture of the tree, with the nest upon one of its branches. Although in the majority of cases the photographs resembled trees, there was one case in which it resembled a horse-shoe; another, a cow; a third, a piece of furniture; a fourth, the whole surrounding landscape. This theory of lightning-photographs of neighboring objects on the skin has probably arisen from the resemblance of the burns due to the ramifications of the blood-vessels as conductors, or to peculiar electric movements which can be demonstrated by positive charges on lycopodium powder.

A lightning-stroke does not exhaust its force on a few individuals or objects, but sometimes produces serious manifestations over a large area, or on a great number of people. It is said that a church in the village of Chateauneuf, in the Department of the Lower Alps, in France, was struck by three successive lightning strokes on July 11, 1819, during the installation of a new pastor. The company were all thrown down, nine were killed and 82 wounded. The priest, who was celebrating mass, was not affected, it is believed, on account of his silken robe acting as an insulator. Bryant of Charlestown, Mass., has communicated the particulars of a stroke of lightning on June 20, 1829, which shocked several hundred persons. The effect of this discharge was felt over an area of 172,500 square feet with nearly the same degree of intensity. Happily, there was no permanent injury recorded. Le Conte reports that a person may be killed when some distance--even as far as 20 miles away from the storm--by what Lord Mahon calls the "returning stroke."

Skin-grafting is a subject which has long been more or less familiar to medical men, but which has only recently been developed to a practically successful operation. The older surgeons knew that it was possible to reunite a resected nose or an amputated finger, and in Hunter's time tooth-replantation was quite well known. Smellie has recorded an instance in which, after avulsion of a nipple in suckling, restitution was effected. It is not alone to the skin that grafting is applicable; it is used in the cornea, nerves, muscles, bones, tendons, and teeth. Wolfer has been successful in transplanting the mucous membranes of frogs, rabbits, and pigeons to a portion of mucous membrane previously occupied by cicatricial tissue, and was the first to show that on mucous surfaces, mucous membrane remains mucous membrane, but when transplanted to skin, it becomes skin. Attempts have been made to transplant a button of clear cornea of a dog, rabbit, or cat to the cornea of a human being, opaque as the result of ophthalmia, and von Hippel has devised a special method of doing this. Recently Fuchs has reported his experience in cornea-grafting in sections, as a substitute for von Hippel's method, in parenchymatous keratitis and corneal staphyloma, and though not eminently successful himself, he considers the operation worthy of trial in cases that are without help, and doomed to blindness.

John Hunter was the first to perform the implantation of teeth; and Younger the first to transplant the teeth of man in the jaws of man; the initial operation should be called replantation, as it was merely the replacement of a tooth in a socket from which it had accidentally or intentionally been removed. Hunter drilled a hole in a cock's comb and inserted a tooth, and held it by a ligature. Younger drilled a hole in a man's jaw and implanted a tooth, and proved that it was not necessary to use a fresh tooth. Ottolengni mentions the case of a man who was struck by a ruffian and had his two central incisors knocked out. He searched for them, washed them in warm water, carefully washed the teeth-sockets, and gently placed the teeth back in their position, where they remained firmly attached. At the time of report, six years after the accident, they were still firmly in position. Pettyjohn reports a successful case of tooth-replantation in his young daughter of two, who fell on the cellar stairs, completely excising the central incisors. The alveolar process of the right jaw was fractured, and the gum lacerated to the entire length of the root. The teeth were placed in a tepid normal saline solution, and the child chloroformed, narcosis being induced in sleep; the gums were cleaned antiseptically, and 3 1/2 hours afterward the child had the teeth firmly in place. They had been out of the mouth fully an hour. Four weeks afterward they were as firm as ever. By their experiments Gluck and Magnus prove that there is a return of activity after transplantation of muscle. After excision of malignant tumors of muscles, Helferich of Munich, and Lange of New York, have filled the gap left by the excision of the muscle affected by the tumor with transplanted muscles from dogs. Gluck has induced reproduction of lost tendons by grafting them with cat-gut, and according to Ashhurst, Peyrot has filled the gaps in retracted tendons by transplanting tendons, taken in one case from a dog, and in another from a cat.

Nerve-grafting, as a supplementary operation to neurectomy, has been practiced, and Gersung has transplanted the nerves of lower animals to the nerve stumps of man.

Bone-grafting is quite frequently practiced, portions from a recently amputated limb, or portions removed from living animals, or bone-chips, may be used. Senn proposed decalcified bone-plates to be used to fill in the gaps. Shifting of the bone has been done, e.g., by dividing a strip of the hard palate covered with its soft parts, parallel to the fissure in cleft palate, but leaving unsevered the bony attachments in front, and partially fracturing the pedicle, drawing the bony flaps together with sutures; or, when forming a new nose, by turning down with the skin and periosteum the outer table of the frontal bone, split off with a chisel, after cutting around the part to be removed. Trueheart reports a case of partial excision of the clavicle, successfully followed by the grafting of periosteal and osseous material taken from a dog. Robson and Hayes of Rochester, N.Y., have successfully supplemented excision of spina bifida by the transplantation of a strip of periosteum from a rabbit. Poncet hastened a cure in a case of necrosis with partial destruction of the periosteum by inserting grafts taken from the bones of a dead infant and from a kid. Ricketts speaks of bone-grafting and the use of ivory, and remarks that Poncet of Lyons restored a tibia in nine months by grafting to the superior articular surface. Recently amalgam fillings have been used in bone-cavities to supplant grafting.

In destructive injuries of the skin, various materials were formerly used in grafting, none of which, however, have produced the same good effect as the use of skin by the Thiersch Method, which will be described later.

Rodgers, U.S.N., reports the case of a white man of thirty-eight who suffered from gangrene of the skin of the buttocks caused by sitting in a pan of caustic potash. When seen the man was intoxicated, and there was a gangrenous patch four by six inches on his buttocks. Rodgers used grafts from the under wing of a young fowl, as suggested by Redard, with good result. Vanmeter of Colorado describes a boy of fourteen with a severe extensive burn; a portion beneath the chin and lower jaw, and the right arm from the elbow to the fingers, formed a granulating surface which would not heal, and grafting was resorted to. The neck-grafts were supplied by the skin of the father and brother, but the arm-grafts were taken from two young puppies of the Mexican hairless breed, whose soft, white, hairless skin seemed to offer itself for the purpose with good prospect of a successful result. The outcome was all that could be desired. The puppy-grafts took faster and proved themselves to be superior to the skin-grafts. There is a case reported in which the skin of a greyhound seven days old, taken from the abdominal wall and even from the tail, was used with most satisfactory results in grafting an extensive ulcer following a burn on the left leg of a boy of ten. Masterman has grafted with the inner membrane of a hen's egg, and a Mexican surgeon, Altramirano, used the gills of a cock.

Fowler of Brooklyn has grafted with the skin from the back and abdomen of a large frog. The patient was a colored boy of sixteen, who was extensively burned by a kerosene lamp. The burns were on the legs, thighs, buttocks, and right ankle, and the estimated area of burnt surface was 247.95 square inches. The frog skin was transferred to the left buttocks, and on the right buttocks eight long strips of white skin were transferred after the manner of Thiersch. A strip of human skin was placed in one section over the frog skin, but became necrotic in four days, not being attached to the granulating surface. The man was discharged cured in six months. The frog skin was soft, pliable, and of a reddish hue, while the human white skin was firm and rapidly becoming pigmented. Leale cites the successful use of common warts in a case of grafting on a man of twenty who was burned on the foot by a stream of molten metal. Leale remarks that as common warts of the skin are collections of vascular papillae, admitting of separation without injury to their exceptionally thick layer of epidermis, they are probably better for the purposes of skin-grafting than ordinary skin of less vitality or vascularity. Ricketts has succeeded in grafting the skin of a frog to that of a tortoise, and also grafting frog skin to human skin. Ricketts remarks that the prepuce of a boy is remarkably good material for grafting. Sponge-grafts are often used to hasten cicatrization of integumental wounds. There is recorded an instance in which the breast of a crow and the back of a rat were grafted together and grew fast. The crow dragged the rat along, and the two did not seem to care to part company.

Relative to skin-grafting proper, Bartens succeeded in grafting the skin of a dead man of seventy on a boy of fourteen. Symonds reports cases of skin-grafting of large flaps from amputated limbs, and says this method is particularly available in large hospitals where they have amputations and grafts on the same day. Martin has shown that, after many hours of exposure in the open air at a temperature of nearly 32 degrees F., grafts could be successfully applied, but in such temperatures as 82 degrees F., exposure of from six to seven hours destroyed their vitality, so that if kept cool, the limb of a healthy individual amputated for some accident, may be utilized for grafting purposes.

Reverdin originated the procedure of epidermic grafting. Small grafts the size of a pin-head doing quite as well as large ones. Unfortunately but little diminution of the cicatricial contraction is effected by Reverdin's method. Thiersch contends that healing of a granulated surface results first from a conversion of the soft, vascular granulation-papillae, by contraction of some of their elements into young connective-tissue cells, into "dry, cicatricial papillae," actually approximating the surrounding tissues, thus diminishing the area to be covered by epidermis; and, secondly, by the covering of these papillae by epidermic cells. Thiersch therefore recommends that for the prevention of cicatricial contraction, the grafting be performed with large strips of skin.

Harte gives illustrations of a case of extensive skin-grafting on the thigh from six inches above the great trochanter well over the median line anteriorly and over the buttock. This extent is shown in Figure 228, taken five months after the accident, when the granulations had grown over the edge about an inch. Figure 229 shows the surface of the wound, six and one-half months after the accident and three months after the applications of numerous skin-grafts.

Cases of self-mutilation may be divided into three classes:--those in which the injuries are inflicted in a moment of temporary insanity from hallucinations or melancholia; with suicidal intent; and in religious frenzy or emotion. Self-mutilation is seen in the lower animals, and Kennedy, in mentioning the case of a hydrocephalic child who ate off its entire under lip, speaks also of a dog, of cats, and of a lioness who ate off their tails. Kennedy mentions the habit in young children of biting the finger-nails as an evidence of infantile trend toward self-mutilation. In the same discussion Collins states that he knew of an instance in India in which a horse lay down, deliberately exposing his anus, and allowing the crows to pick and eat his whole rectum. In temporary insanity, in fury, or in grief, the lower animals have been noticed by naturalists to mutilate themselves.

Self-mutilation in man is almost invariably the result of meditation over the generative function, and the great majority of cases of this nature are avulsions or amputations of some parts of the genitalia. The older records are full of such instances. Benivenius, Blanchard, Knackstedt, and Schenck cite cases. Smetius mentions castration which was effected by using the finger-nails, and there is an old record in which a man avulsed his own genitals. Scott mentions an instance in which a man amputated his genitals and recovered without subsequent symptoms. Gockelius speaks of self-castration in a ruptured man, and Golding, Guyon, Louis, Laugier, the Ephemerides, Alix, Marstral, and others, record instances of self-castration. In his Essays Montaigne mentions an instance of complete castration performed by the individual himself.